The Stigma of Burnout Impeding Formal Help: A Qualitative Study Exploring Residents’ Experiences During Training

Introduction

Burnout is an occupational stress syndrome that gives rise to emotional exhaustion (EE) depersonalization (DP) and reduced personal accomplishment (PA).¹ The literature has repeatedly shown increasing rates of burnout among health care professionals with negative impacts on the individual and the health care system.² For example, burnout among physicians has been linked to suboptimal patient care, medical errors, low physician professionalism and low patient satisfaction as well as poor function and reduced sustainability of healthcare organizations.² A systematic review from 45 countries reported variable prevalence rates of burnout among physicians with the highest reports reaching 80.5%.³ The rate of burnout among health care professionals in Arab and Middle Eastern countries appears to resemble results in the global literature.^4,5 However, Saudi Arabia seems to be on the upper end of the spectrum with reports of prevalence higher than 70%.⁵

Many studies have suggested medical trainees and especially residents to be at a higher risk for burnout.^6,7 Middle Eastern and African residents report the highest levels of burnout globally (67.4–69.5%) in comparison to North America (51.2%), Asia (48.8%) and Europe (30.8%).⁷ Saudi studies comparing residents to consultants, as well as studies comparing residents to students demonstrated that residents were at the highest risk for burnout in both groups, with rates as high as 81.22%.^5,8,9

Multiple studies have explored the different factors that may increase a resident’s risk for burnout including individual predictors such as age, gender, medical specialty, family support and resilience, as well as, environmental factors involving work hours, number of call shifts, job satisfaction and suboptimal working conditions.^7,10,11 There appears to be a consensus that burnout is predominantly related to heightened stress levels and poor working environments rather than personal factors.^7,10,11

Teunissen et al suggested that the problem may be related to the nature of residency training and the transition from undergraduate to postgraduate educational structures.¹² Residents were under greater stress caused by interacting with patients and medical staff, learning new material in a more self-directed manner, bearing many responsibilities that accompany the delivery of patient care and the need to take on increasingly more tasks independently.¹² Residents demonstrated mental fatigue and restrained emotions during this phase.¹² In Saudi Arabia, the prevalence of severe stress was found to be higher among residents in training (46.6% −59.4%) when compared to undergraduate students (12.6–35.8%), suggesting that residents in training may be experiencing greater levels of stress.⁵ In addition, multiple Saudi and global papers have linked resident burnout with poor academic performance on training exams, lower social skills, alcohol abuse, substance abuse and self-medication, impaired quality of life, suicide and/or suicidal ideation.^4,5,13

In general, reluctance in seeking professional care for serious emotional concerns is common among residents.¹⁴ However, burnout was found to be independently associated with an increase in that reluctance (OR 1.65; 95% CI 1.17, 2.34; P = 0.004).¹⁴ Ten years of literature involving multiple countries has repeatedly linked burnout among residents with career and specialty choice regret as well as intentions to change specialties or abandon medicine.¹⁵ A Saudi study in Makkah similarly reported an association between burnout and the physicians’ intent to continue or change specialties.¹⁶ In addition to the obvious effects on physicians’ lives and health, these practice changes may reduce patient access to physician care and further strain healthcare systems already struggling to meet the needs of the populations they serve.¹⁵

Although the literature in Saudi Arabia reports high levels of burnout among residents, there is little published information on the factors that contribute to this or how residents chose to manage it and seek support.^5,8,9 Furthermore, there are no studies to our knowledge that have explored residents’ personal experiences with burnout. Thus, in this qualitative study, an in-depth exploration of the factors that contribute to resident burnout, their experiences with burnout and how they choose to mitigate it will be an initial step in addressing this gap.

Methodology

Study Design, Setting and Participants

This qualitative study was conducted using one-on-one interviews at King Khalid University Hospital, part of King Saud University and Medical City in Riyadh, Saudi Arabia. This center has multiple Saudi Board residency programs in both surgical and non-surgical fields of medicine, with programs ranging between 3 and 5 years.¹⁷ Residents at different stages of training (R1-R5) were invited to participate through emails, posters and colleague recommendations (Snowball effect).

Prior to commencing recruitment, ethical approval was obtained by the Institutional Review Board (IRB) number (KSU-IRB017E) which abides by the Declaration of Helsinki.¹⁸ Participants provided written informed consent to participate, including audio recording and publication of anonymized responses. They were assured of the voluntary nature of the participation and of the confidentiality of their information. Each interview lasted between 60 and 90 minutes in person or by phone. Interviews were conducted between November 2019 and November 2020 by 4 researchers (MA, LS, NF, RA) trained in qualitative interviews.

Data Collection

In-depth interviews using a semi-structured interview guide (Appendix I) and additional probes were used to explore the following domains: understanding of burnout, experience, impact, relieving and aggravating factors, aids and barriers to support. The guide was continuously adapted to reflect adjustments from concurrent interviews. Interviews continued until adequate thematic saturation was achieved in analysis (ie, when no new themes emerged with further interviews) by the 14th interview.¹⁹ All interviews were conducted in English, were recorded, and transcribed verbatim after removal of all identifiers. Data collection ended with a total of 14 participants.

Qualitative Analysis

Interpretive thematic analysis was used in this study. This approach was chosen as it provides a deeper exploration of residents’ experiences with burnout; especially, when trying to uncover risk factors and help-seeking behavior. The principle of this design is to reduce individual experiences to a description of the universal essence of the experience while unveiling otherwise hidden meanings in the experience.^20,21 The sequential process of analysis, started with six researchers being divided into groups of two (RA, NF), (MA, LS), (NM, RM) each group worked on 4–5 transcripts. Initially, each researcher independently coded the data and then each group of 2 coders compared, clarified and agreed on the coding. Next, the entire team which included the 6 researchers and 1 qualitative research expert (LW) met to compare, corroborate and group codes into categories within a coding template according to similarities. Subsequently, all categories were repetitively reviewed and revised, expanding to include new data as it emerged and collapsing to remove redundant codes. Finally, categories were organized into the concluding set of overarching themes and sub-themes.

Results

A total of 14 residents were interviewed in this study with ages ranging between (26–35), from both surgical and non-surgical residency training programs (See Table 1 for demographic details).

Table 1 Demographic Details

All participants demonstrated a shared thread of shame in reaching the “level of burnout” and were compelled to continue suffering in silence. Three main interlinked themes were identified during the interviews. Burnout stigma cycle, amalgamated causes of burnout and self-coping with Burnout.

Burnout Stigma Cycle

Unanimously all participants described burnout as a form of mental “breakdown” and “depression”. The participants mostly equated the symptoms to psychiatric diagnoses and physical exhaustion.

Burnout in terms of he lost interest socially, social withdrawn from life! … you don’t show interest either in the training itself, in residency or over all in social life … basically for me burnout is equal to depression. (P11)

Burnout is basically the end stage of stress and anxiety. (P7)

A person reaches a level of exhaustion, that he can’t be productive like he used to. He feels tired from the simplest things. (P6)

A common sense among us [Residents] is when you feel tired even at rest we would call that burnout. (P8)

Interestingly all participants, except for one, described burnout through witnessing or hearing stories of colleagues going through burnout, but rejecting any personal burnout experiences. There was a shared undercurrent of denial among participants in experiencing burnout and shame in reaching that stage.

I believe everyone as medical doctor has experienced burnout! …to be honest for me I did have it like two or three months it wasn’t that significant in my personal perspective, but to some other people it was significant, for me it wasn’t that bad to be honest. I didn’t seek help! I can tolerate it. (P3)

For me I know this [burnout] is a normal part of the job and I know that when I signed up for medicine I knew this was part of it so I’m paying the consequences right now but I mean I know because I have a good coping mechanism that’s why I until now I’m surviving. (P5)

They don’t want to seem weak in front of their colleagues, like ooh he couldn’t handle the stress of residency or he couldn’t handle the stress of [name of specialty] so everyone wanna act tough! (P13)

The shame in reaching the stage of burnout was further perpetuated by embarrassment in pursuing avenues of professional help or feeling that help was useless; creating a stigma cycle of denial, shame, avoiding help and burnout. Figure 1

The stigma I don’t want people to say I saw a psychiatrist! I’m afraid to have the reputation of someone that needs psychiatric help. (P4)

I wasn’t denying the burnout but I thought that nothing will be added from psychiatry or psychologist, I thought whatever they are going to provide I can provide it myself. I’m afraid I don’t want anything to be documented that I went for a psych help, I don’t want people to know or say that I’m taking SSRI, I feel like it’s a weak point. (p9)

I always advocate for patients seeking psych help even with my own family members but when it came to me I don’t know I feel ashamed I think it’s us in the medical field we don’t anything documented. (P14)

Figure 1 Stigma Cycle of Burnout.

Amalgamated Causes of Burnout

Participants related the cause of burnout to a variety of aspects of being a physician. Two distinct sub-themes emerged that reciprocally cause burnout: Intimidating Environment and a Demanding Occupation. See Table 2 and Table 3 for description and quotes.

Table 2 Intimidating Environment Quotes

Table 3 Demanding Occupation

Self-Coping with Burnout

When participants were asked directly about how they would handle burnout, consistently they all enumerated different formal avenues of seeking help including “professional psychiatric assessment”, “available hospital services” and “approaching the program director”. However, none of the participants witnessed or actively pursued any of those avenues. Alternatively, they talked about personal self-coping approaches and silently managing on their own. See Table 4 for mentioned coping strategies and related quotes.

Table 4 Self-Coping Strategies and Quotes

All the themes seem to interplay into a story of suffering in silence. The stigma attached to the strong feelings of “shame” and “weakness” coupled with fear and lack of trust in help and support, resulted in silent suffering and private self-directed coping approaches. Figure 2

Figure 2 The Story of Suffering.

Discussion

In this study, we explored the factors that contributed to occupational burnout affecting residents in training, their approach to managing through burnout and how they sought out support. This is one of the first qualitative studies on the topic in Saudi Arabia. One of the interesting findings of this study was that residents described burnout as psychological stress, anxiety and exhaustion and linked it with shame and a stigma towards being burned-out, which led to avoidance of formal avenues of help and isolated self-coping strategies. In the literature, there appears to be a general trend by the medical culture to strongly stigmatize burnout.^22–25 Physicians tend to view their state of health, especially mental health, as an indicator of their medical competence.²⁵ Physicians suffering from burnout may be seen by colleagues and themselves as weak and incompetent.^22,25 Our results are consistent with many studies around the world with regard to stigma and shame being factors that hinder seeking help. Dyrbye et al found that medical students with burnout had higher perceived stigma scores and a higher fear of discrimination and breach of confidentiality than students without burnout.²² Burnout stigma has been linked to negative influences on medical trainees’ help seeking behavior and increases in their hesitancy to peruse support, with reports of only a third of trainees with burnout seeking formal help.^14,22 Similarly, Weiss et al concluded that burned-out trainees were significantly more likely to perceive stigma than their peers regarding seeking help to deal with psychological problems.²³ Studies have found correlations between the level of burnout and the level of stigma, and in turn the level of help avoidance, ie the higher the burnout the higher the stigma.^22,24–26

One of the concerning findings in our study is the participants’ pursuit of self-coping strategies and the complete avoidance of formal help, creating a cycle of suffering in silence. This is probably directly related to the idea of stigma and shame they have attached to having burnout and needing professional help. Distraction and detachment were the most described coping strategies used by participants in our study. The second most frequently described strategy was normalizing and suppressing feelings. Using self- distraction as a coping mechanism has been reported as one of the most used coping strategies among medical residents globally and is considered a maladaptive approach.^27,28 Studies have also suggested that residency training is a time of heightened vulnerability associated with mental exhaustion and suppressed emotions.¹² A study looking at the impact of emotional regulation on burnout reported that emotional suppression was associated with higher burnout and depersonalization and was also considered maladaptive.²⁹ Alternatively, the presence of compassionate supervisors mitigated residents’ emotional stress and aided their support.²⁹

The literature has repeatedly supported the protective role a good working environment has against resident burnout.^7,10,11,29 With poor working conditions and heavy workloads cited as risk factors that outweigh individual predictors.^7,10,11 Our participants described two main sources of burnout both of which were predominantly environmental in nature, an intimidating environment and a demanding occupation. Many studies have shown that the primary predictors of physicians’ well-being and drivers of burnout are workplace conditions, rather than individual characteristics.^6,15 International and Saudi studies have suggested that residents’ burnout is associated with excessive workload, stressful relationships with supervisors and colleagues, and a perception that personal needs are inconsequential.^6,9,15 All findings that are similar to our participants’ accounts.

In spite of the alarmingly high prevalence of resident burnout both internationally and in Saudi Arabia, and the many initiatives to promote medical trainee wellbeing, yet the prevalence has remained unchanged over the last two decades.^{5,7,10,13,15,29} This suggests that merely offering physiological support services may not be sufficient to assist burned-out residents in need.

Conclusions

This study has added another dimension to our understanding of resident burnout. We have highlighted the pivotal and direct role stigma and shame around being burned-out contribute to residents’ complete avoidance of formal support services, and their choice to self-cope and suffer in silence. Although our study was limited to a university training setting, we believe this area of medical training would benefit from further research especially focusing on prevention, early identification and strategies to overcome the barrier of stigma. In addition, our findings could persuade training centers and programs to support and fund trainee wellbeing curricula that center on early identification of struggling residents with proactive professional interventions.