Burnout Among Mexican Doctors: Perspective of Data from a Population Cohort

Our line of research is based on the problem of burnout syndrome in a hospital in Southeastern Mexico, analysing the impact of competence assessment and mistreatment in the workplace.         

Introduction

Burnout syndrome, first described by Maslach in 1982, is characterised by emotional exhaustion, depersonalisation, and diminished personal achievement. Burnout syndrome was first described in 1974, addressing three fundamental spectra: emotional exhaustion, depersonalisation, and diminished personal achievement. Burnout syndrome is associated with two processes, the first being extreme work demands and distancing behaviours (Maslach et al. 1982).

The hospital environment is particularly vulnerable to the development of burnout syndrome due to high work demands, constant contact with human suffering and, in some cases, the presence of hostile work environments (Bodenheimer et al. 2014). In a hospital centre in Southeastern Mexico, the relationship between competency assessment practices, work mistreatment and the development of burnout in healthcare workers was evaluated. This article seeks to delve into the causes, manifestations and possible intervention strategies related to this phenomenon (Willcock et al. 2004).

Competence Assessment: Promotion or Pressure?

Competency assessments are tools used to measure job performance, but in some cases, they can become a source of stress. The main purpose of competence assessments is to identify areas for improvement and to promote professional development. However, when they focus exclusively on quantitative results, they can be perceived as a source of pressure (Dyrbye et al. 2016).

Data from a line of survey research revealed that 60% of employees perceive appraisals as unfair or disproportionate, contributing to feelings of frustration and demotivation. The imposition of unrealistic goals and lack of adequate feedback leads to high levels of anxiety and, eventually, burnout in employees (Dyrbye et al. 2014).

Workplace Abuse: A Determining Factor

Workplace abuse, defined as physical, verbal or emotional abuse in the work environment, is a significant factor in the development of burnout. There is a need for strategies as teachers of trainee doctors to identify forms of abuse and mitigation strategies (Lachiner et al. 2015).

In the hospital, abuse manifests itself mainly through shouting, public disqualifications and excessive workloads assigned in a punitive manner. Abuse creates a toxic work environment, characterised by mistrust, fear and low collaboration among colleagues. This affects not only the well-being of employees but also the quality of care provided to patients. The implementation of clear codes of conduct and mechanisms for reporting incidents of abuse are essential steps to address this problem (Maslach et al. 1996).

Clinical trials worldwide describe the likelihood of a high degree of emotional exhaustion ranging from 35-45%. A depersonalisation rate of 26-38% and 45-56% with symptoms suggestive of burnout (Low et al. 2019).

Main Features

1. Emotional exhaustion
2. Depersonalisation
3. Decrease in personal performance 

MBI (Maslach Burnout Inventory), for its diagnosis with 22 items, is considered the gold standard that addresses three aspects of the syndrome (Maslach et al. 1981):

1. The exhaustion domain with 9 items.
2. Depersonalisation domain with 5 items.
3. Self-realisation with 8 items.

In this context, a score of 27 for emotional exhaustion, 10 points for depersonalisation and 33 or less for self-fulfilment are considered indicative of burnout. Multivariate analysis in cross-sectional studies has reported an independent relationship between burnout for each additional hour per week at 3% and 3 to 9% for each additional evening or weekend per week, with a more than two-fold increase when work-home conflicts are present (Maslach et al. 1996).

Manifestations of Burnout in Hospital Staff

Burnout in health professionals has serious consequences at both the individual and organisational levels. Hospital workers reported physical exhaustion, depersonalisation and a decreased sense of personal achievement. These symptoms are characteristic of burnout and affect their daily performance (Shanafelt et al. 2009).

Burnout decreases the quality of care, increasing the risk of medical errors and reducing patient satisfaction. It also increases staff turnover rates, which generates additional costs for the institution. Factors such as work overload, lack of resources and long working hours also contribute significantly to the development of this syndrome (Ungur et al. 2024).

Data from Hospital Centre in South-Eastern Mexico

In the Mexican population, from a social point of view, during medical training, expressions such as 'you never stop studying' and 'you have to prepare yourself a lot' are common from the family nucleus. Everyone expresses the satisfaction of having a doctor, but the question is what happens in the life of an adolescent who reaches adulthood with condoned responsibilities by expressing his or her desire to be a 'doctor' from a very young age (Lopez et al. in prep).

A population-based cohort study was conducted to obtain the population characteristics of the variables of interest, where 58% were male and 40.7% female; a survey was conducted among residents of medical specialties, where the highest percentage was in the area of internal medicine, with 18.6%, followed by general surgery and traumatology and orthopaedics with 14.5%, and the lowest percentage by the ophthalmology service with 4.1%. The collection instrument used obtained scores in relation to the characteristics of burnout syndrome; for burnout, a total of 68 residents out of 172 respondents, representing 39.5% of the hospital's resident population; personal accomplishment, a total of 60 residents out of 172 respondents, representing 34.9%; depersonalisation 46 residents out of 172 respondents, representing 26.7%. The characteristics of burnout syndrome in different degrees of severity were explored, and the following data were obtained: degree I 48 residents (27.2%), degree II 55 residents (32%), degree III 69 residents (40.1%) (Lopez et al. in prep).

Discussion

The study conducted in this hospital in Southeastern Mexico reveals a close relationship between competency assessment practices, job mistreatment and burnout. Although appraisals serve a valuable purpose, their inadequate implementation can have adverse effects on employees' mental health. Moreover, workplace mistreatment intensifies these effects, perpetuating a cycle of stress and emotional burnout. It is crucial that healthcare institutions adopt a holistic approach that considers both individual well-being and the creation of a healthy work environment (Shanafelt et al. 2016).

Low et al. (2019), in a systematic review and meta-analysis with a total of 22,778 physicians in training, demonstrated a high prevalence of burnout syndrome in medical and surgical residents, with a prevalence of 51% (95% CI, 45-57%, I2 =97%) in 22778 residents, as measured by the Maslach tool. Among the specialties with the highest prevalence, radiology (l77.16%, 95% CI: 5.99-99.45), neurology (71.93%, 95% CI: 33.09-15.58), and general surgery (58.39%, 95% CI: 32.69-44.37) were the most affected specialties, while psychiatry, oncology and family medicine were the least affected.

Vargas et al. (2023) conducted a systematic review, according to the PRISMA criteria, identifying how work overload, assigned work shift, and the hospital area are relevant factors for the development of burnout syndrome, including 1506 patients with nursing occupations, and correlating burnout syndrome with low work commitment, showing a correlation of 0.46 (95% CI 0.58-0.31).

Ishaket al. (2013) document in a systematic review with meta-analysis with trials described from 1974 to 2011 where burnout syndrome was found to be related to a negative major experience OR 2.594, students rotating on hospital wards and those on night duty were also found to have an increased risk of burnout OR 1.69 and OR 1.48 respectively, no significant frequency was observed with number of duty shifts, number of patients or hospital admissions. A strong relationship was observed between the severity of burnout syndrome and suicidal ideation OR 3.46.

It is important to promote support networks, seek professional support to create and develop a personal strategy to find or maintain meaning in work and training, engage in recreational activities, hobbies, sports and exercise to avoid a delayed gratification mentality (survival mindset), ensure adequate sleep, and maintain personal health and positive reframing (Van der Heijden et al. 2008).

Strategies of Approach

1. Personal adaptation process
2. Balance in vital areas: family, friends, hobbies, rest, work
3. A good working atmosphere with team vision
4. Limiting work schedule
5. Continuous training within the working day

Medical training programmes today need to introduce the concept and curriculum of self-care, well-being and resilience, as well as mindfulness, work-life balance, dealing with suffering and medical errors, debt management, and positive reframing strategies are useful in primary prevention. It goes without saying that there is a need for a curriculum that includes as a priority the strategies of study, understanding and accompaniment of colleagues in difficulty in order to be empathetic and to project the physician as a health professional, avoiding the accusatory attitude of 'that's your problem' as well as bullying and discrimination as social stigmas that would limit training opportunities (West et al. 2006).

Conclusion

Competence assessment and job abuse are key factors in the development of burnout in hospital settings. Combating this problem requires a coordinated effort that includes improvements in assessment practices, the eradication of mistreatment and the establishment of support programmes for staff. This is the only way to ensure a healthier work environment and higher-quality care for patients.

Conflict of Interest

None.

Acknowledgements

We thank all of the resident physicians who participated in the survey for this project, as well as Dr Abad I. Gómez Medrano, resident of the specialty in emergency medicine at Hospital General de Zona No. 13, ‘Norberto Treviño Zapata’ of IMSS Matamoros for his contribution.