The assessment of the burnout syndrome among medical students in Tabuk University, a cross-sectional analytic study

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1 Basic Research Journal of Medicine and Clinical Sciences ISSN Vol. 6(1) pp January 2017 Available online http// Copyright 2015 Basic Research Journal Full Length Research Paper The assessment of the burnout syndrome among medical students in Tabuk University, a cross-sectional analytic study Abdulrahman Eid Albalawi 1, Turki Salem Alhawiti 1, Ahmed Salem Aldahi 1, Yousef Mohammed Alshehri 1, Salem K. Aldahi 2, Hyder Osman Mirghani 3 1 Medical Intern, Ministry of Health, Kingdom of Saudi Arabia 2 Consultant Family and Community Medicine, Senior Clinical Lecturer (GP), Royal College of Surgeons in Dublin Ireland (RCSI) 3 Assistant Professor of Medicine, Medical Department, Faculty of Medicine, University of Tabuk, Saudi Arabia *Correspondence author s.hyder63@hotmail.com Accepted 30 January, 2017 ABSTRACT Objectives: This study assessed the burnout among medical students in Tabuk University. Methods: A cross-sectional study was conducted among the third and fourth class medical students in the Medical College, Tabuk University, Saudi Arabia from January 2016 to June One hundred and forty medical students were invited to sign a written informed consent and respond to a self-administered questionnaire based on the Arabic version of the Maslach Burnout Inventory. The ethical committee of the Medical College of the University approve the research and The Statistical Package for Social Science (SPSS) for the data analysis. Results: among the 140 medical students, the female are more (65.8%), 96.4% were unmarried, the daily hours of study was 4-6 hours in 55% of students and > 6hours in 45%, 60.4% were involved in the recreational activities. The burnout was concluded in 48.6% of medical students, No significant statistical differences was observed between the students with and without the burnout regarding sex, marital status, income, daily studying hours, recreational activities, difficulty in English languish, family cooperation, and examination load. Conclusion: The burnout was prevalent among Saudi Medical Students with no statistical difference between the students with the syndrome and those without regarding sex and various burnout risk factors. Keywords: Burnout, Medical students, Tabuk, Saudi Arabia INTRODUCTION The concept of burnout started as a grassroots description of prolonged occupational stress among human service workers, where formerly engaged employees gradually get overwhelmed by emotional exhaustion, loss of energy, and withdrawal from work. The practice of medicine is inherently stressful. Burnout syndrome refers to a kind of occupational stress that can have psychosomatic, behavioral, emotional, familial and social repercussions; it can also cause absenteeism and loss of efficiency at work (Shams T and El-Masry, 2013). Burnout in the life of health care workers is constructively use to describe the psychological state

2 Hyder et al. 15 Table 1. Categorizationof MBI scores MBI subscales Low Average High Emotional exhaustion (EE) Depersonalization (DP) Personal Accomplishment (PA) resulting from prolonged periods of high stress in their professional lives (Bani et al., 1996). It was originally conceptualized as syndrome arising from contact with people who are suffering from such periods of stress (Cynthia et al., 1993). It is a prolonged response to chronic emotional and interpersonal stressors on the job that includes the three dimensions of exhaustion, cynicism (depersonalization), and inefficacy (Maslach et al., 2001). Also, it has been found to be associated with staff intending to leave a stressful work environment (Cynthia et al., 1993). Exhaustion as a dimension of burnout represents the most visible manifestation of this complex syndrome. Symptoms of burnout include physical, emotional, and mental exhaustion (Maslach et al., 2001). Many studies underscore the role of the academic environment as a source of stress; however, published studies rarely emanate from medical schools in the Arab world. Furthermore, nothing is currently known about the aspects of different medical school curricula that contribute to or alleviate stress in this context, where considerable changes in medical education have taken place during the past two decades. Persons experiencing physical exhaustion report a lack of energy and feelings of being tired during the day accompanied by an inability to sleep at night (Shams and El-Masry, 2013). Emotional exhaustion is manifested by person s feelings of being depressed, helpless, and hopeless In mental exhaustion; individuals negative attitudes toward work and life. A mentally exhausted person is typically impatient towards others and demonstrates a cynical reaction towards emerging problems. The interest in burnout has dramatically increased in the last several years in medical students. Burnout has been cited as a cause of low morale, high absenteeism, turnover, and attrition from the profession. While the hard data to support all these effects is growing, the growing awareness is that the cost of burnout is high. High to the individuals, high to the recipient of care and high to the system that provides the care (John et al., 2000). To our best of knowledge this is the first study to assess the burnout among medical students in Tabuk, Saudi, Arabia, the Kingdom of Saudi Arabia is a vast country with different social and cultural diversity, the study conducted in the Western countries may not apply to the Kingdom. Thus we did this research to assess the burnout and to determine the factors that affect burnout among medical students in Tabuk University. Subjects and Methods A cross-sectional study conducted among 140 medical students in the third and fourth class medical students in the Medical College, Tabuk University, Saudi Arabia during the period from January 2016 to June Participants were invited to sign a written informed consent then responded to a self-administered questionnaire. Two classes were randomly chosen and the students were approached in a ratio of 2:1 (response rate 79%) to collect the following information: Gender, competency, duration of classes, Faculty of Medicine Curriculum, students own desire to join the college of medicine, the frequency of the exams in the college of medicine, previous background about the difficulty of the faculty of medicine and the BMI questionnaire. The BMI questionnaire had been previously validated and assess the three components of the burnout syndrome: emotional exhaustion, depersonalization, and reduced personal accomplishment. The burnout scoring By the MBI response, Burnout was defined as a high score on emotional exhaustion, depersonalization and a low score on personal accomplishment. At present, scores are considered high if they are in the upper third of the normative distribution, average if they are in the middle third and low if they are in the lower third. Table 1. Therefore, Burnout is defined as a high score on emotional exhaustion, depersonalization, and low personal accomplishment (Maslach et al.;2001). The ethical approval was obtained from the ethical committee of the Medical College, University of Tabuk. The (SPSS version 11 was used for data analysis, the data were presented as ranges, percentages or mean± sd, the chisquare was used to compare the categorical data with a P-value<0.05 was considered significant. RESULTS They are 140 medical students, 65.8% were females, only 3.6% were married, the daily studying hours were 4-6 hours in 55% of students and > 6hours in 45%, 60.4% were involved in recreational activities. Table (2).

3 16. Basic Res. J. Med. Clin. Sci. Table 2. Demographic characteristics of the study sample Variables Number (n=111) Percent Gender Female % Male % Marital Status Married 4 3.6% Single % Salary Group (Student's Family) < % % % % > % Daily Studying Hours < 4 hours 0 0.0% 4-6 hours % > 6 hours % Recreational Activity No % Yes % Frequency of Recreational Activity 1-2 times a week % 3-5 times a week % 1-3 times a month % 1-4 times a year % Table 3. Distribution of Factors affecting Burnout among the participants Factors Number (n=111) Percent Outside the Kingdom experience No % Yes 8 7.2% Decision in taking College of Medicine Own Decision % Family Decision 4 3.6% Difficulty in the English Language No % Yes 9 8.1% Non-cooperation from the Faculty Members No 2 1.8% Yes % Burden/loads of examinations No 5 4.5% Yes % Idea about difficulty in Medical College No % Yes % Table 4. Distribution of the study sample according to the Burnout Sub-scale Burnout Sub-Scale Low Average High x-score Emotional Exhaustion % % % Depersonalization 4 3.6% 20 18% % Personal Accomplishment 3 2.7% 6 5.4% % 24.73

4 Hyder et al. 17 Table 5. Distribution of the study sample according to Burnout and some characteristics Characteristics Burnout Total C-square P-value Yes No (n=111) No. % No. % Gender Female Male Marital Status Married Single Salary Group (Student's Family) < > Daily Study Hours 4-6 hours > 6 hours Recreational Activity No Yes Frequency of Recreational Activity 1-2 times a week times a week times a month time a year Outside the Kingdom experience No Yes Decision in taking College of Medicine Own Decision Family Decision Difficulty in the English Language No Yes Non-cooperation from the Faculty Members No Yes Burden/loads of examinations No Yes Idea about difficulty in Medical College No Yes Regarding the factors that affect the burnout, 7.2% had an experience outside Saudi Arabia, 96.4% decided to take the Faculty of Medicine by themselves, only 8.4% had difficulties in the English language (the language of their curriculum), only 1.8% had a non-cooperative family, 4.5% believed that the examinations are heavy burden on them, while 23.4% had an Idea about difficulty in Medical College. Table (3). In the present study, 9.9% of the students had mild emotional exhaustion, 23.4% had moderate, and 66.7% had great exhaustion (x-score=30.56). Table (4) depict the other burnout subscales. In this study no significant statistical difference was seen between women and men regarding the burnout (45.2% vs. 55.3% P-value-0.314), 25% of the married students had burnout vs. 49.5% of unmarried (Pvalue=0.335), while 46.3% of those who were involved in a recreational activities had the burnout vs. 52.3% with no significant statistical difference. Table (5) illustrated the comparison between those with the burnout syndrome and the others without regarding the various parameters. Figure (1): showed that 48.6% of students were affected by the burnout syndrome.

5 18. Basic Res. J. Med. Clin. Sci. Figure 1. Prevalence of burnout DISCUSSION In this study, burnout was reported in 48.6% (half of the sample). A study conducted in the USA (Dyrbye et al., 2008). among seven medical schools that adopted similar curricula and methods of teaching concluded similar results. Our study was in accordance with (Santen et al., 2010) who conducted research in Emory school of Medicine and reported a prevalence of 48.6% among the 3rd and 4th classes. The current finding was higher than the studies carried out in Colombia (Pérez et al., 2007) and Brazil (de Abreu Santos et al., 2011) and observed the burnout syndrome in 9.1% and 14% respectively. The higher rate of burnout in the present research compared to studies with strict criteria for the diagnosis Guthrie et al. (1998); Willcock et al. (2004) pointed to the dangerous situation in our Medical College, an important preventive effort is highly needed. Although the Medical students consider themselves efficacious, they are more cynical and exhausted (Costa et al., 2012), the present data showed that the majority of medical students (78.4%) had depersonalization, more than two-thirds had emotional exhaustion, while 8.1% had low or average accomplishment. The present findings were similar to a previous study conducted among Brazilian medical students (Costa et al., 2012) and lowered to similar researches conducted among students of other health institution (Carlotto et al., 2006). The Medical schools have stressors other than the University education. The dimensions of the burnout syndrome could precipitate each other, the students with poor adaptation to difficulties develop emotional exhaustion and may become indifferent and impersonalized culminating in the sense of failure and dissatisfaction (Costa et al., 2012). The previous literature documented that Lower support, higher stress, and lack of control over one's life were significantly related to burnout using multivariate analysis. Burnout progressively develops over the course of medical education, while a high level of support and low stress decreased burnout (Santen et al., 2008). Other studies report the association of lack of leisure time and dissatisfaction with the course which lead to emotional exhaustion (Carlottoa and Camara, 2008; Martinez et al., 2005) In this study, no statistically significant differences were found between the students who fulfilled the criteria for the burnout and the others regarding the family support, the decision in taking the Medical College, lack of leisure time, and the burden of studying and examination that is more likely to be associated with stress. The small sample of the current study and the differences in the social background could explain the contradiction in the findings. The association between the burnout syndrome and sex is controversial, some studies reported a higher prevalence among females (Martinez et al., 2005), while other observed the reverse (Costa et al., 2012). In the present study, no significant difference was found between gender regarding the burnout syndrome. CONCLUSION The burnout syndrome is prevalent among the medical students in the Medical College, the University of Tabuk in particular for the emotion exhaustion and depersonalization. The level could have been significantly higher due to the strict diagnostic criteria and the fact that all the students were not approached, some students with significant symptoms may drop out. Larger longitudinal studies are highly needed to assess the factors associated with the emotional exhaustion and depersonalization to prevent the occurrence of low professional efficacy. The study limitations are the small size of the survey sample and the fact that the survey was conducted at a single college so generalization cannot be insured.

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