2.

1 Burnout

Frendenberger was the first person who identified 'burnout'. He described it as a feeling of failure
and being worn out. Edelwich and Brodsky defined burnout as a progressive loss of idealism,
energy and purpose. Pines and Aronson defined it as a state of physical emotional and mental
exhaustion. Sarros and Densten described burnout as a maladaptive coping mechanism to
working conditions that are stressful, demanding or lacking sufficient challenge and recognition.
The most commonly accepted definition came from Maslach who described burnout as a
multidimensional condition comprising (i) emotional exhaustion, (ii) depersonalization and (iii)
reduce personnel accomplishment that can occur among individuals who do people work of
some kind. Maslach further described burnout as a psychological process that begins when
human service professionals are overwhelmed with the unexpected and unbearable stressful
aspects of the job that frustrate their efforts to make a positive impact on person.
According to Maslach, continued frustrating events may lead these professionals to feel
emotionally exhausted and lacking the energy to face another day. To cope, they may detach
themselves psychologically and emotionally, depersonalizing those they serve as a means of
distancing themselves from further stress laden situations. Over time these professionals may
begin to develop an attitude of cold indifference to the needs of others, which may ultimately
lead to a sense of reduced personal accomplishment, defined as feelings of incompetence and a
sense of being unsuccessful in work relation achievements.
Although burnout was described as a very vague concept, now it is widely accepted as a
psychological syndrome in response to chronic interpersonal stressors of the job. Now burnout is
categorized under the problems related to life-management difficulty, with the code z73.0 in the
ICD-10 classification. Further research has confirmed Maslachs theory that burnout is more
prevalent among human service professionals such as nurses, teachers, social workers and mental
health workers.
Pines and Aronson described the reason for high prevalence of burnout among human service
professionals. According to them, most individuals entering human service professionals are
motivated to do so by a desire to work with people and to make significant contributions to the
lives of those they serve. These human service professionals have high expectations that they
will succeed in their efforts to help other. If they failed in achieving this expectation, that sets the
stage to potential burnout.

Causes of burnout
Causes of burnout can be categorized mainly into three groups: personal characteristics, job
characteristics and organizational characteristics. On the currently available evidence,
organizational characteristics have more profound effect on burnout, compared to personal and
job characteristics. Demographic factors, lack of social support and high expectations of the job
have been described as personal characteristics. Job characteristics include role conflict, role
overload, role ambiguity and poor interpersonal relations. Job context, contingency and non-
contingency of outcomes were observed as organizational characteristics. According to Albee,
burnout is associated with over work, under appreciation, confusion about expectations and
priorities, anxiety over job security and over commitment for responsibilities.

Sign and symports of burnout

Derobbio and Iwanick have listed anxiety, boredom, anger, cynicism, betrayal, depression,
fatigue, frustration, resentment towards others, substance abuse, psychosomatic symptoms,
mental and family crisis and reduction in commitment as the features of burnout.

Measurement of burnout
There are two main study instruments for the measurement of burnout.
1. Maslach Burnout Inventory (MBI)
2. Burnout Measure (BM)
According to the Shaufeli, Maslach Burnout Inventory (MBI) is by far the most popular
instrument to diagnose burnout throughout the world. More than 90% of scientific publications
and dissertations on burnout are based on the MBI. It has 22 items and can be used as a self-
administered questionnaire. The next most widely used instrument is Burnout Measure by Pines
and Aronson . This is used in about 5% of burnout studies. The BM is an internally consistent
questionnaire, which assesses the individual's level of physical, emotional and mental
exhaustion.
Maslach Burnout Inventory (MBI)
MBI was developed in 1980 to identify burnout among human service professionals. During the
last 25 years it has been translated into several languages and used worldwide to measure
burnout in different occupational settings. Later, minor modifications were made to the original
MBI. Following these initial modifications, two new inventories were developed namely MBI
Educators Survey (MBI-ES) to assess the educators' burnout and MBI- General Survey (MBI-
GS) to assess the burnout among the workers in occupations other than human services. The
original MBI was renamed as MBI-Human Services Survey (MBI-HSS).
All three MBI surveys address the three general scales;
(i) Emotional exhaustion - Feelings of being emotionally overextended and exhausted by one's
work.
(ii) Depersonalization - An unfeeling and impersonal response towards recipients of one's
service.
(iii) Personal accomplishment - Feeling of competence and successful achievement in one's
work.
A number of studies done in different settings worldwide confirmed the validity and reliability of
the MBI-ES. Iwanicki and Schwab studied 469 Massachusetts teachers and reported a
Cronbach's alpha estimates of 0.90 for emotional exhaustion, 0.76 for depersonalization and 0.76
for personal accomplishment. Gold in his study of burnout among 462 California teachers
reported Cronbach's alpha estimates of 0.88 for emotional exhaustion, 0.74 for depersonalization
and 0.72 for personal accomplishment. One study assessed the construction validity of the MBI-
ES using a sample of 750 Australian post primary (high school) teachers. This study confirmed
that three factor structure and showed the inventory to be a reliable one. Schaufeli et al studied
the clinical validity of the MBI. They compared the findings of MBI with the diagnosis of
burnout.by the result of this study they were able to partly differentiate other mental disorders
such as anxiety and depression from burnout.

Prevalence of burnout
Most of the studies on burnout had been carried out in the developed countries and very few
studies had been conducted outside US and Europe. A study conducted in Taiwan found that
26% of primary teachers had burnout. Recently concluded study among the primary school
teachers in the southern province of Sri Lanka. Prevalence of burnout was found to be 59,2%
among the Japanese public health nurses working in mental health services while the public
health nurses working in other units had a slightly lesser prevalence (51,5%)

Consequences of burnout
Absenteeism and attrition are the major negative outcomes of burnout. In addition, there ia a
strong association between burnout and low or diminished job satisfaction. Burnout was also
found to be strongly associated with many other variables that are connected to job satisfaction
such as low level of life satisfaction, low levels of control and low levels of health. All these
factors collectively contribute to reduce the productivity of and employee.

Conclusion
Burnout is a grossly understudied phenomenon in developing countries including Sri Lanka. Its
causes and consequences are complex and interrelated. It adversely affects the employees and the
productivity of an organization. Therefore, both employers and employees should be aware of
burnout. Measures should be introduced to minimise burnout among employees.

2.2 Burnout pada mahasiswa kedokteran

BURNOUT SYNDROME AND ASSOCIATED FACTORS AMONG MEDICAL

STUDENTS: A CROSS-SECTIONAL STUDY
Medical students are continuously exposed to psychosocial stressors throughout training that, if
persistent, can lead to Burnout Syndrome (1). Burnout is a syndrome of emotional exhaustion,
cynicism, and low professional efficacy that occurs frequently among individuals who do
people work of some kind (2). Burnout is defined as a response, which may be inappropriate, to
chronic emotional and interpersonal stressors in the workplace. The term may be applied to
individuals who engage in activities that are psychologically similar to work, such as students
(3,4).
Burnout Syndrome among students has the following three dimensions: 1) emotional exhaustion
(due to educational demands), 2) cynicism (indifference/apathetic attitude toward academic
activities), and 3) low professional efficacy (perception of incompetence as a student) (5).
Researchers have described stressful moments in the academic life of medical students, and
medical training is considered to have high psychological toxicity (6,7). Factors that contribute
to significant stress among students in medical schools that follow a traditional model include
adaptation difficulties at the beginning of coursework due to competitive entrance exams,
leaving high school for the realities of greater autonomy and responsibility, and the frustration
caused by a Basic Sciences Cycle that does not match the expectations of freshmen who want
immediate contact with specific medical disciplines. The transition from the Introductory
Clinical Cycle to the Clerkship Cycle presents another occasion for intense anxiety, uncertainty,
expectations and fears caused by: their feeling of limitations regarding the scientific knowledge
their changes from one stage to another, and the direct contact with seriously ill people who have
hopeless prognoses. The excessive workload and educational content, combined with the high
level of educational demands, a lack of time for leisure, family and friends, studying for
residency exams, the choice of a specialty and the delayed income also contribute to stress
among medical students (1,6,8). In addition to these aspects, personality traits inherent to
medical students include obsessiveness, perfectionism and self-exigency (7,9). These factors are
potentially responsible for the high prevalence of suicide, depression, use of psychoactive
substances, marital problems, stress, burnout, and professional dysfunction in doctors and
medical students (10,11). Previous studies on Burnout Syndrome in medical students have
reported a prevalence from 10% to over 45% (10,12-15). This large variability reflects the use of
various criteria by researchers for the diagnosis of the syndrome, such as bi-dimensionality and
the use of nonspecific instruments with students (12). Thus, additional research using diagnostic
criteria and standardized instruments with scientific rigor is necessary for this population. Mental
disorders among medical students have been reported more frequently in recent years, although
few studies have described Burnout Syndrome (6,8,15-17).

Burnout Syndrome has been well researched among physicians and residents and is believed to
be influenced by adverse conditions in medical school training (5,6,12,13,18). In our institution,
psychiatric morbidity has been studied among medical students, but Burnout Syndrome has not
(19). Burnout Syndrome affects work performance, self-esteem, and psychological health, and it
may progress to other mental disorders. Thus, research that enables early detection of Burnout
Syndrome is needed to encourage the adoption of preventive measures to be shared with the
scientific community.

THE PREVALENCE OF BURNOUT SYNDROME IN MEDICAL STUDENTS

The mental health of medical students has long been a cause for concern. An inordinate number
of tasks overload stressful schedules, and demanding responsibilities to learn about and care for
human beings drain dedication and become potential triggers or concurrent causes of emotional
disturbances. A rupture in doctors and students equilibrium may lead to significant
psychological changes that are reflected in drug use, depression, suicide and professional
dysfunction1. Stressors create psychological toxicity that affects medical students training and
activities; such conditions are also present in the courses for other health professions2-4. Thus,
the excessive study workload; the demanding educational requirements; the lack of time for
leisure, family and friends; and individual personality traits such as perfectionism and self-
imposed standards become potential triggers of stress and dysfunctional behaviors1,5-8. In
addition, at certain points during students medical education, critical stress triggers may emerge,
such as contact with patients and serious illnesses and death or the students graduation, which is
accompanied by uncertainty about the future2,9. Several methodologies have been proposed to
evaluate the stress levels that medical students are subjected to, including the Lipp Stress
Symptoms Inventory for Adults10 and the World Health Organizations Quality of Life
Questionnaire. In recent decades, additional methods for investigating levels of suffering and
sensations such as mental and physical exhaustion, frustration and failure in the employment
context have been developed, including Maslach and Leiters tool for assessing burnout
syndrome (BS)11. Burnout is an English term used to describe the cessation of something due to
a complete lack of energy. In common parlance, it can also mean being consumed by excessive
drug use. Figuratively, it is someone or something that has reached its limits due to lack of
energy. Currently, the expression refers to suffering in the workplace context caused by exposure
to excessive wear12. The term first appeared in the 1953 Miss Jones case study by Schwartz
and Will, which described the work-related illness of a psychiatric nurse. Later, in the 1970s, BS
was characterized for the first time. Its symptoms included frequently unspecified clinical
manifestations such as fatigue, somnolence, eating disorders, headache and emotional
instability13. BS is now a significant psychosocial problem with repercussions for diverse
professional groups, especially those with direct contact with the public. Studies have shown a
high incidence of BS in health professionals14-16. BS also occurs in individuals whose activities
are psychologically similar to work, such as students17. The syndrome results from the
interaction between chronic stress at work and individual factors, and its symptoms and signs are
grouped into three multidimensional factors: emotional exhaustion (EE), depersonalization (DE)
or skepticism and reduced professional satisfaction (PS). BS differs from depression because it is
workplace-specific, whereas depression extends to other nonprofessional contexts16. In 1981,
Maslach and Jackson created the Maslach Burnout Inventory (MBI), which is currently the most
commonly used scale in the world for assessing the syndrome18. There have been three revisions
of the MBI, the first in 1981, the second in 1986 and the most recent in 1996 by psychologist
Michael Leiter. The MBI has three versions: the MBI-Human Service Survey (MBI-HSS),
designed for professionals working in people-centered services, such as doctors, nurses,
psychologists and students of health professions; the MBIEducator Survey (MBI-ED) for
educators (teachers, coordinators, school principals, etc.); and the MBI-General Survey (MBI-
GS) for categories not clearly oriented to a specific population. The versions differ in the
terminology used to designate the professional responsible for the work being evaluated8. The
MBI evaluates the prevalence of Burnout based on the sum of the scores for each dimension.
High scores for EE and DE and low scores for PS lead to a high Burnout index, whereas high PS
scores and low EE and DE scores are an indication of its absence. The PS dimension has an
inverse score the higher the score, the better the individuals perception of their professional
satisfaction and efficacy11. Several Brazilian studies have translated, adapted and validated the
MBI. In 2001, Benevides-Pereira, a member of the Nucleus of Advanced Studies of Burnout in
Brazil (NEPASB), worked with a variety of professionals, including doctors, nurses and nursing
assistants, to translate and adapt the MBI-HSS to the Brazilian context8,19. The reference values
found by the NEPASB, which are considered the standards in the literature for the Brazilian
population, were used to diagnose and classify the severity of the symptoms of the students
participating in this study (Figure 1). The NEPASBs results for the MBI-HSS are presented
below. EE is the subjective sensation of fatigue or stupor related to coping with work. EE results
in low tolerance, a feeling of frustration and irritability. DE is a persons attempt to promote an
affective distancing and indifference to work and others through the defensive use of ironic, cold
and cynical attitudes16. Reduction in PS is a sense of dissatisfaction with common activities.
Professionals with low PS feel like failures at work. They believe that they have not reached
their objectives and that what they do has little or no value. This can lead to low self-esteem, a
lack of motivation and decreased performance. In the most serious cases, a professional may
abandon his or her career13. Research has observed that students mental health deteriorates as
courses progress, with increased burnout among those entering the more advanced stages of their
education20,21. Potential consequences include poor work performance, alcohol and drug
dependence/abuse, an increased risk of cardiovascular diseases, sleep disorders, neglect of
personal health and risky behavior13,22,23. There is not enough research on therapeutic
interventions to determine whether they can offer a satisfactory resolution to the problem.
Approaches aimed at cognitive restructuring to achieve behavioral changes are advocated24.
Maslach suggests that individual-level changes are the first step in reversing burnout. In addition,
if institutions acknowledge the potential for work-related burnout, the probability of individuals
blaming themselves for stressors that occur in the professional sphere would be reduced25. The
present study considered the growing importance of the problem and the possibility of
contributing to the early detection of BS. Moreover, it is designed to stimulate the monitoring of
the changes that occur during academic training and the offering of help and support to students
showing signs of change. The main objective was to determine the prevalence of burnout
syndrome in medical students in their first through eighth semesters at a university in the State of
Cear, Brazil and to correlate the findings with several socio-economic and work-related
variables.

GENDER DIFFERENCES IN ACADEMIC STRESS AND BURNOUT AMONG

MEDICAL STUDENTS IN FINAL YEARS OF EDUCATION
Medical undergraduate education is a long process where students face multiple stressors such as
common academic overload, lack of leisure time, emotional pressure to maintain good grades,
and specific conditions of learning complex medical procedures while working concurrently with
patients (Masten et al.2009, Toevski et al. 2010). Resulting distress has adverse effects on
professional development, and can produce decline in empathy and humanitarian attitudes
among medical students (Stewart et al. 1999, Hojat et al. 2004). Results obtained from the study
conducted in Slovenia failed to show significant differences in strategies of coping with stress
between medical and other students (Masten et al. 2009). Several studies have revealed that
student`s mental health has special issues, and can even deteriorate during the study of medicine
(Gutrie et al. 1998, Tyssen et al. 2001, Roberts et al. 2001, Dahlin & Runeson 2007). By using
the questionnaire GHQ-12, the signs of distress were found in 2236% of students, and
documented psychiatric morbidity in 16% in the longitudinal sample of medical students. (Gutrie
et al, 1998). The mental health status of medical students from Belgrade, explored one month
after enrollment and checked two years later, showed prevalence rates of all mental disorders of
16.1% and 17.5%, respectively. (Eri et al. 1988). In the recent surveys conducted at the Schools
of Medicine (155 students) and Pharmacy (101 students), University of Belgrade, the symptoms
of anxiety and depression were more frequent in the medical student sample, and female medical
students manifested marked personal sensitivity (Obradovi et al. 2009).

Studies show that female students and residents had higher level of anxiety and depression
compared to their male counterparts (Lloyd & Gartrell 1981). Higher anxiety in female students
could be explained by specific psychosocial profiles and warrant further investigation (Hojat et
al. 1999) Burnout syndrome denotes particular work-related adverse reactions strongly
associated with decreased physicians professional performance and low career satisfaction. The
incidence of burnout syndrome among practitioners in Serbia and worldwide ranged from 25%
to 76% depending on medical specialty, and was more common in the population of young
doctors (uri & uri 2009, Lei et al. 2009, Vienti et al. 2010, Shanfelt et al. 2002).
Nowadays, burnout is considered as a measure of distress in the educational process, and
recently has been discovered in up to 50% of medical students, with the incidence increasing
during the length of their studies (Dyrbye et al. 2009).