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Psychology, Health & Medicine
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Burnout in medical residents: A questionnaire and interview study
Rik Ringrose a; Saskia Houterman a; Willem Koops a; Guid Oei ab
a MMC Academy, Máxima Medical Centre, Veldhoven, the Netherlands b Department of Obstetrics and
Gynaecology, Máxima Medical Centre, Veldhoven, the Netherlands
Online Publication Date: 01 August 2009
To cite this Article Ringrose, Rik, Houterman, Saskia, Koops, Willem and Oei, Guid(2009)'Burnout in medical residents: A
questionnaire and interview study',Psychology, Health & Medicine,14:4,476 — 486
To link to this Article: DOI: 10.1080/13548500903012822
URL: http://dx.doi.org/10.1080/13548500903012822
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Burnout in medical residents: A questionnaire and interview study
Rik Ringrose
a
, Saskia Houterman
a
*, Willem Koops
a
and Guid Oei
a,b
a
MMC Academy, Ma
´xima Medical Centre, Veldhoven, the Netherlands;
b
Department of
Obstetrics and Gynaecology, Ma
´xima Medical Centre, Veldhoven, the Netherlands
(Received 16 September 2008; final version received 1 May 2009)
High burnout levels have been observed in medical residents. The purpose of this
study is to assess the burnout rates and potential determinants of burnout in a
sample of medical residents. In total, 58 medical residents working in a Dutch
teaching hospital, received questionnaires at home, including the Maslach
Burnout Inventory (MBI). In addition, they were asked for an in-depth interview
to investigate the relevant indicators for developing burnout. In total, 47 residents
responded (81%) from which 15 (31%) met the MBI criteria for burnout. Work-
family conflict, work-related autonomy and level of work-engagement were
significantly associated with burnout. Ten respondents were interviewed; none of
those reported any serious burnout symptoms but two met the criteria for
burnout. In this study, burnout rates from questionnaires and interviews in
medical residents are not consistent. Regular burnout screenings and performing
interviews are recommended in addition to burnout questionnaires, in order to
efficiently identify residents at risk for burnout. This allows improved monitoring
of a resident’s mental state thus facilitating prevention of escalating burnout
symptoms. Future research could focus on preventive factors for developing
burnout.
Keywords: burnout; questionnaire; interview; medical residents
Introduction
Burnout is a syndrome characterised by emotional exhaustion, depersonalisation
and a decreased sense of personal accomplishment that occurs frequently among
individuals who do ‘people-work’ of some kind (Maslach & Jackson, 1981). Several
negative physical health consequences have been observed, including a variety of
stress-related symptoms and increased substance use. In addition, several mental
health outcomes are associated with burnout as well, such as increased risk of
feelings of anxiety, depression and lowered self-esteem (Maslach, Schaufeli, & Leiter,
2001).
Research on burnout in medical residents is scarce (Thomas, 2004). A recent
review on burnout in medical residents showed that only 19 studies have been
published with prevalence rates ranging from 18 to 82% (Prins et al., 2007). The
quality of these studies is disputable, as only five studies met more than two of the
Cochrane quality criteria. In the Netherlands, a burnout prevalence rate of 21% was
found in a national sample of 2115 Dutch medical residents (van der Heijden,
*Corresponding author. Email: s.houterman@mmc.nl
Psychology, Health & Medicine
Vol. 14, No. 4, August 2009, 476–486
ISSN 1354-8506 print/ISSN 1465-3966 online
Ó2009 Taylor & Francis
DOI: 10.1080/13548500903012822
http://www.informaworld.com
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Dilling, Sprangers, & Prins, 2006). For these medical residents, the combination of
several occupational aspects, such as combining work and study, resulting in high
workload, concurrent emotional exhaustion (van der Heijden et al., 2006) and work-
family conflicts (Visser, Smets, Oort, & de Haes, 2003). The latter also appears to be
an important determinant for developing burnout (Linzer et al., 2001). A Dutch
study among 166 medical residents showed that important factors that impose an
increased pressure on work-home interference include a high quantitative workload,
a spouse who works overtime frequently, a troublesome relationship with the
supervisor and an unfavourable work schedule (Geurts, Rutte, & Peeters, 1999). A
study on self-reported patient care and burnout found burnout to be associated with
suboptimal care (Shanafelt, Bradley, Wipf, & Back, 2002). Other studies found high
levels of emotional exhaustion, as well as high depersonalisation and low personal
accomplishment to be associated with higher numbers of medical errors (Landrigan
et al., 2004; West et al., 2006). In a sample of 123 American residents in paediatrics,
74% met the criteria for burnout and 20% met the criteria for depression
(Fahrenkopf et al., 2008). In this study, burnout did not correlate with an increased
rate of medical errors, but depressed residents made more than six times as many
medication errors per resident per month as residents who were not depressed.
A potential protecting factor for developing burnout concerns work engagement
(Schaufeli & Bakker, 2003). Work engagement is defined as: ‘‘a positive, fulfilling,
work-related state of mind that is characterised by vigour, dedication and
absorption’’ (Schaufeli, Salanova, Gonzalez-Roma
´, & Bakker 2002). According to
Langelaan (2007), the concepts of burnout and work engagement can be seen as
complementary concepts in a two-dimensional model of activation and identifica-
tion. Dutch medical residents with a high level of burnout also showed a high level of
work engagement (van der Heijden et al., 2006).
The current study has two goals. First, it investigates the prevalence of burnout
in a sample of Dutch residents using validated questionnaires. Second, this study
investigates potential determinants of burnout as well as the subjective impact of
high workload and burnout on the residents. The hypothesis is that a high burnout
score on the Maslach Burnout Inventory (MBI) is associated with a high subjective
unwell being and/or feelings of being unable to perform the job well.
Method
Participants
The sample of the current study consists of all residents (N¼58; year of training 1–
6) that were working in the Ma
´xima Medical Centre (MMC), locations Eindhoven
and Veldhoven, the Netherlands on 1 February 2007.
In total, 47 residents returned the questionnaire (81% response rate). Of these
respondents, 45% (N¼21) was willing to undergo an in-depth interview. From this
group, 10 randomly selected residents were interviewed, including two residents who
met the criteria of burnout, two residents high on emotional exhaustion, one resident
high on depersonalisation and five residents for a control group.
Measurements
To measure the level of burnout, the 15-item validated general Dutch version of the
Maslach Burnout Inventory (MBI) was used (Utrechtse BurnOut Schaal, UBOS-A)
Psychology, Health & Medicine 477
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(Schaufeli & van Dierendonck, 2000). This questionnaire distinguishes three subscales:
emotional exhaustion, depersonalisation and personal accomplishment. Criteria used
for burnout were either a high score on emotional exhaustion and depersonalisation or
a high score on emotional exhaustion in combination with a low score on personal
accomplishment. The scores were compared with the norm group of the general Dutch
working population (Schaufeli & van Dierendonck, 2000).
The level of work engagement was measured, using the 9-item Utrecht Work
Engagement Scale (UWES) (Schaufeli, Bakker, & Salanova, 2006). This validated
questionnaire consists of the subscales vigour, dedication and absorption.
The third validated questionnaire used is the Dutch version of the Edinburgh
Depression Scale (Pop, Komproe, & van Son, 1992). This 12-item depression
screening list calculates a sum score of all items, resulting in potential total scores,
ranging from 0 to 30, with a cut-off point of 12 or higher.
Self-constructed items were added to the questionnaire: one item on work-family
conflict and one item on work-related autonomy. The items were stated as follows:
‘‘To what extent can you combine your work and family life?’’ and ‘‘Can you control
several aspects of your job, such as time-table planning, working overtime and the
way you do your work?’’ Participants could answer both items on a 4-point scale.
For the analysis, the categories bad and moderate of work-family conflict, and
reasonable and good were joined together, to high- and low work-family conflict,
respectively. For work-related autonomy, the categories no- and little work-related
autonomy, and reasonable- and much work-related autonomy were joined, to little-
and much work-related autonomy.
Other requested resident characteristics were gender, age, medical specialism, if
the resident is/has been performing scientific studies and/or a Ph.D. study, year of
training, presence of children, hours of work per week (according to the contract)
and the average number of hours the resident works overtime per week.
The interviews were taken with a tailor-made questionnaire that was reviewed by
several experts. On average, the interview took 30 min. The interviews were taken 2
months after sending the questionnaires.
The interview was designed around constructs of relevant indicators for developing
burnout that resulted from previous research. To obtain a detailed picture of work
perception, several aspects were questioned such as job satisfaction (‘‘Does your job
make you happy?’’), personal accomplishment (‘‘Do you have self-efficacy?’’) and
work-family conflict (‘‘Does your job influence your family-life?’’). Other aspects
concerned work-related autonomy (‘‘Are you able to set your own limits?’’), contact
with colleagues (‘‘How is your cooperation with tutors, other residents, and nurses?’’),
contact with patients (‘‘How do you experience the contacts with patients?’’) and their
ideas about the most important determinants for developing burnout in residents
(‘‘What is, in your opinion, the most important cause of developing burnout?’’).
Finally, the residents were asked for suggestions to improve their working conditions.
All interviews were recorded, and transcribed into written form on a computer.
After transcription, the answers of all residents were pooled and analysed. The most
important aspects of all answers were selected into a summary, based on the
frequency of appearance. In addition, answers which indicated a serious problem or
dysfunction, were selected for the summary, regardless of the frequency they were
mentioned. Subjects that were discussed were workload, work-family conflict, work-
related autonomy, setting boundaries, the resident’s view on burnout and their
dealing with their workload.
478 R. Ringrose et al.
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Procedure
All residents (N¼58) received a questionnaire at home. Three weeks after sending
the first questionnaire, all residents who had not responded received a reminder
including a questionnaire. The residents were asked whether they agreed to co-
operate with an interview. If they were willing to co-operate, the researcher
contacted the residents by e-mail or phone. All interviews were individually taken by
the same interviewer.
Statistical analyses
Differences in burnout were evaluated using the Mann–Whitney test (for continuous
variables) and the Fisher’s exact test (for categorical variables). In addition, several
univariable logistic regression analyses were performed, for variables that appeared to be
relevant determinants for burnout in earlier studies. Carrying out these logistic
regression analyses, significant variables wereselected, calculating odds ratios (ORs) and
95% confidence intervals. All statistics were calculated using SPSS 13.0 for Windows.
Results
Questionnaire
All resident characteristics are provided in Table 1. The residents had a mean age of
30.3 years (+3.3) and men and women were equally represented. In total, 17% of the
residents had one or more children. The average amount of overtime hours per week
is 9.7 (+3.9), with a mean contract time of 44 (+6.3) hours per week. One fourth of
the sample was poorly or moderately able to combine their work and family life and
38% experienced no or little work-related autonomy.
In Table 2, the mean, standard deviation and range for burnout-, work-
engagement- and depression scores are shown. The means of all subscales are within
one standard deviation from the mean burnout score, compared with the norm
group of professionals in healthcare.
For the group as a whole, 15 of the 47 residents met the criteria for burnout,
which corresponds with a 31% burnout rate (Table 3). Residents who met the
criteria for burnout were significantly less engaged in their work (p50.001) and
scored significantly higher on depression (p50.001), compared to residents who
did not meet the criteria for burnout.
The distribution of burnout according to selected baseline characteristics is
shown in Table 4. Residents in the burnout group experienced significantly higher
work-family conflicts (p¼0.03) and experienced less work-related autonomy
(p¼0.06).
Table 5 shows the results of the univariate logistic regression analyses. This table
shows that work-family conflict (OR ¼4.7; 95% CI 1.2–19.0), work-related
autonomy (OR ¼0.3; 95% CI 0.07–0.95) and work-engagement (OR ¼0.8; 95%
CI 0.7–0.9) are significantly associated with burnout prevalence.
Interview
First of all, all the 10 interviewed residents enjoy their work and the personal
development because of the work leads to high job satisfaction. However, seven
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Table 2. Burnout, work-engagement and depression measured in residents active in Ma
´xima
Medical Centre, the Netherlands (n¼47).
Variable
Mean
sumscore
(SD) Mean (SD) Range Normgroup
Burnout (UBOS-A)
Emotional exhaustion 11.04 (5.03) 2.21 (1.01) 0.60–4.40 High (2.00–3.63)
Depersonalisation 5.74 (4.02) 1.44 (1.01) 0.00–4.50 Average (0.50–1.74)
Personal accomplishment 26.87 (3.70) 4.47 (0.61) 2.67–5.50 Average (3.50–4.82)
Work-engagement (UWES)
Vigor 12.26 (2.59) 4.09 (0.86) 1.67–6.00 Average (3.26–4.80)
Dedication 13.96 (2.49) 4.65 (0.83) 2.67–6.00 Average (2.91–4.70)
Absorption 11.68 (3.23) 3.89 (1.08) 1.00–5.67 Average (2.34–4.20)
Total score 37.89 (7.29) 4.21 (0.81) 2.33–5.89 Average (2.89–4.66)
Depression (EDS)
Total score – 6.98 (3.88) 1.00–16.00
Table 1. Baseline characteristics in residents, active in Ma
´xima Medical Centre, the
Netherlands (n¼47).
Variable N(%)
Personal characteristics
Man 23 (48.9%)
Children present 8 (17.0%)
Age (mean and jjSD) 30.3 (3.3)
Job-characteristic variables
Training for specialism
Internal medicine 10 (21.2%)
Surgery 9 (19.1%)
Orthopedia 8 (17.0%)
Gynaecology 7 (14.9%)
Emergency care 4 (8.5%)
Sports medicine 3 (6.4%)
Pediatry 2 (4.3%)
Cardiology 2 (4.3%)
Urology 2 (4.3%)
Performing PhD study 8 (17.0%)
Scientific articles published 30 (63.8%)
Year of training (mean and SD) 2.6 (1.5)
Hours contract (mean and SD) 43.9 (6.3)
Hours work overtime (mean and SD) 9.7 (3.9)
Combining family-work situation
Bad 2 (4.2%)
Moderate 10 (21.3%)
Reasonable 29 (61.7%)
Good 6 (12.8%)
Work-related autonomy
No 1 (2.1%)
Little 17 (36.2%)
Reasonable 26 (55.3%)
Much 3 (6.4%)
480 R. Ringrose et al.
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residents (70%) experience high work pressure. However, most of them realise that
high workload is inherent to their jobs.
Workload
Workload is experienced to be the highest at the start of the training. The current
study found three factors that may explain this tendency. First, during the initial
phases of the training, the efficiency of the working methods is suboptimal and
increases gradually. Second, residents experience a strong need to prove themselves.
Table 3. Mann–Whitney tests for association between burnout and other variables (mean
(SD)) in residents active in Ma
´xima Medical Centre, the Netherlands (n¼47).
Variable
Burnout
p-value
Yes (n¼15) No (n¼32)
Age 30.6 (2.3) 30.1 (3.7) 0.3
Contract hours 41.5 (8.1) 45.0 (5.0) 0.08
Hours overtime 10.2 (5.4) 9.5 (3.0) 0.7
Work engagement 32.0 (6.3) 40.7 (6.1) 50.001
Depression 9.7 (3.2) 5.7 (3.6) 0.001
Table 4. Fisher’s exact test for association between burnout and other variables in residents
active in Ma
´xima Medical Centre, the Netherlands (n¼47).
Variable
Burnout
p-value
Yes (n¼15) No (n¼32)
Gender 0.5
Men 6 (26.1%) 17 (73.9%)
Women 9 (37.5%) 15 (62.5%)
Children present 0.09
Yes 5 (62.5%) 3 (37.5%)
No 10 (25.6%) 29 (74.4%)
Performing PhD study
a
0.7
Yes 3 (37.5%) 5 (62.5%)
No 11 (28.9%) 27 (71.1%)
Scientific articles published
a
1.0
Yes 9 (30.0%) 21 (70.0%)
No 5 (31.3%) 11 (68.8%)
Year of training 0.5
1 and 2 7 (26.9%) 19 (73.1%)
3–6 8 (38.1%) 13 (61.9%)
Work-family conflict 0.03
Low 8 (22.9%) 27 (77.1%)
High 7 (58.3%) 5 (41.7%)
Work-related autonomy 0.06
Little 9 (50.0%) 9 (50.0%)
Much 6 (20.7%) 23 (79.3%)
Depressive 0.2
No 11 (27.5%) 29 (72.5%)
Yes 4 (57.1%) 3 (42.9%)
a
Excluding 1 missing value.
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In addition, because of this, and because of a lack of assertiveness, most new
residents do not set any boundaries.
Another important cause of work pressure is the difficulty that most residents
experience in combining several aspects of their job, such as working at the hospital,
their training, preparing and participation in the curricular parts of the training
program, carrying out and publication of research. Studying has to be done in off-
working hours, which often leads to work-family conflicts.
Work-related autonomy
All residents experience little control over several aspects of their jobs, such as
getting a day off, determining working hours and working overtime. Work-related
autonomy again is particularly a problem for new residents. Several residents
mention that taking time for a patient, often results in schedule delays.
Consequently, residents who take too much time for their patients end up with
complaining patients and working more overtime.
Work-family conflict
Not surprisingly, because of the number of hours working and studying in their own time,
less spare time is left. Nine out of ten residents regularly experience work-family conflicts.
work-family conflicts appear to be most problematic for residents who have children,
because their home lives are more demanding than those of residents without children.
Setting boundaries
Setting boundaries is not only a problem when residents just started their training, but
also when they get more experienced. According to several residents, it is impossible to
set boundaries. The remaining residents report of having serious difficulties with this.
Residents’ view on burnout
None of the residents was aware of any feelings of depersonalisation, or decreased
self-efficacy. However, the majority of the interviewed residents sometimes
Table 5. Odds ratios (OR) with 95% confidence intervals (CI) of the independent variables in
a univariable logistic regression analysis with burnout (yes or no) as dependent variable in
residents active in Ma
´xima Medical Centre, the Netherlands (n¼47).
Variable OR (95% CI)
Gender 1.70 (0.49–5.90)
Children present 0.21 (0.04–1.03)
Performing PhD study 0.68 (0.14–3.34)
Scientific articles published 1.06 (0.29–3.95)
Year of training (1–2 vs. 3–6) 1.67 (0.49–5.75)
Work-family conflict (low vs. high) 4.73 (1.17–19.0)
Work-related autonomy (little vs. much) 0.26 (0.07–0.95)
Depression (no vs. yes) 3.52 (0.68–18.3)
Work engagement (total score UWES) 0.81 (0.71–0.92)
482 R. Ringrose et al.
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experienced feelings of exhaustion, either mentally or physically. Residents that
complained about exhaustion did not report any serious disabling consequences,
either in their personal or professional domain.
The majority of residents could remember at least one occasion in which they had
made mistakes provoked by exhaustion or high workload, like wrongly looking up
information of a patient, prescribing wrong medication, or forgetting to perform
checks on a patient. According to the interviewed residents, no fatal mistakes were
made. However, they were aware of being less focussed whenever experiencing high
workload or exhaustion.
Dealing with the load of working as a resident
Most residents experience the workload of their jobs as very high, but most of them
were highly motivated to achieve their goal, and become a medical specialist. The
notion of the training being only temporary, made the workload bearable. Most
residents considered their training years as a tough period, in which they should put
on their blinkers.
Comparison of questionnaire and interview results
During the interviews, no obvious differences between the burned out and non-
burnedout residents drew the attention of the interviewer. However, after confronting
the two burned out residents with their scores, both of them were able to explain their
scores. They described the period they completed their questionnaire as hectic, thus
explaining their high scores. Both of them stated they had recovered from that hectic
period.
Discussion
In total, 31% of the medical residents in this study meet the criteria for burnout. This
is higher than the burnout prevalence rate of 21% that was found in another Dutch
study with medical residents (van der Heijden et al., 2006).
Significant effects of high levels of work-family conflict, little work-related
autonomy and low work-engagement, corresponded with findings in earlier studies
(Keeton, Fenner, Johnson, & Hayward, 2007; Maslach et al., 2001; Piko, 2006;
Schaufeli & Bakker, 2003).
In contrast with results in previous studies, no significant difference was found in
burnout prevalence for the different years of training (Martini, Arfken, & Balon,
2006; Nyssen, Hansez, Baele, Lamy, & de Keyser, 2003). An explanation for this
result might be that in the current study, the subgroup of first and second year
burned out residents is too small. Because of that, first and second year
residents were joined together. However, the burned out part of this group remained
small.
Striking in the current study is that the burnout rates from questionnaires and
interviews in medical residents are not consistent. There are several potential
explanations. First, in contrast to work engagement which is a more persistent and
pervasive trait, feelings of burnout, exhaustion, depersonalisation and low personal
accomplishment are state-like feelings (Schaufeli et al., 2002). This might imply that
the questionnaire is a good measure to signal burnout (-symptoms). However, the
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score on this questionnaire is likely to only represent the state of the respondent,
during a short period of time (e.g. weeks or months).
A second explanation might be that the nature of the job and personal
characteristics of the residents might function as a protecting factor for the
development of burnout. During the interviews, several residents stated that their job
was often tough and exhausting. Notwithstanding these feelings, they are very
motivated to do and complete their training. These residents consider themselves
relatively high on vigour and dedication to their jobs. This is consistent with their
above-average scores on these subscales. Vigour and dedication are two of the three
work engagement concepts, implying that residents indeed are highly engaged in
their jobs. In addition, the current study found a significant negative relationship
between work-engagement and burnout. Consequently, the residents who score
relatively high on work engagement might be protected for burnout by their
engagement. In addition, all residents consider their jobs to be very interesting,
which results in satisfaction. Earlier studies found that satisfaction could act as a
preventive factor (Collins & Long, 2003; Martini et al., 2006). In the current study,
this might be a good explanation for residents scoring high on the MBI, without
experiencing serious burnout symptoms. Their development from a resident to
become a medical specialist, and all the new theoretical and practical knowledge and
experience that is inherent to their training, is another stimulant. Besides that,
residents are likely to know that their training period will be a hard period. Resulting
preparedness might be another protecting factor for their experienced stress level.
Finally, the temporary character of the training is a factor which might make the
work load more bearable.
A major conclusion of the current study is that high burnout scores based upon
only a questionnaire should be interpreted cautiously. Obviously, it is important to
identify individuals at risk for developing burnout but falsely classifying individuals
as burned out, might result in overestimating the burnout rate in the population of
medical residents. This will reduce the accuracy and efficiency of burnout screening
and treatment. In addition, individuals who do not experience burnout (-symptoms)
might be told they are burned out. To prevent false positives, individuals that score
high on a burnout questionnaire should be further examined, by an interview, thus
acquiring relevant background information. This might lead to a more complete
picture of the person and the work- and family circumstances.
Moreover, screening for burnout using questionnaires should probably be carried
out several times a year. Therefore, a regular burnout screening will be useful to
identify individuals at risk in time. In turn, this might make early treatment possible,
and prevent symptoms from escalating.
The most important limitation of this study is a possible social desirability bias.
In western society, burnout often is considered to be a weakness. With the
questionnaire, as well as with the interview, researchers stressed the fact that all
results would be made public anonymously. Also, supervisors and specialists were
encouraged not to interfere with the current study, in order to minimise their
influence. However, the possibility that this bias influences the outcomes cannot be
excluded.
In conclusion, nearly one-third of the residents met the criteria for burnout.
Obviously, this is a striking result which must be taken seriously. Regular burnout
screenings and performing interviews are recommended in addition to burnout
questionnaires, in order to efficiently identify residents at risk for burnout. Future
484 R. Ringrose et al.
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research could focus on possible preventive factors for developing burnout, including
work engagement and work satisfaction.
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