Prevalence of burnout among intensive care physicians: a systematic review

We conducted a systematic review of the MEDLINE and PubMed® databases (last update 04.02.2019) with the goal of summarizing the evidence on burnout among intensive care unit physicians. We included all studies reporting burnout in intensive care unit personnel according to the Maslach Burnout Inventory questionnaire and then screened studies for data on burnout among intensive care unit physician specifically.

Results:

We found 31 studies describing burnout in intensive care unit staff and including different healthcare profiles. Among these, 5 studies focused on physicians only, and 12 others investigated burnout in mixed intensive care unit personnel but provided separate data on physicians. The prevalence of burnout varied greatly across studies (range 18% - 49%), but several methodological discrepancies, among them cut-off criteria for defining burnout and variability in the Likert scale, precluded a meaningful pooled analysis.

Conclusion:

The prevalence of burnout syndrome among intensive care unit physicians is relatively high, but significant methodological heterogeneities warrant caution being used in interpreting our results. The lower reported levels of burnout seem higher than those found in studies investigating mixed intensive care unit personnel. There is an urgent need for consensus recommending a consistent use of the Maslach Burnout Inventory test to screen burnout, in order to provide precise figures on burnout in intensive care unit physicians.

Keywords:
Burnout, professional/epidemiology; Working conditions; Physicians/psychology; Occupational diseases/epidemiology; Depression; Prevalence; Intensive care units

PICOS	Characteristics of studies included in the systematic search
Participants	Intensive care physicians
Intervention	Assessment of burnout syndrome with any form of the MBI questionnaire
Comparison	None
Outcomes	Risk of burnout syndrome evaluated either overall or according to subscales for burnout
Study design	Prospective surveys including at least 10 intensive care physicians

Authors	Population and response rat e	ICU setting, country/region	Burnout questionnaire Likert scale	Burnout in physicians	Subscale scores for physicians	Criteria for burnout classification
Colville et al.⁽³⁴34 Colville GA, Smith JG, Brierley J, Citron K, Nguru NM, Shaunak PD, et al. Coping with staff burnout and work-related posttraumatic stress in intensive care. Pediatr Crit Care Med. 2017;18(7):e267-e273.⁾	74 physicians (and 285 nurses) RR 51% overall, not available for categories	Seven ICUs at two hospitals (pediatric, cardiac, neuro, general) United Kingdom	Abbreviated MBI 9q Likert not specified	High 49%	Not reported	EE (≥ 27 points), DP (≥ 10 points) and PA (≤ 33 points), calculated as weighted/prorated scores Burnout if high levels of EE or DP
Lederer et al.⁽³⁵35 Lederer W, Kinzl JF, Traweger C, Dosch J, Sumann G. Fully developed burnout and burnout risk in intensive care personnel at a university hospital. Anaesth Intensive Care. 2008;36(2):208-13.⁾	33 physicians (and 150 nurses) answered RR 59% overall	5 ICUs Innsbrusk, Austria	Modified MBI (25q: EE 9, DP 5, PA 7, and Consternation 4) 6-point scale (1 to 6)	High in 45% (15/33)	Not reported	High risk burnout defined as EE mean value ≥ 4 or DP mean value ≥ 4, or PA mean value ≤ 4.
See et al.⁽³⁶36 See KC, Zhao MY, Nakataki E, Chittawatanarat K, Fang WF, Faruq MO, Wahjuprajitno B, Arabi YM, Wong WT, Divatia JV, Palo JE, Shrestha BR, Nafees KMK, Binh NG, Al Rahma HN, Detleuxay K, Ong V, Phua J; SABA Study Investigators and the Asian Critical Care Clinical Trials Group. Professional burnout among physicians and nurses in Asian intensive care units: a multinational survey. Intensive Care Med. 2018;44(12):2079-90.⁾	992 physician (out of 1296) and 3100 nurses (out of 4895, RR 63.3%) RR of 76.5% physicians	Medical, surgical and mixed ICUs Asia	Full MBI (22q: EE 9, DP 5, PA 8) Likert not specified	50.3%	EE high: 39.9% DP high: 35.2% PA low: 54.7%	EE (≥ 28 points), DP (≥ 11 points) and PA (≤ 33 points) Overall high burnout if high score in EE or DP domain
Barbosa et al.⁽³⁷37 Barbosa FT, Leao BA, Tavares GM, Santos JG. Burnout syndrome and weekly workload of on-call physicians: cross-sectional study. Sao Paulo Med J. 2012;130(5):282-8.⁾	67 physicians RR not available	Various types of ICUs (general, cardiac, pediatrics/neonatal, others) Brazil	Full MBI (22q: EE 9, DP 5, PA 8) 5-point scale (1 to 5)	High in at least 1 domain 70.1% High in all domains 17.9%	EE high:41.8% DP high:37.3% PA low: 58.2%	EE (≥ 27 points), DP (≥ 10 points) and PA (≤ 33 points) Burnout diagnosed if at least one domain altered
Fumis et al.⁽³⁸38 Fumis RR, Junqueira Amarante GA, de Fatima Nascimento A, Vieira Junior JM. Moral distress and its contribution to the development of burnout syndrome among critical care providers. Ann Intensive Care. 2017;7(1):71.⁾	283 ICU providers, 33 (out of 49) physicians, with a RR of 67.3%	General and neuro ICUs + step-down ICU Brazil	Full MBI (22q: EE 9, DP 5, PA 8) Likert not specified	Severe 18.2%	EE 27.3%	EE (≥ 27 points), DP (≥ 10 points) and PA (≤ 33 points) Severe if all domains altered
Garcia et al.⁽³⁹39 Garcia TT, Garcia PC, Molon ME, Piva JP, Tasker RC, Branco RG, et al. Prevalence of burnout in pediatric intensivists: an observational comparison with general pediatricians. Pediatr Crit Care Med. 2014;15(8):e347-53.⁾	35 physicians (compared with 35 general pediatricians) RR 90% overall	2 pediatric ICUs Brazil	Full MBI (22q: EE 9, DP 5, PA 8) 7-point scale (0 to 6)	High in 1: 71% High in 2: 51% High in 3: 17%	EE high: 63% DP high: 40% PA low: 29%	EE (≥ 27 points), DP (≥ 13 points) and PA (≤ 30 points)
Tironi et al.⁽⁴⁰40 Tironi MO, Teles JM, Barros DS, Vieira DF, Silva Filho CM, Martins Júnior DF, et al. Prevalence of burnout syndrome in intensivist doctors in five Brazilian capitals. Rev Bras Ter Intensiva. 2016;28(3):270-7.⁾	180 (out of 600 randomly selected) physicians RR 30% physicians	60 ICUs (of responding physicians 70.6% worked in adult ICUs, 29.4% in pediatric/neonatal ICUs) Brazil	Full MBI (22q: EE 9, DP 5, PA 8) 7-point scale (0 to 6)	Overall High in 1: 36.7% High in 2: 20.0% High in 3: 38.3% Adult High in 1: 33.1% High in 2: 23.6% High in 3: 36.2% PED/Neonatal High in 1: 45.3% High in 2: 11.3% High in 3: 43.4%	Overall EE high: 50.6% DP high: 26.1% PA low: 15.0% Adult EE high: 51.9% DP high: 30.7% PA low: 18.9% PED/Neonatal EE high: 47.2% DP high: 15.1% PA low: 5.7%	EE (≥ 27 points), DP (≥ 13 points) and PA (≤ 31 points)
Embriaco et al.⁽⁴¹41 Embriaco N, Azoulay E, Barrau K, Kentish N, Pochard F, Loundou A, et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007;175(7):686-92.⁾	978 physicians (62% attending physicians, 14% fellows, 24% interns and residents) RR 82.3%	189 of 318 various ICUs (59.4%) France	Full MBI (22q: EE 9, DP 5, PA 8) 7-point scale (range unspecified)	High 46.5% Moderate 30.2% Low 23.3%	Overall: EE high: 19% DP high: 37% PA low: 39%	EE (≥ 27 points), DP (≥ 10 points) and PA (≤ 33 points) High if global MBI score ≥ -8, moderate level -21 to - 9, low level -45 to -22
Garrouste-Orgeas et al.⁽⁴²42 Garrouste-Orgeas M, Perrin M, Soufir L, Vesin A, Blot F, Maxime V, et al. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. Intensive Care Med. 2015;41(2):273-84.⁾	330 physicians (out of 401) (and 1204/1587 nurses) RR 82% physicians	31 mixed, surgical or medical ICUs France	Full MBI (22q: EE 9, DP 5, PA 8) 7-point scale (0 to 6)	Def 1: 2.5%Def 2: 40.3%	EE high: 10.6% DP high: 24.5% PA low: 31.5%	EE (≥ 30 points), DP (≥ 12 points) and PA (≤ 33 points) Definition 1 High if all domains altered Definition 2 High if global MBI score ≥ - 9
Malaquin et al.⁽⁴³43 Malaquin S, Mahjoub Y, Musi A, Zogheib E, Salomon A, Guilbart M, et al. Burnout syndrome in critical care team members: A monocentric cross sectional survey. Anaesth Crit Care Pain Med. 2017;36(4):223-8.⁾	32 physicians (and 129 nurses or nursing assistants) RR 90% overall	3 ICUs at single center (medical-surgical, cardiothoracic and vascular, and neurosurgical) France	Full MBI (22q: EE 9, DP 5, PA 8) Likert not specified	56% moderate 0% high	EE severe: 6% EE moderate: 32% DP severe: 29% DP moderate: 29% PA severe: 48% PA moderate: 22%	Low, 1 domain altered Moderate, 2 domains altered Severe, all domains altered
Giannini et al.⁽⁴⁴44 Giannini A, Miccinesi G, Prandi E, Buzzoni C, Borreani C; ODIN Study Group. Partial liberalization of visiting policies and ICU staff: a before-and-after study. Intensive Care Med. 2013;39(12):2180-7.⁾	71 physicians and 127 nurses (at baseline) RR 89% overall	8 ICUs (7 mixed medical-surgical, 1 pediatric) Italy	Full MBI (22q: EE 9, DP 5, PA 8) Likert not specified	High 32.4%	Not reported	EE (≥ 24 points), DP (≥ 9 points) and PA (≤ 29 points) High if global MBI score ≥ -9
Raggio et al.⁽⁴⁵45 Raggio B, Malacarne P. Burnout in intensive care unit. Minerva Anestesiol. 2007;73(4):195-200.⁾	Physicians (25) and nurses responding in total) RR not reported	1 mixed and 1 post-transplant ICU Italy	Full MBI (22q: EE 9, DP 5, PA 8) 7-point scale (0 to 6)	Not reported	EE high: 36% DP high: 56% PA high: 28%	EE (≥ 24 points), DP (≥ 9 points) and PA (≤ 29 points)
Shenoi et al.⁽⁴⁶46 Shenoi AN, Kalyanaraman M, Pillai A, Raghava PS, Day S. Burnout and psychological distress among pediatric critical care physicians in the United States. Crit Care Med. 2018;46(1):116-22.⁾	275 (out of 686) physicians (20 excluded for questions unanswered) RR physicians 40% (37% excluding the 20)	Pediatric ICU, non-random sample of physicians United States	Full MBI (22q: EE 9, DP 5, PA 8) Likert not specified	Severe 21.0%	EE high: 34% DP high: 21% PA low: 20%	EE (≥ 27 points), DP (≥ 10 points) and PA (≤ 32 points) Severe burnout defined as high EE associated with high DP or low PA scores
Ntantana et al.⁽⁴⁷47 Ntantana A, Matamis D, Savvidou S, Giannakou M, Gouva M, Nakos G, et al. Burnout and job satisfaction of intensive care personnel and the relationship with personality and religious traits: An observational, multicenter, cross-sectional study. Intensive Crit Care Nurs. 2017;41:11-7.⁾	149 (out of 221) physicians (and 320 nurses) RR physicians 67.4%	21 multidisciplinary ICUs > 6 beds Greece	Full MBI (22q: EE 9, DP 5, PA 8) Likert not specified	Not reported	EE high: 22.8% DP high: 42.3% PA low: 54.4%	EE (≥ 27 points), DP (≥ 10 points) and PA (≤ 33 points)
Teixeira et al.⁽⁴⁸48 Teixeira C, Ribeiro O, Fonseca AM, Carvalho AS. Burnout in intensive care units - a consideration of the possible prevalence and frequency of new risk factors: a descriptive correlational multicentre study. BMC Anesthesiol. 2013;13(1):38.⁾	82 physicians and 218 nurses RR 78% physicians	10 adult ICUs (of 13 invited) Portugal	Full MBI (22q: EE 9, DP 5, PA 8) 7-point scale (range unspecified)	High: 24.7%	Not reported	EE (≥ 25 points), DP (≥ 10 points) and PA (≤ 32 points) High burnout if all domains altered
Merlani et al.⁽⁴⁹49 Merlani P, Verdon M, Businger A, Domenighetti G, Pargger H, Ricou B; STRESI+ Group. Burnout in ICU caregivers: a multicenter study of factors associated to centers. Am J Respir Crit Care Med. 2011;184(10):1140-6.⁾	Physicians (465 of 678), nurses and nurse's assistants RR 69% physicians	72 of 92 ICUs (RR 80%) Switzerland	Full MBI (22q: EE 9, DP 5, PA 8) 4-point scale (range unspecified)	High: 31%	Not reported	High if global MBI score ≥ -9
Galván et al.⁽⁵⁰50 Galván ME, Vassallo JC, Rodríguez SP, Otero P, Montonati MM, Cardigni G, Buamscha DG, Rufach D, Santos S, Moreno RP, Sarli M; Members of Clinical and Epidemiological Research Group in Pediatric Intensive Care Units - Sociedad Argentina de Pediatría. Professional burnout in pediatric intensive care units in Argentina. Arch Argent Pediatr. 2012;110(6):466-73.⁾	162 (out of 270) physicians RR 60% physicians	Pediatric ICU Argentina	Full MBI (22q: EE 9, DP 5, PA 8) Likert not specified	41%	EE high: 25% DP high: 19% PA low: 6%	EE (≥ 27 points), DP (≥ 10 points) and PA (≤ 32 points) Burnout high risk defined if at least one domain altered

Study	Variables found to be associated or correlated with burnout
Colville et al.⁽³⁴34 Colville GA, Smith JG, Brierley J, Citron K, Nguru NM, Shaunak PD, et al. Coping with staff burnout and work-related posttraumatic stress in intensive care. Pediatr Crit Care Med. 2017;18(7):e267-e273.⁾	The analysis on the overall staff (physicians and nurses) showed that burnout significantly overlapped with post-traumatic stress disorder and anxiety. Multivariate analyses on variables correlated with burnout were performed according to two models. Resilience and being a doctor were the strongest predictors of reporting burnout. Attending a debriefing was correlated with halving the risk of burnout, whereas venting emotion and using alcohol were correlated with increased burnout reporting.
Lederer et al.⁽³⁵35 Lederer W, Kinzl JF, Traweger C, Dosch J, Sumann G. Fully developed burnout and burnout risk in intensive care personnel at a university hospital. Anaesth Intensive Care. 2008;36(2):208-13.⁾	The authors also included four questions in the MBI that were related to consternation, which is defined as fear resulting from the awareness of being susceptible to psychological trauma. This element was not included in the burnout definition and thus did not alter the results on burnout. The authors did not find significant differences in burnout between the subgroups for age, gender, level of training, years of employment or family status. ICU personnel with fully established burnout planned to change professions more frequently than participants with no burnout.
See et al.⁽³⁶36 See KC, Zhao MY, Nakataki E, Chittawatanarat K, Fang WF, Faruq MO, Wahjuprajitno B, Arabi YM, Wong WT, Divatia JV, Palo JE, Shrestha BR, Nafees KMK, Binh NG, Al Rahma HN, Detleuxay K, Ong V, Phua J; SABA Study Investigators and the Asian Critical Care Clinical Trials Group. Professional burnout among physicians and nurses in Asian intensive care units: a multinational survey. Intensive Care Med. 2018;44(12):2079-90.⁾	In the multivariate analysis of this Asian continental survey, protective factors against burnout for physicians were religiosity, years of experience in the current department, shift work and number of stay-at-home calls. The number of days worked per month was positively correlated with higher burnout.
Barbosa et al.⁽³⁷37 Barbosa FT, Leao BA, Tavares GM, Santos JG. Burnout syndrome and weekly workload of on-call physicians: cross-sectional study. Sao Paulo Med J. 2012;130(5):282-8.⁾	The study found that 50% of the participants who did not practice physical activity had high levels of EE. Several sources of stress were investigated, but their influence on burnout was not directly evaluated.
Fumis et al.⁽³⁸38 Fumis RR, Junqueira Amarante GA, de Fatima Nascimento A, Vieira Junior JM. Moral distress and its contribution to the development of burnout syndrome among critical care providers. Ann Intensive Care. 2017;7(1):71.⁾	Moral distress (evaluated by the Moral Distress Scale-Revised questionnaire) correlated moderately with EE and weakly with PA (inversely) and DP.
Garcia et al.⁽³⁹39 Garcia TT, Garcia PC, Molon ME, Piva JP, Tasker RC, Branco RG, et al. Prevalence of burnout in pediatric intensivists: an observational comparison with general pediatricians. Pediatr Crit Care Med. 2014;15(8):e347-53.⁾	The authors found higher burnout among pediatric intensivists than among general pediatricians. No other demographics or personal characteristics were associated with burnout in the univariate analysis.
Tironi et al.⁽⁴⁰40 Tironi MO, Teles JM, Barros DS, Vieira DF, Silva Filho CM, Martins Júnior DF, et al. Prevalence of burnout syndrome in intensivist doctors in five Brazilian capitals. Rev Bras Ter Intensiva. 2016;28(3):270-7.⁾	Study including only physicians who were working in adult or pediatric/neonatal ICUs. Functional characteristics and occupational stress factors were reported, but their association with burnout was not analyzed. When considering high scores in all the three dimensions simultaneously, burnout was only observed in doctors working in adult ICUs (7.1%).
Embriaco et al.⁽⁴¹41 Embriaco N, Azoulay E, Barrau K, Kentish N, Pochard F, Loundou A, et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007;175(7):686-92.⁾	In this study, 50% of physicians with high levels of burnout wished to leave their job. The univariate analysis showed higher levels of burnout in females, in younger staff and in those not married and not having children. Burnout was also associated with withholding or withdrawing treatment, workload, and recent conflicts with nurses, families and colleagues. In the multivariate analysis, the factors remaining correlated with burnout were female gender, workload, and conflicts. Protective effects were good quality relationships with the chief nurse and nurses. The authors subsequently published other results of this study highlighting that, in the same cohort of physicians, depressive symptoms were correlated with high levels of burnout (Embriaco N et al. Annals of Intensive Care 2012).
Garrouste-Orgeas et al.⁽⁴²42 Garrouste-Orgeas M, Perrin M, Soufir L, Vesin A, Blot F, Maxime V, et al. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. Intensive Care Med. 2015;41(2):273-84.⁾	Burnout was correlated with depression scores, as evaluated by the Centre of Epidemiologic Studies Depression scale, but not with safety attitudes, as evaluated by the Safety Attitude Questionnaire - ICU version. The study focused on the association between burnout and medical errors in the ICU.
Malaquin et al.⁽⁴³43 Malaquin S, Mahjoub Y, Musi A, Zogheib E, Salomon A, Guilbart M, et al. Burnout syndrome in critical care team members: A monocentric cross sectional survey. Anaesth Crit Care Pain Med. 2017;36(4):223-8.⁾	Prevalence of burnout was not different between physicians and non-physicians or among the three different ICUs in this single center study. Severe burnout was more likely due to low PA than to high DP or EE. However, severe burnout was observed only in the cardiothoracic and vascular ICU (9%). After multivariate analysis, only the prevalence of depressive symptoms, low well-being and absence of a hobby were correlated with burnout.
Giannini et al.⁽⁴⁴44 Giannini A, Miccinesi G, Prandi E, Buzzoni C, Borreani C; ODIN Study Group. Partial liberalization of visiting policies and ICU staff: a before-and-after study. Intensive Care Med. 2013;39(12):2180-7.⁾	The study evaluated burnout and other outcomes, such as anxiety, in nurses and physicians regarding the liberalization of visiting times in the ICU. Staff was surveyed at three time-points, and nurses always had a significantly greater predominance of high burnout levels. Staff with favorable opinions regarding liberalization had lower burnout levels. Burnout level increased during the surveyed period in both nurses and physicians.
Raggio et al.⁽⁴⁵45 Raggio B, Malacarne P. Burnout in intensive care unit. Minerva Anestesiol. 2007;73(4):195-200.⁾	The study evaluated the prediction of burnout according to results of the "profile of mood state" questionnaire that studies the profile of the state of mood in the previous week (58 specific sensations). Apart from the state of mood, the study showed a higher degree of DP in male physicians and a higher degree of EE in female physicians.
Shenoi et al.⁽⁴⁶46 Shenoi AN, Kalyanaraman M, Pillai A, Raghava PS, Day S. Burnout and psychological distress among pediatric critical care physicians in the United States. Crit Care Med. 2018;46(1):116-22.⁾	Approximately two thirds of the investigated population of physicians recently considered leaving their job in the pediatric ICU. Burnout and severe burnout were significantly associated with willingness to leave the job (4 and over 9 times higher risk, respectively). Severe burnout was significantly associated with psychological distress (over 8 times higher risk). The correlation between the EE score and the psychological distress score was moderate to high, while it was low to moderate for DP and PA.
Ntantana et al.⁽⁴⁷47 Ntantana A, Matamis D, Savvidou S, Giannakou M, Gouva M, Nakos G, et al. Burnout and job satisfaction of intensive care personnel and the relationship with personality and religious traits: An observational, multicenter, cross-sectional study. Intensive Crit Care Nurs. 2017;41:11-7.⁾	In the overall study evaluating nurses and physicians, female sex was associated with higher EE and lower PA scores. Regarding EE, the multivariate analysis found a correlation with job satisfaction, satisfaction with end-of-life care, feelings of isolation after providing end-of-life care, neuroticism and extraversion traits.
Teixeira et al.⁽⁴⁸48 Teixeira C, Ribeiro O, Fonseca AM, Carvalho AS. Burnout in intensive care units - a consideration of the possible prevalence and frequency of new risk factors: a descriptive correlational multicentre study. BMC Anesthesiol. 2013;13(1):38.⁾	Physicians and nurses were included in this study, and the data were mostly reported as pooled outcomes. The only significant difference found was the lower scores for EE in physicians compared with nurses (17 vs 20, respectively). The authors subsequently published other results for the same cohort highlighting that nurses' burnout (and in particular EE) was associated with ethical decisions (withdrawing or withholding treatments, terminal sedation), while this was not the case for physicians (Teixeira C et al J Med Ethics 2013).
Merlani et al.⁽⁴⁹49 Merlani P, Verdon M, Businger A, Domenighetti G, Pargger H, Ricou B; STRESI+ Group. Burnout in ICU caregivers: a multicenter study of factors associated to centers. Am J Respir Crit Care Med. 2011;184(10):1140-6.⁾	The study evaluated stress and burnout in a mixed population of physicians, nurses and nurse assistants in Swiss ICUs. The latter healthcare workers had significantly higher burnout (41%)than nurses (28%) and physicians (31%). The multivariate analysis in the overall population showed a higher risk of burnout according to individual factors (males, having no children, being younger than 40 years old), patients' related factors (higher ICU mortality), and organizational factors (working in German-speaking ICUs and having a lower proportion of females nurses). Moreover, a positive answer to the question about "Feeling stressed" was the predominant independent factor increasing burnout risk.
Galván et al.⁽⁵⁰50 Galván ME, Vassallo JC, Rodríguez SP, Otero P, Montonati MM, Cardigni G, Buamscha DG, Rufach D, Santos S, Moreno RP, Sarli M; Members of Clinical and Epidemiological Research Group in Pediatric Intensive Care Units - Sociedad Argentina de Pediatría. Professional burnout in pediatric intensive care units in Argentina. Arch Argent Pediatr. 2012;110(6):466-73.⁾	The score in the PA domain was independent from the scores in the EE and DP domains, while the latter scores had significant associations between them. In the multivariate analysis, being certified as a pediatric ICU physician and working in a public practice was protective against burnout, while a higher workload (more than 36 hours/week as on-call duties).

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[1] Corresponding author: Filippo Sanfilippo, Department of Anesthesia and Intensive Care, A.O.U. “Policlinico -Vittorio Emanuele”, 95125 Catania, Italy. E-mail: filipposanfi@yahoo.it