Burnout in Primary Care Pediatrics and the Additional Burden from the COVID-19 Pandemic
2023; Elsevier BV; Volume: 260; Linguagem: Inglês
10.1016/j.jpeds.2023.113447
ISSN1097-6833
AutoresLuigi Nigri, Angel Carrasco-Sanz, Tudor Lucian Pop, Ida Giardino, Mehmet Vural, Pietro Ferrara, Flavia Indrio, Massimo Pettoello‐Mantovani,
Tópico(s)COVID-19 and Mental Health
ResumoThe term burnout describes a condition of work-related stress that leads individuals to exhaust their mental and physical resources.1AAAAInformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in health care (IQWiG); 2006-. Depression: what is burnout?.https://www.ncbi.nlm.nih.gov/books/NBK279286/Date: 2020Date accessed: January 30, 2023Google Scholar Burnout is a manifestation of negative psychological symptoms, including apathy, nervousness, restlessness, and demoralization, which may also be associated with physical problems, including headaches, sleep disturbances, and gastrointestinal disorders.2Murthy V.H. AABBConfronting health worker burnout and well-being.N Engl J Med. 2022; 387: 577-579https://doi.org/10.1056/NEJMp2207252Crossref PubMed Scopus (58) Google Scholar This condition can affect any worker performing any task, in any work environment. However, the most severe consequences of a stressful working condition are generally observed in the helping professions,3Jameson D. BBDDPersistent burnout theory of chronic fatigue syndrome.Neurosci Med. 2016; 2016: 66-73Google Scholar, 4Montgomery A. Panagopoulou E. Esmail A. Richards T. Maslach C. AACCBurnout in healthcare: the case for organisational change.BMJ. 2019; 366: l4774https://doi.org/10.1136/bmj.l4774Crossref PubMed Scopus (108) Google Scholar, 5Manzano-García G. Ayala-Calvo J.C. BBFFNew perspectives: towards an Integration of the concept "burnout" and its explanatory models.An Psicolog. 2013; 29: 800-809Google Scholar including physicians, nurses, pharmacists, social workers, and staff members of private and public health organizations who are dedicated to others.4Montgomery A. Panagopoulou E. Esmail A. Richards T. Maslach C. AACCBurnout in healthcare: the case for organisational change.BMJ. 2019; 366: l4774https://doi.org/10.1136/bmj.l4774Crossref PubMed Scopus (108) Google Scholar Concern about the problem of burnout in health care workers goes back many years.6Freudenberger H.J. AADDStaff burn-out.J Soc Issues. 1974; 30: 159-165https://doi.org/10.1111/j.1540-4560.1974.tb00706.xCrossref Scopus (2738) Google Scholar However, the COVID-19 pandemic, which introduced new and unexpected stressors in almost all areas of life, has significantly increased the workload of health care workers in a short period of time. The level of physical and emotional stress has increased to the point that, because of the threat posed by this condition to the nation's health, several countries in Europe and the United States have declared the health-worker burnout crisis and the protection of their well-being a national priority.2Murthy V.H. AABBConfronting health worker burnout and well-being.N Engl J Med. 2022; 387: 577-579https://doi.org/10.1056/NEJMp2207252Crossref PubMed Scopus (58) Google Scholar,7Prasad K. McLoughlin C. Stillman M. Poplau S. Goelz E. Taylor S. et al.Prevalence and correlates of stress and burnout among U.S. healthcare workers during the COVID-19 pandemic: a national cross-sectional survey study.EClinicalMedicine. 2021; 35: 100879https://doi.org/10.1016/j.eclinm.2021.100879Abstract Full Text Full Text PDF PubMed Scopus (217) Google Scholar, 8Global ResearchBurnout in the medical workplace: the European perspective.https://m3globalresearch.blog/2020/10/15/burnout-in-healthcare-europe/Date accessed: January 30, 2023Google Scholar, 9Szwamel K. Kaczorowska A. Lepsy E. Mroczek A. Golachowska M. Mazur E. et al.Predictors of the occupational burnout of healthcare workers in poland during the COVID-19 pandemic: a cross-sectional study.Int J Environ Res Public Health. 2022; 3634: 19https://doi.org/10.3390/ijerph19063634Crossref Scopus (15) Google Scholar Several studies have highlighted the role of COVID-19 in causing increased burnout in various categories of health care professionals working in different settings and roles, and in other fields including finance, administration, academics, and the military.10Stone K.W. Kintziger K.W. Jagger M.A. Horney J.A. Public health workforce burnout in the COVID-19 response in the U.S.Int J Environ Res Public Health. 2021; 18: 4369https://doi.org/10.3390/ijerph18084369Crossref PubMed Scopus (66) Google Scholar, 11Buckley L. Berta W. Cleverley K. What is known about paediatric nurse burnout: a scoping review.Hum Resour Health. 2020; 18: 9https://doi.org/10.1186/s12960-020-0451-8Crossref PubMed Scopus (51) Google Scholar, 12Tufts L. Worthy M. Putty K. Wallace T. Waldeck K. Waldeck J.M. et al.Improving resident experience during the pediatric intensive care unit rotation.Glob Pediatr. 2023; 3: 10029https://doi.org/10.1016/j.gpeds.2022.100029Crossref Google Scholar However, limited attention has been paid to the phenomenon of burnout in primary care pediatrics which was exacerbated by the COVID-19 pandemic, with negative effects on public health. Alarming recent data show that the COVID-19 pandemic has significantly increased the pressure on the workforce of general pediatricians and significantly worsened from 10%-30% to 40%-70% of the burnout levels generally observed prior to the pandemic.13Sivarajasingam V. BBGG-1Address the emerging threat of burnout among primary care staff. MedscapeUK.https://www.medscape.co.uk/viewarticle/address-emerging-threat-burnout-among-primary-care-staff-2022a1001ij2Date accessed: January 30, 2023Google Scholar,14BBIIQuotidianoSanità. Work and Professions. From sleep disturbances to anxiety to fear: more and more doctors are victims of burnout.https://www.quotidianosanita.it/lavoro-e-professioni/articolo.php?articolo_id=104149#:∼:text=Disturbi%20del%20sonno%2C%20stress%2C%20ansia,e%20al%203%25%20degli%20odontoiatriDate accessed: January 30, 2023Google Scholar This commentary, compiled by the EPA-UNEPSA social pediatrics working group in collaboration with the European Confederation of Primary Care Pediatricians (ECPCP) and the Italian Federation of Primary Care Pediatricians (FIMP), briefly discusses the growing frequency of burnout in primary care and in primary care pediatrics, and debates how to reduce the risk of burnout and mitigate stress caused by this condition. Burnout was first described in 1974 by psychoanalyst Freudenberger,6Freudenberger H.J. AADDStaff burn-out.J Soc Issues. 1974; 30: 159-165https://doi.org/10.1111/j.1540-4560.1974.tb00706.xCrossref Scopus (2738) Google Scholar who analyzed the stressful dedication to work, which can cause workers to experience physical signs and behavioral symptoms considered indicators of extreme pressure.6Freudenberger H.J. AADDStaff burn-out.J Soc Issues. 1974; 30: 159-165https://doi.org/10.1111/j.1540-4560.1974.tb00706.xCrossref Scopus (2738) Google Scholar Initially, the debate focused on the positive and negative aspects that dedication and commitment to caring for people can entail for health care workers and the consequences caused by an overload of energy leading to a strong feeling of failure.6Freudenberger H.J. AADDStaff burn-out.J Soc Issues. 1974; 30: 159-165https://doi.org/10.1111/j.1540-4560.1974.tb00706.xCrossref Scopus (2738) Google Scholar,15De Hert S. CCAABurnout in healthcare workers: prevalence, impact and preventative strategies.Local Reg Anesth. 2020; 13: 171-183Crossref PubMed Scopus (158) Google Scholar,16Hilden J.M. Rajka T. Dalseg J. Solevåg A.L. A newly established pediatric high dependency unit in Norway – Interaction with existing pediatric intensive care.Glob Pediatr. 2021; 1: 100002https://doi.org/10.1016/j.gpeds.2021.100002Crossref Google Scholar However, its meaning and use have gradually expanded to include any type of professional, whose occupation has caused exhaustion, apathy, and inability to cope. Over the past 4 decades, the concept of burnout has become increasingly popular and the condition described by this term has gradually permeated various fields of civil society. The term burnout has evolved to become an indicator of individual distress with important repercussions in various organizational contexts, often far removed from the health care area, including the manufacturing sector, military personnel, and economic, administrative, and academic institutions.17Rodrigues H. Cobucci R. Oliveira A. Cabral J.V. Medeiros L. Gurgel K. et al.Burnout syndrome among medical residents: a systematic review and meta-analysis.PLoS One. 2018; 13: e0206840https://doi.org/10.1371/journal.pone.0206840Crossref PubMed Scopus (190) Google Scholar,18Huibers M.J. Beurskens A.J. Prins J.B. Kant I.J. Bazelmans E. Van Schayck C.P. et al.BBEEFatigue, burnout, and chronic fatigue syndrome among employees on sick leave: do attributions make the difference?.Occup Environ Med. 2003; 60: i26-i31PubMed Google Scholar That is, academic burnout commonly describes students' feelings of debilitation, pessimism, and low self-efficacy, symptoms experienced by students pressured and stressed by demanding school schedules. Academic burnout can also refer to feelings of fatigue and disengagement experienced by teachers due to the need to complete large programs.19Oloidi F.J. Sewagegn A.A. Amanambu O.V. Umeano B.C. Ilechukwu L.C. BBBBAcademic burnout among undergraduate history students: effect of an intervention.Medicine. 2022; 101: e28886Crossref PubMed Scopus (5) Google Scholar In military personnel, burnout is currently a commonly used term to describe the level of stress associated with the duties and challenges of professional life for combatants and their families.20Wu L. Chen Y. Liu X. Fang P. Feng T. Sun K. et al.The influence of job burnout on the attention ability of army soldiers and officers: evidence from ERP.Front Neurosci. 2022; 16: 992537Crossref PubMed Scopus (1) Google Scholar In 2019, the World Health Organization (WHO) noted that job burnout has become an important indicator of mental health.21BBCC-1 World Health OrganizationBurn-out an "occupational phenomenon": International Classification of Diseases.https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseasesDate accessed: January 29, 2023Google Scholar Therefore, it proposed its inclusion in the 11th edition of the International Classification of Diseases21BBCC-1 World Health OrganizationBurn-out an "occupational phenomenon": International Classification of Diseases.https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseasesDate accessed: January 29, 2023Google Scholar,22World Health OrganizationInternational organization of Diseases 11th revision.https://icd.who.int/enDate accessed: February 1, 2023Google Scholar (ICD-11). However, there is still no unanimous consensus for the definition of the condition of burnout and currently several definitions are used to refer to the same concept, including "occupational exhaustion syndrome," "psychological exhaustion," "fatigue syndrome," and "burned out syndrome".3Jameson D. BBDDPersistent burnout theory of chronic fatigue syndrome.Neurosci Med. 2016; 2016: 66-73Google Scholar Several studies have been conducted over the years exploring the relationships between persistent fatigue among employees, burnout, and chronic fatigue syndrome, 3 fatigue conditions that share several conceptual similarities and characteristics.18Huibers M.J. Beurskens A.J. Prins J.B. Kant I.J. Bazelmans E. Van Schayck C.P. et al.BBEEFatigue, burnout, and chronic fatigue syndrome among employees on sick leave: do attributions make the difference?.Occup Environ Med. 2003; 60: i26-i31PubMed Google Scholar However, results have been indecisive and currently a consensus definition of occupational burnout is still lacking, despite evidence of its impact on society.5Manzano-García G. Ayala-Calvo J.C. BBFFNew perspectives: towards an Integration of the concept "burnout" and its explanatory models.An Psicolog. 2013; 29: 800-809Google Scholar,23Guseva Canu I. Marca S.C. Dell'Oro F. Balázs A. Bergamaschi E. Besse C. et al.Harmonized definition of occupational burnout: a systematic review, semantic analysis, and Delphi consensus in 29 countries.Scand J Work Environ Health. 2021; 47: 95-107Crossref PubMed Scopus (75) Google Scholar This may explain the large variability in the prevalence of burnout among physicians (from 0% to 80.5%) reported in a recent review of data from 45 countries.15De Hert S. CCAABurnout in healthcare workers: prevalence, impact and preventative strategies.Local Reg Anesth. 2020; 13: 171-183Crossref PubMed Scopus (158) Google Scholar,24Rotenstein L.S. Torre M. Ramos M.A. Rosales R.C. Guille C. Sen S. et al.Prevalence of burnout among physicians: a systematic review.JAMA. 2018; 320: 1131-1150Crossref PubMed Scopus (892) Google Scholar Burnout has been extensively studied in various types of health care workers in public and private health care organizations. The Physician Health and Wellness guideline published in November 2022 by the American Academy of Pediatrics reports that from 2011 to 2014, the prevalence of burnout in general pediatricians increased by 10%, from 35.3% to 46.3%.25McClafferty H.H. Hubbard D.K. Foradori D. Brown M.L. Profit J. Tawfik D.S. Section on integrative medicine. Physician health and Wellness.Pediatrics. 2022; 150 (e2022059665)Crossref PubMed Scopus (4) Google Scholar The National Physician Burnout & Depression Report 2022, which surveyed more than 15 000 physicians from 29 specialties working in the United States, shows high rates of burnout in many medical specialties, including pediatrics (49%), after 3 years of COVID-19 pandemic management. The report also revealed that a significant increase in burnout was reported by physicians of all specialties in 2021 (47%) compared with 2020 (42%). Not surprisingly, a marked increase in burnout, from 43% to 60%, was also described in emergency medicine physicians during the same period. However, 54% of survey participants reported that burnout had a strong-to-severe impact on most aspects of their lives.26BBGG Cision Pr NewswireMedscape Physician Burnout & Depression Report 2022 shows Pandemic's Continued impact.https://www.prnewswire.com/news-releases/medscape-physician-burnout–depression-report-2022-shows-pandemics-continued-impact-301465333.htmlDate accessed: January 29, 2023Google Scholar However, data on pediatricians working in primary care settings were not included in these reports. Similar studies conducted in Europe show that especially after the pandemic, sleep disorders, stress, and anxiety have affected a large group of health care workers with an impact on their physical, emotional, and psychological well-being. Over the past decade, a considerable number of health care workers have left or are considering leaving their jobs due to physical and mental factors causing chronic exhaustion and unhappiness at work,13Sivarajasingam V. BBGG-1Address the emerging threat of burnout among primary care staff. MedscapeUK.https://www.medscape.co.uk/viewarticle/address-emerging-threat-burnout-among-primary-care-staff-2022a1001ij2Date accessed: January 30, 2023Google Scholar,27Staten A. Lawson E. BBGG-2GP wellbeing—combatting burnout in general practice.https://www.perlego.com/book/1575179/gp-wellbeing-combatting-burnout-in-general-practice-pdfDate: 2018Date accessed: January 30, 2023Google Scholar which are characteristic symptoms of burnout.28Hall L. Johnson J. Watt I. O'Connor D. BBGG-3Association of GP wellbeing and burnout with patient safety in UK primary care: a cross-sectional survey.Br J Gen Pract. 2019; 69: e507-e514Crossref PubMed Scopus (35) Google Scholar,29Petito A. Pop T.L. Namazova-Baranova L. Mestrovic J. Nigri L. Vural M. et al.The burden of depression in adolescents and the importance of early recognition.J Pediatr. 2020; 218: 265-267.e1Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar In the United Kingdom, the 2015 Commonwealth Fund survey revealed that 30% of general practitioners intended to leave the profession within 5 years, and later in 2019, a study reported a 3-fold increase in their early retirement compared with the previous decade.13Sivarajasingam V. BBGG-1Address the emerging threat of burnout among primary care staff. MedscapeUK.https://www.medscape.co.uk/viewarticle/address-emerging-threat-burnout-among-primary-care-staff-2022a1001ij2Date accessed: January 30, 2023Google Scholar This social phenomenon has caused a significant workforce shortage in primary care, which was further exacerbated by the COVID-19 pandemic. Primary care physicians have faced significant levels of stress since the onset of the pandemic, with more than half of physicians under 55 years of age experiencing emotional distress and burnout.30Bailey V. BBHHYounger primary care physicians seeing high levels of burnout, stress.https://revcycleintelligence.com/news/younger-primary-care-physicians-seeing-high-levels-of-burnout-stressDate accessed: January 29, 2023Google Scholar A survey conducted by the Federation of Italian Medical Boards reports that after the pandemic, 24% of community physicians experience sleep disturbances, stress, and fear, while depression and anxiety are reported in 20.5% and 25.8% of cases, respectively.31Antoninu C. More and more doctors victims of burnout: data from the Federation of Italian physicians. Emergency life.https://emergency-live.com/co/it/nutizzi/sempre-piu-medici-vittima-di-burnout-i-dati-della-federazione-degli-ordini-fnomceo/Date accessed: January 30, 2023Google Scholar However, in studies devoted to burnout and its manifestations in health care workers, the working condition of primary care pediatricians has received relative attention,32Jacobs L.M. Nawaz M.K. Hood J.L. Bae S. Burnout among workers in a pediatric health care system.Workplace Health Saf. 2012; 60: 335-344https://doi.org/10.1177/216507991206000803Crossref PubMed Google Scholar and studies assessing their state of work-associated emotional, mental, and physical exhaustion are scarce. Early identification of the many physical, emotional, and behavioral factors that are recognized as warning signs of burnout in health care workers33Maslach C. Leiter M.P. Schaufeli W.B. BBLLMeasuring burnout.in: Cooper C.L. Cartwright S. The Oxford handbook of organizational well-being. Oxford University Press, Oxford, United Kingdom2009: 86-108Google Scholar,34Bruce S.P. BBMMRecognizing stress and avoiding burnout.Curr Pharm Teach Learn. 2009; 1: 5764Google Scholar (Table I) can help develop useful strategies to prevent or mitigate this condition and introduce stress-reducing practices into the lifestyle that can safeguard their well-being35Peart N. BBNNMaking work less stressful and more engaging for your employees.in: HBR guide to beating burnout. Harvard Business Review Press, Brighton, Massachusetts2021: 139-148Google Scholar, 36Saunders E.G. BBOOSix causes of burnout, and how to avoid them.in: HBR guide to beating burnout. Harvard Business Review Press, Brighton, Massachusetts2021: 23-28Google Scholar, 37Somekh I. Somech R. Pettoello-Mantovani M. Somekh E. Changes in routine pediatric practice in light of Coronavirus 2019 (COVID-19).J Pediatr. 2020; 224: 190-193Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar (Table II).Table IBurnout in health care workers: revealing signesWarning signs of burnout in health care workersPhysical Migraine or dizziness Muscle strain or pain Cramps, persistent nausea, or vomiting episodes Colitis Chest sprain or strain or a tachycardia Changes in sexual activity Sense of fatigue Worsened health conditions Shortness of breath Loss of appetite Eating disorders Sleeping disordersMental and emotional Attention disorders impaired decision-making ability Overwhelming thoughts Negative thinking and constant worrying Absent-mindedness Forgetfulness Loss of self-confidence Sense of failure Feelings of hopeless and helpless Detachment and loneliness Low motivation and frustration. Development of suspiciousness and negative outlook. Feeling of missing accomplishment Feeling of work overload and excessive job demand Feeling of pressure Inability to manage conflicting situations Feeling poorly rewarded for the work performed Feeling isolated and emarginated. Inability to start new relations at work and in the personal life Perceiving the work to be unfair or inequitable or meaninglessBehavioral Avoiding responsibilities. Social isolation. Slower performance at work Introducing drugs or alcohol to cope. Overeating Oversleeping Insomnia Sense of frustration Irregular attendance at work Absenteeism Hyperactivity disorders, irritability Increased smoking Loss of personal goals and commitments Difficulty in keeping relationships active Breaking friendships Making careless mistakes Obstructive and uncooperative behavior Careless spending Open table in a new tab Table IIBurnout stress reducing practicesStress reducing practices recommended to safeguard the well-being of health care workers with burnout• Making changes in the personal lifestyle• Making changes in the work environment• Reorganizing working hours• Taking breaks during the working days or taking days off during the weeks or months.• Knowing the list of signs typical of burnout to perform self-examinations.• Introducing physical exercising in the daily schedule• Keeping control of the diet and avoid eating disorders• Keeping control of the daily schedule• Keeping control of the sleeping schedule• Avoiding routine activities perceived as stressing factors.• Avoiding relaxing behaviors that can cause boredom.• Considering the practice of meditation and yoga• Socializing with colleagues• Connecting with a friend or family members and dedicate time to catch up• Checking in with a therapists.• Seeking professional help• Taking advantage of support or advocacy groups Open table in a new tab Preventive strategies include identifying, removing or reducing stress-causing factors, developing a supportive social network, taking care of personal health, reorganizing work life and setting clear expectations, increasing understanding of self-identity and acquiring a stable and consistent perception of it through careful reorganization of personal values, thinking, and actions.33Maslach C. Leiter M.P. Schaufeli W.B. BBLLMeasuring burnout.in: Cooper C.L. Cartwright S. The Oxford handbook of organizational well-being. Oxford University Press, Oxford, United Kingdom2009: 86-108Google Scholar, 34Bruce S.P. BBMMRecognizing stress and avoiding burnout.Curr Pharm Teach Learn. 2009; 1: 5764Google Scholar, 35Peart N. BBNNMaking work less stressful and more engaging for your employees.in: HBR guide to beating burnout. Harvard Business Review Press, Brighton, Massachusetts2021: 139-148Google Scholar, 36Saunders E.G. BBOOSix causes of burnout, and how to avoid them.in: HBR guide to beating burnout. Harvard Business Review Press, Brighton, Massachusetts2021: 23-28Google Scholar Numerous studies show that health care workers are particularly exposed to burnout.6Freudenberger H.J. AADDStaff burn-out.J Soc Issues. 1974; 30: 159-165https://doi.org/10.1111/j.1540-4560.1974.tb00706.xCrossref Scopus (2738) Google Scholar,33Maslach C. Leiter M.P. Schaufeli W.B. BBLLMeasuring burnout.in: Cooper C.L. Cartwright S. The Oxford handbook of organizational well-being. Oxford University Press, Oxford, United Kingdom2009: 86-108Google Scholar Since the COVID-19 pandemic, higher rates of burnout have been reported in all medical specialties, including pediatrics. Burnout can now be considered a COVID-19 pandemic-related health condition affecting an increasing number of primary care physicians. However, only occasional data on the effects of burnout in primary care pediatricians are reported. EPA-UNEPSA, in collaboration with the FIMP and ECPCP, has established a working group to study the condition of burnout in primary care pediatrics in Europe. The goal is to develop a guide for early identification and mitigation of this condition in pediatricians working in primary care settings.38Pettoello-Mantovani M. Namazova-Baranova L. Ehrich J. 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