Burnout syndrome in family physicians – experiences from Bosnia and Herzegovina

The burnout syndrome is a response to a long term chronic emotional and interpersonal stressors that are related to workplace. It emerges as the consequence of non-harmonized relations between employees on one, and working environment on the other side. It is defined as chronic work stress that includes three dimensions: the sense of the emotional exhaustion, the negative approach to providing services (depersonalization) and the sense of reduced personal accomplishment. It occurs most often in persons who work in direct contact with other people. Medicine is one of the professions at the greatest risk of suffering from burnout syndrome. The results of the studies conducted in the neighbouring countries, in Europe and in the world showed a big prevalence of burnout syndrome among medical workers, especially in physicians. The acquired results indicate that there is a need to undertake measures for prevention of the burnout syndrome.


Introduction
Term "burnout syndrome" was for the first time used by psychoanalyst Herbert Freudeberger from New York in 1970. year to describe status of physical and mental exhaustion caused by the personal professional life. The syndrome presents the process of physical and mental exhaustion in persons employed in certain fields: educational employees, health care employees, workers employed in social services and employed in public services for emergency situations. Burnout syndrome at working place presents special problem in so called "service occupations" where the essence of the job makes relation provider-receiver of services [1][2][3][4].
Burnout syndrome at work is a long term response to emotional and interpersonal stressors that are related to working place. It occures as the consequence of non-harmonized relations between employees on one, and working environment on the other side. It is characterized by psychical or emotional exhaustion, fatigue and depression, whereas there is a grater accent on psychical then physical symptoms. Affected persons have fatigue, malaise, undefined physical pain for longer periods of time (headache, back pain, insomnia, gastric problems etc.). Affected persons are sensitive, permanently tensed, impulsive, grasp at alcohol or drugs, and can express sadness, pessimism, tightness, emotional rigidity, hypersensitivity, helplessness, sense of despair.
Etiopathogenesis of the burnout syndrome at work is complex but it is generally considered that a prolonged "negative stress" is a key factor in its occurrence. Individual characteristics of individuals and impossibility of successful stress overcoming also have an important role. Negative feelings of persons with a high level of the burnout syndrome at work are related to loss of feeling for professional responsibilities, loss of capability for self-realization and loss of personal perspective. Feeling of existence absurdity and loss of interest for everything that happens influence all life spheres of the person with burnout syndrome at work. If the person is in this state for longer period of time it loses capability to enjoy life, and the quality of life of these persons is significantly decreased [5,6].
Burnout syndrome at work is defined as a chronic work stress that includes three dimensions: the sense of the emotional exhaustion, the negative approach in providing services (depersonalization), the sense of decreased satisfaction and the lack of professionalism (lack of personal satisfaction). This definition is recommended by means of basic studies conducted with the aim of finding the best instrument for investigating of these phenomena (Maslach Burnout Inventory, Maslach & Jackson, 1981, 1986 [7].
During the previous period we are all exposed to numerous of stressors coming from the outside environment, and among stressors many are originating from the working environment and causing professional stress. Professional stress is one of the hardest harms for the health care workers that are exposed every day to numerous changes and demands of their working place. All the things that change established life habits, "unbalance the organism" and request adaptation to the new situation present stress. If the causes of stress are regarding to working environment, then we speak about working stress that represents the greatest risk factor for developing of the burnout syndrome at work [8].
Majority of authors think that causes of the syndrome may come from the characteristics of professional activities and from individual characteristics of the persons. According to Maslach, reasons for developing of the burnout syndrome often do not depend on person but on conditions at working place. Some personal characteristics have an effect oh the development of syndrome: high level of emotional liability, high level of self-control (e.g. keeping of negative emotions), predisposition for high level of anxiety and depressive reactions, rigid personality structure. Professional stress is not a problem for mentally "strong" persons, but problems with unsolved situations in relations with associates, unclear social position and support, lack of emotional support of the colleagues and managers also may be the cause for occurrence of the burnout syndrome at work among these persons [9][10][11]. Empirical researches showed that situational factors have stronger influence at status of mental exhaustion compared to personal characteristics of individuals. Persons preoccupied with work and exposed to frequent interpersonal conflicts during the longer period of time in greater number have symptoms of emotional exhaustion [12,13].
Health care workers represent the profession with the highest risk for getting ill from burnout syndrome at work. They give high emotional contribution in solving the most subtle physical, psychical and social problems of their patients. The social contact of health care workers is not only directed towards patients but also towards associates at work, superior structures, patients' parents and relatives and other persons [14,15]. Health care workers are exposed to increased risk of getting ill from burnout syndrome at work also due to the influence of other harmful factors related to working place. Ionizing and non-ionizing radiation, vibrations, various chemical vapours, adverse microclimate conditions, work in unphysiological body posture, work in shifts, and specially night shift work are important risk factors for getting ill from burnout syndrome at work. Stresses at working place and so called "mental pollution" may influence the burnout syndrome developing. As the most common causes of stress at the working place are considered: interpersonal relations at working place (relations with patients, colleagues, managers), satisfaction or dissatisfaction with work, possible conflict situations at working place, insufficient education for performing working tasks, overwork, unrealized promotion in service and other. [16][17][18][19].

Researches in the region and world
Large scale research of the representation of the burnout syndrome at work in family physicians in 12 European countries (Bulgaria, Croatia, France, Greece, Hungary, Italy, Poland, Portugal, Sweden, Spain, Great Britain and Turkey) revealed that 43% examinees had high level of emotional exhaustion, 35% high level of depersonalization, 32% low level of personal satisfaction, and 12% had expressed symptoms of burnout syndrome at work in all three dimensions. The conclusion of this study is that burnout syndrome at work is common problem in physicians at primary health care [20].
The study conducted in Great Britain included 295 physicians at primary health care. Research results showed high level of burnout syndrome with interviewed physicians, and physicians that have not been working full working time had less level of burnout syndrome at work comparing to physicians who have been working full working time [21]. Research conducted among 123 Canadian family physicians showed that 42.5% physicians have high level of stress, and 47.9% high level of emotional exhaustion and depersonalization [22]. Study conducted in Denmark was made by interviewing of 379 active family physicians. Research investigated prevalence of syndrome concerning membership in the group for Continuous medical education. Study results presented that prevalence of burnout syndrome at work with interviewed family physicians was 25%. Prevalence of burnout was significantly higher with physicians that were not members of the group for Continuous medical education [23]. Research about presence of burnout syndrome at work in health care workers in Inđija (Serbia) was conducted among 152 health care employees: 37 physicians, 88 nurses and 27 physical therapists. Research results showed that burnout syndrome at work was present in 46.7% examinees, and considering profession, syndrome was present in 23.9% physicians, 50.0% nurses and 37.0% physical therapists [24]. In the research conducted in Serbia, the level of exposure of physicians to professional stress was investigated, the level of stress in a group of general practitioners and psychiatrists and level of occurrence of the burnout syndrome was compared. Research involved 30 general practitioners from the Health care centre "dr Laza K. Lazarević"from Šabac and 30 psychiatrists from the Institute of Psychiatry of the Clinical centre of Serbia in Belgrade. Research results showed that 58% of examinees are (63% of general practitioners and 53% of psychiatrists) at high risk from burnout syndrome at work on the subscale of emotional exhaustion; 59% of examinees are (47% of general practitioners and 70% of psychiatrists) at high risk from the syndrome on the depersonalization scale, while on the scale of personal satisfaction 93% of examinees are (87% of general practitioners and 100% of psychiatrists) at low and 7% (13% of general practitioners and 0% of psychiatrists) at medium risk from burnout on the personal satisfaction scale [25]. Study conducted in Zagreb(Croatia) where there was interviewed 41 health care worker in internal medicine intensive care unit and 30 health care workers in surgery intensive care unit showed that the majority of examinees meet criteria for moderate level of burnout syndrome at work. Examinees employed in internal medicine intensive care unit expressed higher level of emotional exhaustion comparing to examinees in surgery intensive care [26].
There are numerous researches on presence of burnout syndrome at work in resident physicians. Research conducted in USA showed that syndrome is present in 50% resident physicians. Burnout syndrome at work was the most present in resident physicians from gynaecology and obstetrician (75%), and the least present in physicians at specialization from family medicine (27%) [27]. In the article "Resident Burnout" there are summarized and published results of 15 different researches on prevalence and causes of burnout syndrome at work in resident physicians. Researches were conducted in the period from 1983 until 2004. According to researches' results it is concluded that intensive work, limited control and disturbance of relation jobhome due to numerous obligations at specialization are the most important predisposing factors for developing of the burnout in resident physicians. Studies' results have indicated that a high level of syndrome is connected with depression and inadequate patient care [28].

Researches in Republic of Srpska, Bosnia and Herzegovina
Research conducted during 2011 in family medicine physicians in Republic of Srpska (Bosnia and Herzegovina) included 259 family medicine physicians employed in seven health care centres and physicians at specialization from family medicine. Prevalence of doctors with a high stress level (75.3%) was extremely high. The majority of interviewed physicians had a high (46.0%) level of emotional exhaustion, low (46.9%) level of depersonalization, low (43.1 %) level of personal satisfaction. The level of emotional exhaustion was statistically significantly higher in female examinees, while at levels of stress, depersonalization and personal satisfaction there was not statistically significant difference regarding the sex. Results of the same research showed that there is positive correlation in a stress level in general practitioners and specialists ( p=0.000), whereat specialists had more accentuated stress level compared to general practitioners. General practitioners had higher level of personal satisfaction compared to specialists, while specialists had significantly more expressed emotional exhaustion compared to general practitioners (p=0.000). At depersonalization levels, statistically significant difference between general practitioners and specialists was not found [29]. Results of the same research showed that the level of stress and emotional exhaustion is significantly higher in older physicians (>50 years of life) and with more years of service (>21 years) [30].
Research conducted in resident physicians from family medicine in Republic of Srpska presented that 59.6% of examinees had high level of stress, 25.6% high level of emotional exhaustion, 25.6% high level of depersonalization, and 42.5% low level of personal satisfaction [31]. Research results in resident physicians from family medicine in Republic of Srpska showed that marital status and number of children in the family do not have influence on level of stress and burnout syndrome at work [32].
Research in Republic of Srpska (Bosnia and Herzegovina) was conducted during 2015. in which the level of stress and burnout syndrome at work in physicians employed in hospital and family physicians has been evaluated. In this study 151 physicians participated, out of whom there were 49% family physicians, and 51% hospital physicians. Research results showed that 51.7% of examinees had high level of stress (52.7% of family physicians, 50.6% of physicians in the hospital). High level of emotional exhaustion was found in 27.2% of examinees (29.7% of family physicians, 24.6% of physicians in the hospital), high level of depersonalization in 23.8% of examinees (25.7% of family physicians, 22.1% of physicians in the hospital), and low level of personal satisfaction in 39.7% of examinees (37.8% of family physicians, 41.6% of physicians in the hospital). Although exposure to professional stress was higher in family medicine physicians then in hospital physicians, obtained difference is not statistically significant. Doctors aged 45 and older had statistically significant (p = 0.030) higher level of emotional exhaustion compared to examinees of younger age. This research showed that there is high risk of occurrence of burnout syndrome in physicians in Republic of Srpska [33].

Conclusion
Results of numerous researches conducted in the world, Europe and surrounding countries showed high level of burnout syndrome at work in physicians of all specialties. During the last fifteen years in Republic of Srpska reform in primary health care has been intensively conducted, and each reform aggravates health status of physicians and level of burnout syndrome at work is increased. Family physician is during whole working time in a direct contact with patients, burdened with a great number of patients with chronic diseases, their social and other problems for which he is not always in a possibility to find a solution. Patients often have greater expectations from a family physician then one can give, what often brings physician in a state of chronic stress. Family medicine doctors are additionally burdened with a lot of administration, lack of time to receive all patients, and in Bosnia and Herzegovina they are also significantly burdened with solving their patients' social problems. Self-help and care about oneself is not a part of professional education of doctors and mainly takes very low place on the doctors' priority list. These data indicate necessity of undertaking measures on prevention of stress and burnout syndrome at work.