3 Results
From a total of 486 eligible urologists to participate in this study, 184 respondents (37% response rate) returned the questionnaire. In the sampled group, a majority of the respondents were male, accounting for 92.4% (170 individuals), while females represented a smaller portion at 7.6% (14 individuals). When considering marital status, the majority, 94% (173 individuals), were married, and a smaller proportion, 6% (11 individuals), were single. Respondents' socio-demographic characteristics are presented in Table
1.
Table 1
Respondents' socio-demographic characteristics
Age, years old, median (range) | 39 (30–77) |
Gender, n (%) |
Male | 170 (92.4%) |
Female | 14 (7.6%) |
Marital status, n (%) |
Single | 11 (6%) |
Married | 173 (94%) |
Number of workplaces, n (%) |
1 | 16 (18.7%) |
> 1 | 168 (91.3%) |
Working experience, years, median (range) | 5 (1–45) |
Primary workplace, n (%) |
Primary teaching hospital | 55 (29.9%) |
Affiliated teaching hospital | 50 (27.2%) |
Non-teaching public hospital | 36 (19.6%) |
Private hospital | 43 (23.4%) |
Structural position, n (%) |
Yes | 84 (45.7%) |
No | 100 (54.3%) |
Questionnaire filling time, n (%) |
Before COVID-19 pandemic | 72 (39.1%) |
After COVID-19 pandemic | 112 (60.9%) |
Overall burnout syndrome rate among respondents was 23.4%. In the emotional exhaustion (EE) dimension, a majority of the participants, 54.9% (101 individuals), reported low levels. For the depersonalization (DP) dimension, a significant 77.7% experienced low levels. Regarding personal achievement (PA), 41.8% had low scores. Meanwhile, in terms of those with more severe burnout, 15.2% scored high in EE dimension, 4.9% scored high in DP dimension, and 12.5% scored high in PA dimension. The MBI classification distribution for each dimension of MBI and it score are shown in Table
2. Moreover, analysis of socio-demographic variables and possible stress variables which might influence burnout syndrome is shown in Table
3,
4 and
5.
Table 2
Overall prevalence and level of MBI dimensions among Indonesian urologist
EE | 101 (54.9%) | 55 (29.9%) | 28 (15.2%) | 16.3 ± 9.9 |
DP | 143 (77.7%) | 32 (17.4%) | 9 (4.9%) | 4.17 ± 4.1 |
PA | 77 (41.8%) | 84 (45.7%) | 23 (12.5%) | 37.5 ± 6.3 |
Table 3
Statistical analysis comparing sub-stratified independent variables with burnout among Indonesian urologist
Age, years |
≤ 44 | 34 (27.9) | 2.2 (1.0–5.1) | 0.04* |
> 44 | 9 (4.5) | 0.4 (0.2–0.9) |
Marital status |
Married | 37 (21.4) | 0.23 (0.1–0.8) | 0.021* |
Divorced | 3 (75) | 0.4 (0.31–5.151) | 0.60 |
Single | 3 (42.9) | Ref. | |
Number of workplace |
1 | 2 (12.5) | 0.4 (0.9–2) | 0.36 |
≥ 2 | 41 (24.4) | 2.5 (0.5–1.1) |
Structural position | 15 (17.9) | 0.5 (0.3–1.1) | 0.10 |
Vacations |
Once a week | 7 (18.4) | Ref | Ref |
Once every 2 weeks | 2 (25) | 1.5 (0.2–8.9) | 0.64 |
Once a month | 6 (24) | 1.4 (0.4–4.8) | 0.75 |
Once every 3 months | 12 (23.1) | 1.3 (0.5–3.8) | 0.79 |
Once every 6 months/less | 16 (26.2) | 1.5 (0.6–4.3) | 0.46 |
COVID-19 Era | 20 (17.9) | 0.4 (0.2–0.9) | 0.03* |
Table 4
Stress factors related to burnout syndrome based on Likert scale
Operative stress | 3.4 ± 1.2 (2.92–3.79) | 2.9 ± 0.9 (2.63–3.08) | 0.002* |
Administrative workload | 3.3 ± 1.2 (2.85–3.73) | 2.6 ± 1.1 (2.32–2.84) | 0.003* |
Inadequate support/communication with management | 3.1 ± 1.3 (2.57–3.56) | 2.1 ± 1.0 (1.83–2.30) | < 0.001* |
Salary | 3.1 ± 1.1 (2.73–3.53) | 2.2 ± 0.8 (1.96–2.36) | < 0.001* |
Inadequate support/communication from colleague | 2.8 ± 1.2 (2.34–3.21) | 1.9 ± 1.0 (1.67–2.12) | < 0.001* |
Patient decision-making or care in wards/clinic | 2.8 ± 0.8 (2.51–3.17) | 2.1 ± 0.8 (1.89–2.28) | < 0.001* |
Working in private hospital | 2.5 ± 0.8 (2.14–2.76) | 1.8 ± 0.9 (1.62–2.02) | < 0.001* |
Working in type B hospital | 2.7 ± 1.1 (2.26–3.03) | 1.8 ± 0.9 (1.64–2.04) | < 0.001* |
Teaching | 2.3 ± 1.1 (1.89–2.69) | 1.9 ± 0.9 (1.67–2.07) | 0.022* |
Working in type C hospital | 2.6 ± 1 (2.18–2.91) | 1.7 ± 0.8 (1.53–1.89) | < 0.001* |
Medicolegal issues | 2.83 ± 1.1 (2.13–3.54) | 2.9 ± 1.0 (2.61–3.33) | 0.67 |
Research | 2.9 ± 1.5 (2.41–3.31) | 2.6 ± 1.2 (2.45–2.83) | 0.437 |
Working in primary teaching hospital | 1.8 ± 1.2 (1.08–2.59) | 2.2 ± 1.1 (1.79–2.57) | 0.416 |
Working in affiliated teaching hospital | 1.7 ± 0.9 (1.10–2.23) | 1.8 ± 0.9 (1.51–2.14) | 0.071 |
Working in type A hospital | 1.67 ± 1.1 (0.98–2.35) | 2.1 ± 0.9 (1.76–2.41) | 0.804 |
Working in non-teaching public hospital | 1.3 ± 0.7 (0.92–1.75) | 1.7 ± 0.8 (1.38–1.97) | 0.191 |
Structural position | 1.2 ± 0.6 (0.8–1.53) | 2.3 ± 1.0 (1.91–2.62) | 0.145 |
Table 5
Multivariate analysis of significant variables
Age, years |
≤ 44 | 34 (27.9) | 88 (72.1) | 122 | 2.2 (1.0–5.1) | 0.04 | 1.8 (0.8–4.3) | 0.13 |
> 44 | 9 (4.5) | 53 (85.5) | 62 | |
Marital status |
Married | 37 (21.4) | 136 (78.6) | 173 | 0.2 (0.1–0.8) | < 0.01* | 0.3 (0.1–0.9) | 0.04* |
Divorced | 3(75) | 1 (25) | 4 | 0.4 (0.3–5.1) | 0.60 |
Single | 6 (85.7) | 1 (14.3) | 7 | Ref | | | |
Structural |
Yes | 15 (17.9) | 69 (82.1) | 84 | 0.5 (0.3–1.1) | 0.1 | 0.6 (0.3–1.3) | 0.22 |
No | 28 (28) | 72 (72) | 100 | | | | |
COVID Era |
Yes | 20 (17.9) | 92 (82.1) | 112 | 0.4 (0.2–0.9) | 0.03* | 0.5 (0.2–0.9) | 0.052 |
No | 23 (31.9) | 49 (68.1) | 72 | | | | |
As for the outcomes, we evaluate smoking and alcohol consumption. Bivariate analysis using Chi-square showed respondents with burnout syndrome smoking rate were higher than those without burnout syndrome (OR 3, 95% CI, 1.3–7). A similar result was shown in alcohol consumption; those with burnout syndrome tend to consume alcohol more than those without burnout syndrome (OR 2.7, 95% CI, 1.1–6.7).
4 Discussion
From the results, most of the respondents have low EE (54.9%), low DP (77.7%), and moderate PA (45.7%). Urologists below 44 years old are considered young urologists who are 2.2 times more likely to develop burnout syndrome. The component of burnout syndrome most associated with age is DP, and EE
10. Higher rates of DP and EE in younger urologists might be caused by routine cognitive workload, performance anxiety, and fear of patient complications since such urologists are relatively inexperienced
11. This is consistent with previous study conducted by Franc-Guimond et al.
6, which explains that junior urologists have more multiple administrative roles in academic institutions than their senior counterparts.
Urologists at their early stages are considered to be 'vulnerable' at that point in their careers
6. A study by Rodriguez-Socarras et al.
12 found that young urologists and residents have tendencies to exercise too little and consume an unbalanced diet. Also, both groups often suffer from sleep disturbances. Those factors may be associated with a higher risk of burnout syndrome
12. Roumiguie et al.
13 explained that burnout syndrome severity decreased along with increased age and senior status. This finding may also reflect the 'survivor effect,' especially for those who felt unable to manage the position demands
2. Porto et al.
9 explained that older physicians tend to experience less burnout due to developed coping mechanism, which includes becoming more mature and confident, toward the demands of being a physician.
Urologists who are currently married decreased risk of burnout (
p = 0.021). This might be due to the reason that married physicians are usually older and more psychologically mature, thus being able to cope with stress better
14. Other than that, such physicians have higher interpersonal skills, problem-solving skills, and adaptability as they have been involved with their families
11. However, a study by Guler et al. (2019) found that burnout syndrome test scores were not significantly different between single and married health professionals
15. Franc-Guimond et al.
6 also stated that even the presence of familial support seems to be weighed down by professional factors such as poor professional relationships and malpractice claims. Thus, it can be concluded that the association between marital status perhaps the ‘quality’ of the marriage is also a factor and burnout syndrome is still inconsistent. Even so, based on research, divorce has an influence on burnout. It was discovered that higher levels of divorce fatigue were strongly predicted by fewer prior divorces, former spouses initiating divorce, not having a new partner, and higher levels of burn out
16. In this study, specifically for divorce respondents, it has an MBI value of emotional exhaustion domain 24
\(\pm\) 8.28, depersonalization domain 7.5
\(\pm\) 4.43, personal achievement domain 31.75
\(\pm\) 7.7.
This study found that the COVID-19 era is associated with a lower risk of burnout syndrome in the participants (OR = 0.4,
p = 0.03). This may be because of the physical and social distancing policy to tackle the COVID-19 health problem in Indonesia. Patients in this era tend to avoid going to health care facilities due to fear of being infected. Thus, patients in the urology department decrease, minimizing the workload of urologists. However, this pandemic actually increases the risk of burnout syndrome in other departments, such as emergency unit, intensive care, and radiology, which are considered front line medical staff for COVID-19
15. Outside the COVID-19 era, specialties associated with increased risk of burnout syndrome include emergency, family, and internal medicine
17. Other than doctors, nurses are also affected in the same manner, although less than medical personnel
18. Increased risk of burnout syndrome in those departments is due to high workload, fear of being infected, lack of personal protective equipment, and disrupted social support because of isolation or quarantine.
19
The change of working environment and shift of the national health coverage toward COVID-19 diagnosis and treatment also play a role. This altered state of national health coverage from the past results in more time and work relegated to the documentation required by the medical staff and/or patient to successfully claim the insurance. A study by Reith et al.
20 stated that such confusing and burdensome bureaucratic tasks lead to a higher risk of burnout and reduce the critical time that physicians need to provide optimal care for the patients.
The most influential stress factor for burnout syndrome is operative stress (
p = 0.002), followed by administrative workload (
p = 0.003), inadequate support/communication with management (
p < 0.001), and salary (
p < 0.001). Operative stress is more commonly found in younger surgeons and is independently associated with a perceived lack of autonomy and frustration at work
2. Such lack of independence in junior surgeons is common in Indonesia, since much of the work tends to be delegated to the juniors. Other than surgical workload, it also leads to the more administrative workload of junior surgeons, such as more electronic health record (EHR) work.
11
Inadequate support/communication with hospital management plays a role in increasing burnout risk
2. Unfinished inquiry related to late wage payment due to incoordination between hospital and national health coverage in Indonesia was one of the biggest issues. Practicing physicians are more concerned with providing patients with services that often result in cost overruns. On the contrary, management seeks to minimize cost, but in doing so, the goals of delivering the best medical treatment sometimes forfeited in the process. Therefore, lack of communication with hospital management might increase the likelihood of burnout, causing clinicians to put in more effort in achieving these goals with the little amount of working room provided, in terms of cost and budget. Late wage payment directly impacts salary; therefore, it becomes the fourth major stress factor which is pictured as lack of appreciation. Compared to two other studies, similar results were showed that salary or financial concern acts as a causative factor.
2,
6
In this study, burnout syndrome leads to increased alcohol consumption (OR = 3) and smoking activity (OR = 2.7). Alcohol may be an effort of the physicians to combat their burnout state
6. This shows that such physicians are reluctant to seek professional help
2. Alcohol consumption is also more commonly found in urology residents who are junior urologists, up to 2–3 times/week
12. Another study by Porto et al.
9 found that surgeons had a higher mean PA score, which shows that alcohol is related to the presence of stress and vulnerability at work. Since this is a cross-sectional study, it is unclear whether alcohol and smoking are indeed the outcomes or the factors preceding burnout syndrome. Alcohol and smoking could be a risk factor for burnout syndrome, as a similar study with a systematic review conducted by Galaiya et al.
21 found that surgeons who misuse alcohol and smoke cigarettes have higher levels of burnout
22. However, some studies found no significant difference in burnout syndrome between smokers and non-smokers [
9,
23]. It should be taken into account that the prevalence of alcohol consumption and smoking in Indonesia is less than in other countries; thus, it could explain any differences in results or magnitude.
This study has some limitations. First, this study does not implement a randomized sampling method, as we excluded urologists who does not reply or does not respond after we contact the urologist. Other than that, there might be subjective respondent unwillingness, to be honest, answering questions related to alcohol and smoking, most probably due to fear of judgment. This may create a response bias. Another limitation is that this study has a cross-sectional design, in which the exposures and outcomes are measured at the same point in time. This creates an observation bias, especially for the alcohol and smoking variables, as it cannot be determined which variable preceded the other, thus not allowing causal explanation. Finally, the Maslach Burnout Inventory (MBI) used in this study is translated into the Indonesian language and officially published in JP3I (Jurnal Pengukuran Psikologi dan Pendidikan Indonesia) [
24].