Burnout is a psychosocial syndrome characterised by emotional exhaustion, elevated depersonalization, and low personal accomplishment. The prevalence of burnout is relatively high among health professionals around the world1,2 and entails potentially serious consequences for both professionals as well as patients.

Depersonalization is associated with worse patient care3,4, while good personal accomplishment helps prevent emotional exhaustion and depersonalization5,6, thereby reducing the risk of psychiatric morbidity7,8. In Spain, we have observed a prevalence of burnout syndrome among internists of 33.4%. The syndrome is more frequent in younger doctors and is related to poor working environment, the feeling that professional progression is not possible, insufficient economic compensation, and threats from patients or colleagues9.

In addition, the COVID-19 pandemic has put considerable pressure on health professionals and systems10 with the prevalence of burnout syndrome situated at 38% among Spanish internists in 202011.

In light of these results, there was a need to conduct a comparative study of the prevalence of burnout syndrome in order to quantify and describe in greater detail its effects on healthcare workers, and to facilitate decision-making regarding preventive measures and better training for health professionals.

The aim of this study is the study the prevalence of burnout syndrome in internal medicine attending physicians in Spain before and after the pandemic caused by SARS-CoV-2, estimating that an increase in prevalence of the syndrome will be observed.

Two surveys were created using the Google Forms® platform. It was shared via email and the Spanish Society for Internal Medicine (SEMI) social networks (Facebook, Twitter, Instagram) from February to April 2019 and in May 2020. The first sample (from February to April 2019) was conducted to study the prevalence of the syndrome as well as the factors contributing to its onset, the results of which have already been published9.

To quantify the degree of burnout among professionals, the Spanish version of the Maslach Burnout Inventory12 (MBI) questionnaire was used, which explores the three dimensions of the syndrome through 22 questions: 9 regarding emotional exhaustion, 5 on depersonalization, and 8 about personal accomplishment. The 22 items are formulated as statements with a Likert scale from 0 to 6. For each dimension, the signs of burnout were determined by a score of more than 26 for the questions related to emotional exhaustion; more than 9 for depersonalization, and less than 34 for personal accomplishment.

Burnout syndrome is defined as presenting excessive emotional exhaustion, elevated depersonalization, and low personal accomplishment. Only the responses from internal medicine attending physicians working within Spanish territory were taken into consideration. The age and sex distribution of the participants is comparable to the distribution of all the SEMI members.

This study complies with the Declaration of Helsinki criteria. The surveys were anonymous and all the participants agreed to their responses being used for research purposes and to the publication of the results. Approval was requested from the Hospital Universitario Gregorio Marañón Ethics Committee. Said committee stated that, due to the characteristics of the study (anonymous and no confidential data), approval was not needed.

A comparative analysis was carried out using the χ2 test (or Fisher’s exact test for n < 5) for the qualitative variables, and Student’s t-test for the quantitative variables. To reject the null hypothesis and establish statistical significance, a p-value of p < 0.05 was established.

The analysis was performed using the SPSS V. 22.0 program (SPSS, Chicago, Illinois, USA).

A total of 934 responses were obtained in 2019 and 765 in 2020 (Table 1) which corresponds to a 14.75% and 12.08% participation rate based on the number of SEMI members, respectively. A significant increase in low personal accomplishment was observed (33.0% vs. 66.4%; p < 0.002).

However, though not significant, an increase in emotional exhaustion was observed (43.3% vs. 56.7%; p = 0.66), as was depersonalization (40.8% vs. 59.2%; p = 0.418), and burnout syndrome in general (34.4% vs. 38%; p = 0.112). We did not find any significant differences in terms of sex or age among the participants with burnout syndrome.

A non-significant increase in burnout syndrome has been observed in internal medicine attending physicians from 2019 to 2020; other publications have confirmed a significant increase following the outbreak of COVID-1910,13. It is likely that the high degree of burnout among our internists prior to the pandemic has affected this result.

The rate for the two periods is in line with the interval established in prior publications (30%–60%)1,2. A significant increase in low personal accomplishment was detected. This finding is concerning given that personal accomplishment has been associated with preventing the two other dimensions of burnout, namely emotional exhaustion and depersonalization5,6, as well as reducing the risk of psychiatric morbidity7,8.

In the publication by Wu et al.14, a lower prevalence of burnout was observed among the health professionals working on the front-line during the pandemic than those working on regular wards. It is likely that the latter had more information about SARS-CoV-2 infection and, therefore, had a greater feeling of control over the situation.

In the past, interventions have been proposed in order to specify the roles and responsibilities of health professionals given that a negative correlation has been detected between ambiguity regarding responsibilities and personal accomplishment15. The longitudinal study by Wade et al.16 details how the level of control that professionals perceive is inversely related to burnout.

It must be mentioned that during the pandemic, our internists were exposed to unprecedented, significantly heavy workloads. In the analysis conducted to study which factors have been associated with higher burnout rates during the pandemic, a greater association was observed with factors related to fear of infection (treating patients with COVID, not having PPE, or using public transport to get to work) and excessive workload with no posterior recognition (no exemptions from being on-call, increased responsibilities, and unpaid overtime hours)11. Likewise, during the pandemic, health professionals often had to make difficult decisions that went against their ethical principles, with the resulting negative impact on their feelings of personal accomplishment.

The results of the survey integrated with the MBI from Shanafelt et al.3, aimed at a group of internal medicine residents, indicate that the participants experiencing burnout were significantly more likely to classify it as a “survival attitude” or as “important” or “essential” for adequate stress management.

We find it necessary to shine a spotlight on the creation of measures for individuals on how to respond to a chaotic environment. To do so, the entropy model of uncertainty as proposed by Hirsch et al.17 is particularly interesting and can be applied to this context. This theoretical framework applies the concept of entropy, derived from thermodynamics, to current psychological models. This comparison illustrates a key process: the same instability present in environmental challenges, in other words, the same increase in internal entropy, which is responsible for the formation of new cognitive structures and, therefore, adaptation, may also be responsible for a decline in the system if said uncertain situation lasts too long and is not productive. Therefore, the development of personal skills aimed at reducing perceived entropy and uncertainty could promote better cognitive and behavioural adaptation18.

In terms of the study limitations, it must be mentioned that, given the design and delivery system of the surveys, it is possible that participants who experienced some form of burnout syndrome were more likely to take part in the study, thus overestimating the result. However, we believe that the large number of survey participants helps mitigate this effect. What’s more, it is likely that a portion of the participants answered both of the surveys, so in terms of the statistical analysis, it would have been more appropriate to have performed a paired t-test. However, since the two surveys were anonymous, it was not possible to pair the results, therefore an unpaired test was performed.

Lastly, this study does not aim to evaluate the factors that have brought about an increase in burnout, and solely aims to discuss a review of the relevant literature. We believe that, despite the limitations, the study results are assessable.

That said, we believe there is a need to implement training programs on how to manage situations that are charged with uncertainty, as well as to provide training in relaxation techniques to help prevent this increase in burnout among health workers who are experiencing excessive workloads like those that we have experienced19. In addition, it would be useful to analyse and reflect on the organisation of services to better distribute workload and properly recognise the effort of healthcare workers.

Lastly, a survey should be repeated in 2023 to know the current circumstances among the internal medicine staff following subsequent waves of COVID-19.

In sum, this study showed a non-significant increase in burnout syndrome among internal medicine attending physicians in Spain following the pandemic. Nevertheless, an increase in low personal accomplishment was detected. As this can lead to a decline in patient care, we believe it would be convenient to implement training programs on how to manage stressful situations and on relaxation techniques, as well as to better organise the internal medicine services to enable a more equitable distribution of workload and responsibilities.

This study did not receive any external funding from a public or private source.

The authors confirm they have no conflicts of interest.