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Medicina Clínica 157 (2021) 130–140 www.elsevier.es/medicinaclinica Special article Work stress and resident burnout, before and during the COVID-19 pandemia: An up-date夽 Estrés laboral y burnout en los médicos residentes, antes y durante la pandemia por COVID-19: una puesta al día Ricard Navinés b,c , Victoria Olivé b,d , Francina Fonseca c,e , Rocío Martín-Santos a,b,c,∗ a Grupo de Investigación en Vulnerabilidad, Psicopatología y Género, Servicio de Psiquiatría y Psicología, Programa de Atención al Personal Sanitario, Hospital Clínic, IDIBAPS, CIBERSAM, Barcelona, Spain b Unidad Funcional de Psiquiatría, Departamento de Medicina, Instituto de Neurociencias, Universidad de Barcelona (UB), Barcelona, Spain c Societat Catalana de Psiquiatria i Salut Mental (SCPiSM), Barcelona, Spain d Servicio de Prevención de Riesgos Laborales, Hospital Clínic, Barcelona, Spain e Grupo de Investigación en Adicciones, Instituto de Investigación Médica Hospital del Mar (IMIM), Universidad Autònoma de Barcelona, Instituto de Neuropsiquiatría y Adicciones (INAD), Red de Trastornos Adictivos (RediTA), Barcelona, Spain a r t i c l e i n f o Article history: Received 27 January 2021 Accepted 6 April 2021 Available online 6 July 2021 Introduction from the cerebral processing of the subject’s interaction with the environment,3 which is specific to each person, and which will also In recent years there has been an extensive national and inter- depend on the threatening stimulus (e.g., more intense in social national debate on whether residency years constitute a risk to threats than in physical ones).3 Uncontrollable stress is a biological the mental health of the resident physician.1 The specialty train- state of transition to disease3 and can precipitate various cardio- ing period involves a level of general activation and coping with vascular, digestive, musculoskeletal diseases, as well as mental new situations that most residents find stimulating and reward- disorders such as anxiety and depression.3,4 ing. However, for others it may mean an increase in the body’s Work stress can be defined as the response that occurs when response to stress, which, when prolonged in time and intensity, work demands, and pressures do not correspond to the knowl- does not allow adequate adaptation, and leads to psychobiological edge and skills of the worker and exceed his/her ability to cope.2 exhaustion or burnout.2 All workers experience pressure at work, but when the individ- Stress is a term used to refer to the state of anti-homeostatic ual perceives that the demands are beyond his or her resources to biological activation that occurs when the body fails in its attempts cope, work stress and the risk of burnout2 may occur. On the other to adapt to the demands of its immediate environment.3 This hand, and according to the effort-reward model at work,3 the risk of biological activation is accompanied by unpleasant emotions (anx- stress and psychosomatic disorders would occur when effort is not iety, sadness, irritation) and by physiological modifications of compensated by reward factors, such as salary, recognition, career the adaptive subsystems (autonomic and neuroendocrine activa- advancement or job security. tion and immune and behavioural inhibition) that decrease the Although the weight of the work environment is key in burnout, capacities to maintain homeostasis when interacting with the envi- chronic work-related stress affects the biological functioning of ronment. Therefore, stress is a complex biological state that results the body. The feeling of lack of control in the face of the multi- ple stressors faced by doctors on a daily basis can in some cases lead to a state of uncontrollable stress, affecting brain functioning. From a neurobiological perspective, there is increasing evidence to 夽 Please cite this article as: Navinés R, Olivé V, Fonseca F, Martín-Santos R. Estrés support the biological substrate of the syndrome,4 whereby a pre- laboral y burnout en los médicos residentes, antes y durante la pandemia por COVID- frontal cortex dysfunction exerts a top-down regulatory effect on 19: una puesta al día. Med Clin (Barc). 2021;157:32–42. ∗ Corresponding author. cognition, behaviour, and mood. The prefrontal cortex is involved in E-mail address: rmsantos@clinic.cat (R. Martín-Santos). many cognitive functions essential to the medical profession, such 2387-0206/© 2021 The Authors. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/). R. Navinés, V. Olivé, F. Fonseca et al. Medicina Clínica 157 (2021) 130–140 as abstract reasoning, decision-making, working memory, insight subgroup of studies with a higher degree of evidence was selected, and empathy.4 Chronic uncontrollable work stress can lead to a with a preference for systematic reviews with or without meta- decrease in motivation, concentration, impaired working mem- analysis for data on prevalence and longitudinal studies regarding ory, organisational skills, decision-making, insight and empathy, risk factors and protection of burnout in residents. characteristic of the worker with burnout. The current COVID-19 pandemic situation carries a high degree of uncertainty, causing a significant impact on the mental wellbeing Stress and burnout during residency of healthcare workers, especially those who work on the frontline or who have been exposed to extreme and continuous pressure, A total of 210 studies published in these years were found in causing physical exhaustion, emotional stress, stigmatisation and the literature search Thirteen were excluded due to duplication, insomnia.5 Before the COVID-19 pandemic, health professions were 77 due to being studies in other samples (e.g., medical students), 8 already considered as highly stressful.5 Research on stress in medical due to sample size, 13 due to being non-observational studies (e.g., residents has shown that this group of professionals is particularly clinical trials) or not relevant to the study subject. Two systematic vulnerable and has a high proportion of burnout.6 Obviously, not all reviews and a longitudinal article were included from the litera- doctors are equally vulnerable, and a number of risk factors have ture review. Of the total of the selected studies (N = 98), 5 were been identified related to the individual (e.g. socio-demographic systematic reviews with and without meta-analysis, 9 longitudinal variables or personality traits), to the healthcare profession itself studies and the rest were cross-sectional studies (N = 84), 7 dur- (e.g. dealing with serious illnesses or long working hours) and to the ing the pandemic. Table 1 shows the results of burnout prevalence organisation of care (e.g. excessive workload or lack of oversight).2,6 data from systematic reviews and Table 2 shows the results of risk In general, professionals can function with high levels of stress if factors in longitudinal studies. Finally, Table 3 shows the results their work gives them positive feedback, which will depend on the of cross-sectional studies of prevalence and risk factors associated degree of resilience and the presence of protective factors.7 with burnout in residents during the first wave of the COVID-19 Traditionally, the burnout syndrome has been clinically diag- pandemic. nosed using Maslach’s burnout scale (Maslach Burnout Inventory [MBI]), which assesses the 3 main dimensions of the syn- Epidemiological data drome: emotional exhaustion, depersonalization and personal accomplishment.8 Emotional exhaustion refers to the experience of The results of the systematic reviews carried out in recent years being emotionally exhausted by the demands of work. Depersonal- show a high prevalence of burnout syndrome in resident physi- ization assesses the degree to which each one recognizes attitudes cians, ranging between 30 and 50%.10–14 A systematic review with of unfeeling and impersonal response from the recipients of their meta-analysis, which included 47 cross-sectional and cohort obser- care. Finally, the personal accomplishment dimension assesses feel- vational studies with more than 22,000 residents from different ings of self-efficacy and accomplishment at work.8 specialties and from various countries in Europe, Asia, and America, The American Psychiatric Association’s classification of mental found a 51.0% mean prevalence of burnout using Maslach’s question- disorders, the DSM-5 (2013), does not include burnout syndrome as naire (95% CI: 45.0%–57.0%).13 This prevalence was higher than that a specific disease, but rather it is included in other problems that can found in a previous meta-analysis that included 26 cross-sectional be the object of medical care, in this case related to employment. studies from different countries, with almost 5000 residents of However, in 2019 the World Health Organisation has officially medical and surgical specialties assessed with the same question- recognised burnout as an occupational phenomenon following the naire, 35.7% (95% CI: 26.8%–43.5%)14 (Table 1). ratification of the eleventh revision of the International Statistical Since the onset of the COVID-19 pandemic several studies have Classification of Diseases and Related Health Problems (ICD-11), investigated its impact on the occurrence of burnout in medical which is due to come into force on 1 January 2022.9 Thus, the residents showing a wide range of prevalence, between 26% and burnout syndrome has been identified as one of the main men- 76%.15,16 This may be due to the heterogeneity of the studies con- tal health problems and the prelude to many mental disorders ducted, for example, using different burnout17,18 assessment scales. resulting from this syndrome’s poor control and lack of primary Some of the studies found higher prevalence depending on the prevention. This already challenging situation will be exacerbated number of COVID-19 patients seen.19,20 Others found prevalence by the high stress that caring for COVID-19 patients places on many lower than those obtained before the pandemic with the same health care workers, including resident doctors. Resident doctors assessment itools21 (Table 3). have had their current clinical care work and training programme disrupted and are experiencing particularly stressful situations. In this context, the aim of this paper has been to provide an Individual and psychosocial factors related to the update through a literature review of the main evidence on burnout occurrence of stress and burnout syndrome during residency in medical residents, its prevalence, risk, and protective factors, before and during the COVID-19 pandemic. Sociodemographic variables There are a wide variety of individual and work factors that can Methodology affect burnout rates in resident physicians. First, sociodemographic variables have been analysed. Regard- A review was made of publications in English or Spanish on ing gender, the results are contradictory. In a systematic review by burnout in residents in PubMed databases for the last 5 years Low et al. (2019),13 male gender was a risk factor, as was being (2016–2020), as well as publications referring to the first wave older, while in Rodrigues et al. (2018) it was being a woman and of the COVID-19 pandemic. The keywords b̈urnout¨, r̈esident train- being young.14 However, the results of longitudinal studies seem ing¨, p̈revalence¨, r̈isk factors¨, M̈aslach Burnout Inventory¨, Öldenburg to confirm an increased risk for women22–24 (Tables 2 and 3). Burnout Inventoryänd C̈OVID-19änd the Boolean operators AND With respect to the burnout dimensions, it seems that there and OR were used. Studies with samples smaller than 50 subjects could be sociodemographic differences. Thus, there are studies that and non-observational studies have been ruled out. Literature ref- show that women score more in emotional exhaustion and men in erence lists have been used to identify additional studies. Finally, a depersonalization.22 In relation to marital status, being married or 131 R. Navinés, V. Olivé, F. Fonseca et al. Table 1 Systematic reviews on the prevalence and risk factors of the burnout syndrome in residents published in the last 5 years in PubMed (using the Maslach or Oldenburg burnout scales). Authors and N Countries Specialty Questionnaires Burnout Risk factors Protective factors Comments year burnout /others % Verougstraete 4 articlesa Iran, Jamaica, Emergency MBI PRISMA criteria and Idrissi, 685 subjects USA, Medicine ↑ EE, ↑ D or ↓ 55.6%–77.9% High quality of 202010 2008−2018 China PA included studies (20.7/22) Includes cross-sectional studies Galaiya et al., 62 articles Saudi Arabia, Surgical MBI Young age Having children PRISMA criteria 202011 68.977 Australia, China, specialties ↑ EE or ↑ D 22.2%–85.1% Female gender Work environment Includes subjects USA, France, ↑ EE, ↑ D or ↓ Single support cross-sectional and 2008−2018 Fiji, Great Britain, PA Workload Supervisor longitudinal studies Ireland, Peer and patient Physical activity (N = 7, 11%) Italy, Lithuania, conflicts Emotional intelli- 24% studies with less Switzerland, Neuroticism gence/strength of than 50 cases Pakistan Depression/substance charac- Diagnostic criteria use ter/mindfulness heterogeneity Extraversion, 132 kindness, conscientiousness Academic work Absence of economic concern Chan et al., 22 articles Canada, Korea, Psychiatry MBI 33.7%b Not having a partner PRISMA criteria 201912 883 subjects USA, France, ↑ EE, ↑ D or ↓ 27.9%–87%, First year of residency Includes observational 2000−2019 Japan, Italy, PA 32%–40%, 4.4%–33% Not being the priority and experimental Lebanon, Holland, specialty studies New Zealand OLBI No supervision Differences in response Utrecht Workload rate Burn-Out Scale Insufficient rest Cut-off point Other stressors differences even on the Anxiety or depression same burnout scale symptoms Participation bias Low empathy Few coping strategies Self-medication Medicina Clínica 157 (2021) 130–140 Use of Mental Health services R. Navinés, V. Olivé, F. Fonseca et al. Table 1 (Continued) Authors and N Countries Specialty Questionnaires Burnout Risk factors Protective factors Comments year burnout /others % Low et al., 47 articles Saudi Arabia All MBI All specialties Older PRISMA criteria 201913 22,778 subjects Australia, Brazil 51.0% (95% CI: Male gender 50% studies with N < 100 1974-2018 Canada, USA, 45.0−57.0) Geographic location subjects > Surgical specialties Meta-analysis Egypt, Spain Surgical > medical Specialty type: > USA than other countries France, Pakistan, 53.27% (95% CI: Radiology, Neurology Response rate on potential Turkey 46.27−60.15) and General Surgery participants decreased <50% in Asian many cases Countries > Ameri- No publication bias can > European Meta-analysis 57.18% (95% CI: 45.80−67.85) 51.64% (95% CI: 46.96−56.28) 27.72% (95% CI: 17.40−41.11) Psychiatry <50% 42.05% (95% CI: 133 33.09−51.58) Radiology > 70% 77.16% (95% CI: 5.99−99.45) Rodrigues 26 articles Argentina, All MBI All specialties Lack of confidence in PRISMA criteria: et al., 201814 4664 Australia, Saudi (does not ↑ EE, ↑ D or PA 35.7% (95% CI: acquiring medical > 50% studies with N < 100 subjects1974− Arabia include ↓ 26.8−43.5) knowledge subjects 2018 Brazil, Canada Psychiatry) EE: 43.6% (95% CI: Difficulty reconciling Study response ratio not Meta-analysis USA, Spain, 38.4−48.9) family/work life specified France, Greece D: 38.9% (95% CI: Poor workplace Global heterogeneity: I2 Hungary, Iran 31.8−46.0) relations 87.6−98.6% Pakistan, Turkey PA: 34.3% (95% CI: Female gender No publication bias 21.3−47.2) Young age Meta-analysis To be single Surgical/emergency Excessive workload > medical Medicina Clínica 157 (2021) 130–140 MBI: Maslach burnout inventory and its dimensions (EE: emotional exhaustion, D: depersonalization and PA: personal accomplishment); OLBI: Oldenburg burnout inventory. a This systematic review also included studies in emergency medicine’s attending physicians which are not shown on this table. b Of the 22 studies, 13% used a categorical definition and percentage of burnout. R. Navinés, V. Olivé, F. Fonseca et al. Table 2 Longitudinal studies of burnout syndrome in residents published in the last 5 years in PubMed (using Maslach’s or Oldenburg’s burnout inventories). Authors and N (% response) Country Specialty Questionnaires Type of study Burnout%/mean Risk factors Protective factors year Evaluation times burnout (SD) Year of completion National Kemper 1664 (61%) A USA Paediatrics MBI Survey 56% A Stress < Hours of Empathy et al., 202027 20162153 (66%) B ↑ EE, ↑ D national, 54% B sleep > Medical errors Self-pity 20172 prospective, 54% C Family/work life Quality of life on-line dissatisfaction Confidence in being 241 (61%) C 2018 able to provide 2016-2018 compassionate care Kocalevent 1011 (48%) Germany All MBI Multicenter survey, Significant Female gender (>EE) et al., 202022 R1, R2, R3, R4, R5 ↑ EE, ↑ D or ↓ PA prospective, increase in EE Male gender (>D) 2009-2016 on-line and D and PA Work/family reconciliation from R1 to R5 Effort/reward imbalance 134 Dyrbye et al., 3574 (81.2%) USA All Adapted MBI Survey 45.2% Female gender High levels of 20182. 3 Baseline ↑ EE, ↑ D national, prospective, symptoms R2 Urology, Neurology, empathy in the (graduation) and on-line Emergency medicine, university stage R2 Ophthalmology, General 2010-2014 Surgery > Internal Medicine University-stage anxiety Specialty regret Galatea 478 (57.5%) B Catalonia All OLB Prospective, 18.4 (2.99): R1 >Workload Foundation, 290 (34.9%) R1 (Spain) multicenter survey, 19.2 (3.02): R4 Year of residency: R5 Emotional et al., 202026 2015−2019 Surgery ↑ EE, ↑ D prospective, 68% (2015) (64%) and R1 (38%) intelligence on-line 53% (2019) Suffering disruptive Sense of wellness behaviour (being taken Professional career advantage of, being development humiliated) Lindeman 88 (61.5%) A USA General MBI Multicenter survey, 24% A Female gender (EE) High emotional et al., 201724 64 (44.8%) B Surgery ↑ EE prospective, 17% B Beginning and end of intelligence 69 (48.3%) C on-line 32% C residency Emotional stability, kindness Positive work experiences B: baseline; MBI: Maslach burnout inventory and its dimensions (EE: emotional exhaustion, D: depersonalization and PA: personal accomplishment); OLBI: Oldenburg burnout inventory; R1: first year of residency; R4: fourth year of residency. Medicina Clínica 157 (2021) 130–140 R. Navinés, V. Olivé, F. Fonseca et al. Table 3 Studies on burnout syndrome in residents during the first wave of the COVID-19 pandemic in 2020. Authors N/% responders Country Specialty Burnout Type of study Burnout Risk factors questionnaire Mean (SD)/% Degraeve et al., 126 Belgium Urology CBI subscales: National, CBIP: 47% reduction 202015 50% CBIP, CBIPro cross-sectional survey CBIPro: 48% reduction and CBIR on-line CBIR: 32% reduction Dimitriu et al., 100 Romania First line 50% MBI National, 76% First line: 66% 202016 Other cross-sectional survey Other departments: 86% departments on-line 50% Osama et al., 112 Pakistan Surgery MBIm score National, 72% score reduction 60%), followed by Internal Medicine, Traumatology, Dermatol- ogy, Gynaecology and Neurosurgery (50%), and those of Medical One of the factors that can contribute to and even predict the Oncology and Family Medicine (40%). The studies that included occurrence of stress and burnout is the decrease in sleep hours (< 6 h) Psychiatry residents (N = 245) showed a prevalence of 43%.12,13 and alteration of the circadian rhythm. This relationship holds even Data from Rodrigues et al. (2018)14 show that prevalence was when considering other variables, such as work demand or work higher in surgical and emergency specialties (40%) compared to pressure or thoughts about work during leisure time.32 Poor quality medical specialties (25%). In relation to other factors, it has been of sleep and decreased hours of sleep have been observed as specific described that both the first year and the last year of residency,24 risk factors for burnout in residents of different specialties.12,27 The other recent stressful events15,28 and dissatisfaction with the cho- longitudinal survey of residents from all over Catalonia in 2018 sen specialty12,23 constitute risk factors for burnout (tables 1 and 2). showed that before starting the residency only 10% of residents Most of the studies on burnout among resident physicians during slept less than 6 h a day, a year into the residency this was the the COVID-19 pandemic that we have found were cross-sectional case for 50% of them and at the end of the residency it reached and conducted in surgical specialties15,17,20,21 . This group has had to 60%. The decrease in sleeping hours was related to the increase in move on many occasions to other units, such as Intensive Care Units the number of working hours.30 Sleep deprivation and fatigue are or specific care wards for COVID-19 patients, which is an added known to produce metabolic and physiological abnormalities that stress factor.21 During the pandemic, being a first-year resident was lead to cognitive deficits.4 Therefore, paying attention to this aspect also a risk factor for burnout.21 This fact reflects the need not to could be a relatively easy way to decrease the risk of burnout in neglect the mentoring of especially younger residents at this time residents also, to the extent possible, in a crisis situation such as (Table 3) (Fig. 1). the current pandemic (Fig. 1). Working conditions Physical exercise and diet A high workload with excessive working hours, a hostile work environment and generally poor workplace conditions have Regular physical exercise and relaxation techniques such as been reported as risk factors for the occurrence of stress and mindfulness have been shown to be protective against burnout in burnout8,12,22,29,30 among residents. Poor oversight and support, not residents. Regular exercise was the only burnout-protective activ- having an identifiable manager, poor relationships with superiors ity in a study of nearly 5000 American obstetrics and gynaecology and diminished perception of peer support are other risk factors that residents.32 However, several studies show that residents reduce may contribute to poor adaptation and have been associated with physical activity during the training period from 60% at the begin- the development of stress and burnout in residents12,22,26,30 (Fig. 1). ning to 40% in the final year.30 These data are in line with the results There are many differences in practice depending on the type of of a sample of 2623 doctors, nurses, and residents from 5 Euro- hospital. General, university hospitals may generate more tension pean countries which found that insufficient exercise and increased due to high internal competition, although they tend to have a consumption of fast food were associated with the occurrence of 137 R. Navinés, V. Olivé, F. Fonseca et al. Medicina Clínica 157 (2021) 130–140 Burnout syndrome Risk factors Protective factors Areas of preventive interventions Individual Individual Individual Personality traits (neuroticism, Being married/partnership Work-burnout association introversion) Capacity for empathy training History of depression/anxiety Emotional intelligence Fostering empathy Early stressors Enough hours of sleep Stress management skills Previous year stressors Regular physical exercise Psychosocial skills training High perception of stress Leisure activities Help create appropriate expectations Emotional distress Social relationships Effective time management High expectations Work/family life balance Promote healthy habits Substance use Social support Self-care, mindfulness workshops Individual health surveillance protocols Work-related Work-related Work-related First year of residency Role identification Mentoring organization Long hours Supervision Decrease on-call duty hours Inadequate care load Structured mentorship Favour mentor/resident communication On-call duty Peer support Positive feed-back Lack of autonomy Resident's areas Promote group activities Serious patient care Acknowledged training Improve resident-specific areas Not satisfied choice opportunities Not having to fill structural specialty Recognition/compensation positions Hostile work environment Tracking and rewarding overtime Fig. 1. Risk and protective factors for burnout syndrome in residents and possible areas of preventive action. Table 4 Impact of the COVID-19 pandemic on resident doctors in the following dimensions: healthcare, training and personal. Healthcare aspects Training aspects Personal aspects/risk perception Timetable change/elective rotation/holidays Training plan reorganization. Impact on mental health in vulnerable residents Relocation to other departments or shift Elimination of rotas/training stays (women, first year in residence, infected colleagues, grouping Less direct contact with attending/mentors previous mental illness, number of infected patients Elimination/reduction of work in outpatient Less contact with peers cared for) clinics, Implementation of innovative training and Fear of becoming infected or potentially infecting or change to telehealth participation capacity building solutions family members and close people Elimination/reduction of elective/emergency Adaptation of the educational programmes of the Residency development concern surgery institution or scientific societies to other formats Little recognition effort made Restrictions due to lack of sufficient protective (videoconferences, recordings, etc.). Search alternative residency avoid infecting equipment or maintenance of safety measures Increased availability for study/research Mobility difficulties outside the area Negative impact on clinical or surgical Increased participation time in e-learning Decreased social support experience conferences Risk of loss of healthy habits Negative impact on meeting the minimum number of visits/interventions required in the training plan Concern to improve or maintain the skills of the specialty burnout.33 Exercise and a healthy diet meet the high energy needs likely that this situation limited access to a protective stress factor in for proper brain function, particularly that of the prefrontal cortex. residents. Finally, the consumption of alcohol and other psychoactive Maintaining both of these healthy habits despite the stressful work substances has also been linked to burnout.32,33 Those residents who situation should be considered a priority in order to support proper consume alcohol on 4 or more occasions per week during residency functioning.4 have a 3.3 increased risk (odds) of developing burnout syndrome.32 During the pandemic, restrictions put in place by governments Alcohol consumption, although it may initially produce a sense of have limited access to gyms or the possibility of practicing sports. stress relief, worsens brain physiology in the long term, promoting We did not find data on this particular aspect in our review, but it is emotional distress and depression.4 138 R. Navinés, V. Olivé, F. Fonseca et al. Medicina Clínica 157 (2021) 130–140 Social and leisure activities the risk and the risk quadrupled in those who cared for 60 or more patients. Adequate social support, being involved in social activities and a The management and prevention of burnout syndrome during suitable work-life balance have been reported as burnout protectors residency remains a pending issue, which should consider not only in residents22,26,30 (Fig. 1). The ’within work’ activities that residents the psychosocial aspects of the work environment, but also the associated with relaxation were the possibility of having time to underlying biological changes in the person experiencing it. The review clinical notes, talk to patients and to be able to assess articles COVID-19 pandemic has underlined the importance of being aware and study. Also, having areas where they could relax (office) and of this problem among professionals in training because of the having a chance to hold informal conversations or discuss patients enormous impact it can have both on the individual and on ade- improved the stress of the professionals. Unfortunately, there is an quate patient care. increasing tendency to eliminate this type of areas in the workplace. In general, during the pandemic, institutions have prioritised the physical safety of their workers, with less emphasis on mea- Funding sures to support the emotional well-being. A shortage of wellness spaces at work has been reported as a risk factor for burnout This work has been carried out in part thanks to the PREVENT in residents during this pandemic.20 These results underline the XI grant: DN040611 (VO, RN) and the support of the Comisionado importance of implementing wellness programmes in institutions para las Universidades e Investigación DIUE of the Generali- and maintaining them during times of health crisis such as formal tat de Catalunya (2017/SGR/1798 [RMS]). FF has the support of counselling space, relaxation spaces or relaxation and meditation Acció instrumental d’Intensificació de Professionals de la Salut- programmes.20 Despite the social restrictions imposed by the pan- Facultatius especialistes (PERIS: SLT006/17/00014). demic, residents reported in several studies that during this period they had more time to spend on study activities or pursuing a hobby Conflict of interests at home, and this was rated positively by them21 (Table 4). All authors declare that they have no conflict of interest. The Limitations funding sources had no participation in the design, development, or publication of the study. The literature review carried out has the limitation of not being systematic. However, it highlights the lack of consensus on the References most widely used validated instrument, the MBI, due to the use of different cut-off points, different criteria for the subscales (emo- 1. Ironside K, Becker D, Chen I, Daniyan A, Kian A, Saheba N, et al. Resident and tional exhaustion, depersonalisation, personal accomplishment) faculty perspectives on prevention of resident burnout: a focus group study. needed to make the diagnosis and different versions of the inven- Perm J. 2019;23:18–85, http://dx.doi.org/10.7812/TPP/18-185. 2. Navinés R, Martín-Santos R, Olivé V, Valdés M. Work-related stress: implications tory (Tables 1–3). This represents a challenge in understanding the for physical and mental health. Med Clin (Barc). 2016;146:359–66. prevalence of burnout syndrome in the resident physician popu- 3. Valdés M. El estrés. Desde la biología hasta la clínica”. Barcelona: Editorial lation with greater accuracy. Most of the studies reviewed have a Siglantana-Ergon; 2016. 4. Amstem FT, Shanafelt T. Physician distress and burnout, the neurobiological cross-sectional design and few studies have a longitudinal design perspective. Mayo Clin Proc. 2021;96:763–9. that allows an analysis of incidence and risk/protective factors. 5. Danet Danet A. Impacto psicológico de la COVID-19 en profe- In the case of resident burnout during COVID-19, a longitudinal sionales sanitarios de primera línea en el ámbito occidental. Una follow-up will be of great interest in order to observe what happens revisión sistemática. Med Clin (Bar). 2021;S0025-7753:30825–33, http://dx.doi.org/10.1016/j.medclin.2020.11.009. throughout the different stages of the pandemic. On the other hand, 6. Sharp M, Burkart KM. Trainee wellness: Why It matters, and how to promote It. the samples do not always include all specialties or study the same Ann Am Thorac Soc. 2017;14:505–12. risk or protective factors. As all studies were conducted through 7. Zabar S, Hanley K, Horlick M, Cocks P, Altshuler L, Watsula-Morley A, et al. “I cannot take this any more!” Preparing interns to identify and help a struggling on-line surveys, it was not possible to study any biological variables colleague. J Gen Intern Med. 2019;34:773–7. associated with the presence of burnout. Another limitation is the 8. Maslach C, Jackson SE. The measurement of experienced burnout. J Occup Behav. sample size and response rate of some of the surveys. 1981;2:99–113. 9. Burn-out as “occupational-phenomenon”: International Classification of Disea-ses, 2019 [Accessed 20 Apil 2020]. Available: http://www.who.int/ news/item/28-05-2019-burn-out-an-occupational-phenomenon-international Conclusions -classification-of-diseases. 10. Verougstraete D, Idrissi SH. The impact of burn-out on emergency physicians The average prevalence of burnout in residents observed in and emergency medicine residents: a systematic review. Acta Clinica Belgica. 2020;75:57–79. the systematic reviews examined, mostly cross-sectional studies, 11. Galaiya R, Kinross J, Arulampalam T. Factors associated with burnout syndrome is around 50%. Burnout syndrome seems to increase over time in surgeons: a systematic review. Ann R Coll Surg Engl. 2020;102:401–7. throughout residency in the longitudinal studies reviewed. The 12. Chan MK, Chew QH, Sim K. Burnout and associated factors in psychiatry resi- dents: a systematic review. Int J Med Educ. 2019;30:149–60. most commonly observed risk factors for burnout during residency 13. Low ZX, Yeo KA, Sharma VK, Leung GK, McIntyre RS, Guerrero A, Lu B, et al. were confirmed by those found in the cross-sectional studies; they Prevalence of burnout in medical and surgical residents: a meta-Analysis. Int J were female gender (greater emotional exhaustion), male gender Environ Res Public Health. 2019;16:E1479. (greater depersonalisation), surgical specialities, making mistakes, 14. Rodrigues H, Cobucci R, Oliveira A, Cabral JV, Medeiros L, Gurgel K, et al. Burnout syndrome among medical residents: a systematic review and meta-analysis. little sleep, difficulty in reconciling family/work life and work over- PLoS One. 2018;13:e0206840. load. The protective factors were emotional intelligence, empathy 15. Degraeve A, Lejeune S, Muilwijk T, Poelaert F, Piraprez M, Svistakov I, et al. and being able to develop a professional career. When residents work less, they feel better: lessons learned from an unprecedent context of lockdown. Prog Urol. 2020;30:1060–6. Due to the heterogeneity of the studies, the prevalence of 16. Dimitriu MCT, Pantea-Stoian A, Smaranda AC, Nica AA, Carap AC, Constantin VD, burnout in residents during the first wave of the COVID-19 et al. Burnout syndrome in Romanian medical residents in time of the COVID-19 pandemic in the cross-sectional studies reviewed was found to pandemic. Med Hypotheses. 2020;144, 109972. 17. Osama M, Zaheer F, Saeed H, Anees K, Jawed Q, Syed SH, et al. Impact of COVID- encompass a very wide range (26%–76%). The most important asso- 19 on surgical residency programs in Pakistan; A residents’ perspective. Do ciated risk factor was the number of COVID-19 patients cared for programs need formal restructuring to adjust with the “new normal”? A cross- directly by the resident. Caring for 1−30 patients almost doubled sectional survey study. Int J Surg. 2020;79:252–6. 139 R. Navinés, V. Olivé, F. Fonseca et al. Medicina Clínica 157 (2021) 130–140 18. Civantos AM, Byrnes Y, Chang C, Prasad A, Chorath K, Poonia SK, et al. Men- 26. Gleason F, Baker SJ, Wood T, Wood L, Hallis RH, Chu DI, et al. Emotional tal health among otolaryngology resident and attending physicians during the intelligence and burnout in surgical residents: a 5 year study. J Surg Edu. COVID-19 pandemic: National study. Head Neck. 2020;42:1597–609. 2020;77:e63–70. 19. Cravero AL, Kim NJ, Feld LD, Berry K, Rabiee A, Bazarbashi N, et al. 27. Kemper KJ, Schwartz A, Wilson PM, Mahan JD, Schubert CJ, Staples BB, Impact of exposure to patients with COVID-19 on residents and fel- et al. Pediatric Resident Burnout Resilience Study Consortium. Burnout lows: an international survey of 1420 trainees. Postgrad Med J. 2020, in Pediatric Residents: Three Years of National Survey Data. Pediatrics. http://dx.doi.org/10.1136/postgradmedj-2020-138789. Epub ahead of print (21 2020;145(1):e20191030. October 2020). 28. OĆonnor P, Lydon S, OĎea A, Hehir L, Offiah G, Vellinga A, et al. A longitudinaland 20. Coleman JR, Abdelsattar JM, Glocker RJ, RAS-ACS COVID-19 Task Force. COVID- multicentre study of burnout and error in Irish junior doctors. Postgrad Med J. 19 pandemic and the lived experience of surgical residents, fellows, and early- 2017;93:660–4. career surgeons in the American College of Surgeons. J Am Coll Surg. 2021;232, 29. Cubero DIG, Fumis RRL, Herick de Sa T, Dettino A, Osorio Costa F, Adam Van Eyll 119-35e20. BRRH, et al. Burnout in medical oncology fellows: A prospective multicenterco- 21. Khalafallah AM, Lam S, Gami A, Dornbos DL, Sivakumar W, Johnson JN, hort study in Brazilian institutions. J Can Educ. 2016;31:582–7. et al. National survey on the impact of the COVID-19 pandemic upon 30. Galatea Fundació. Estudi longitudinal sobre la salut, estils de vida i burnout and career satisfaction among neurosurgery residents. J Clin Neurosci. condi-cions de treball dels MIR de Catalunya; 2018. Colegio Oficial 2020;80:137–42. Médicos de Barcelona. [Accessed 21 January 2019]. Available from: 22. Kocalevent R, Pinnschmidt H, Selch S, Nehls S, Meyer J, Boczor S, et al. Burnout https://www/galatea.org/Upload/documents/912/9216.pdf. is associated with work-family conflicto and gratification crisis among German 31. Eisenach JH, Sprung J, Clark MM, Shanafelt TD, Johnson BD, Kruse TN, et al. resident physicians. BMC Med Education. 2020;20:145–52. The psychological and physiological effects of acute occupational stress in new 23. Dyrbye LN, Burke SE, Hardeman RR, Herrin J, Wittlin NM, Yeazel M, et al. Asso- anesthesiology residents: a pilot trial. Anesthesiology. 2014;121:878–93. ciation of clinical specialty with symptoms of burnout and career choice regret 32. Winkel AF, Woodland MB, Nguyen AT, Morgan HK. Associations between res- among US resident physicians. JAMA. 2018;320:1114–30. idents’ personal behaviors and wellness: a national survey of obstetrics and 24. Lindeman B, Petrusa E, McKinley S, Hashimoto DA, Gee D, Smink DS, et al. gynecology residents. J Surg Educ. 2020;77:40–4. Association of burnout with emotional intelligence and personality in surgical 33. Alexandrova-Karamanova A, Todorova I, Montgomery A, Panagopoulou E, Costa residents: can we predict who is most at risk? J Surg Educ. 2017;74:e22–30. P, Baban A, et al. Burnout and health behaviors in health professionals from 25. Cortez AR, Winer LK, Kassam A, Hanseman DJ, Kuethe JW, Sussman JJ, et al. seven European countries. Int Arch Occup Environ Health. 2016;89:1059–75. Exploring the relationship between burnout and grit during general surgery resi- dency: a longitudinal, single-institution analysis. Am J Surgery. 2020;219:322–7. 140