key: cord-0787661-bfnwi996 authors: Zaed, Ismail; Jaaiddane, Youssef; Chibbaro, Salvatore; Tinterri, Benedetta title: Burnout among neurosurgeons and residents in neurosurgery: a systematic review and meta-analysis of the literature. date: 2020-08-07 journal: World Neurosurg DOI: 10.1016/j.wneu.2020.08.005 sha: 949c51568dadb438da0468715f45e51e506dcd5a doc_id: 787661 cord_uid: bfnwi996 ABSTRACT Background Burnout syndrome (BS) is a condition, very common among medical professionals. It is composed of 3 different subdimensions, namely emotional exhaustion (EE), depersonalization (DP) and reduced personal accomplishment (PA). In the last years, interest in BS in the neurosurgical community has increased. Objective To estimate burnout among neurosurgeons and residents in neurosurgery. Methods A systematic review with meta-analysis was performed following PRISMA guidelines. A search of bibliographic databases was conducted, from inception to February 2020. A total of 16377 studies were found. In the final analysis, 6 papers were included. Their references were checked for additional studies, but none were found. Results From the initial 16377, only 6 met the inclusion criteria, for a total of 3310 physicians. The general prevalence of 48%. When considered alone, neurosurgeons showed a prevalence of 51.1%, which was higher than the prevalence showed by residents in neurosurgery (45.4%). Regarding sub-dimensions, personal accomplishment seemed to be the most influential factor for burnout development among neurosurgeons (42.57%) and residents (51.56%). Conclusion Neurosurgery is a rewarding career choice, but some (togliere) many challenges and stressors can lead to lower levels of satisfaction and dangerously increased levels of burnout. We hope these results will generate discussion, raise awareness, stimulate further studies, and lead to programs designed to mitigate excessive stress and burnout within neurosurgery. Burnout syndrome (BS) is defined as a condition of emotional exhaustion, feelings of 2 depersonalization, and a lack of personal accomplishment, which are all specifically related to stress 3 at work 1 . Despite the growing interest from the medical communities on this topic in the most 4 recent years BS has been known for several decades, since its first description has been published in 5 1974 by Freudenberger 2 . Burnout is related to an increasing workload, typical of healthcare 6 professionals, that leads to job stress, intense time pressure as well as lack of organizational support. 7 This stressful situation is showed to be an issue for the personal mental health of healthcare 8 workers, but also to the related economy 3 . 9 the stress in the workplace, which can also be manifested with emotional exhaustion and irritability 10 in the work environment, tend to lead to mental issues, such as BS, which is characterized by three 11 main aspects, namely emotional exhaustion, depersonalization and feeling of diminished personal 12 accomplishment 4 . 13 However, it is important to notice that in such a physical and mentally demanding field like 14 neurosurgery, there are few studies concerning work-stress and burnout syndrome. The situation 15 appears to be dramatic. A recent American national survey about BS in the neurosurgical 16 community showed that more than half of the respondents presented its signs and that only a third 17 of them would recommend a career in neurosurgery 5 . Studies on career satisfaction and burnout are 18 therefore instrumental in identifying factors that precipitate psychological distress so that reforms 19 can be instituted to stem the tide of disgruntled physicians. 20 In this study, we aim to summarize the scientific literature about the burnout syndrome in 21 neurosurgery and estimate its prevalence among neurosurgery residents and neurosurgeons. To better define the state of burnout in the neurosurgical community and the overall prevalence, a 24 systematic review and a meta-analysis has been performed, following the Preferred Reporting Items 25 for Systematic Reviews and Meta-Analyses (PRISMA) 6 . The keywords selected, were: "burnout", "burnout syndrome", "neurosurgery", "neurosurgeon," 1 and "resident". To collect all the articles related to the topic of the study, several online databases 2 have been accessed: Embase, PubMed, Scopus, and Cochrane Library. Electronic searches were 3 made for articles published from January 1974, when burnout was the first described 2 , to February 4 2020. Quality evaluation of the primary studies 6 An evaluation of the methodological quality/risk of bias of the primary cross-sectional studies was 7 performed using the Newcastle-Ottawa Quality assessment scale (NOS) 7 . The NOS scale is an epidemiological tool, composed of 8 items, used for assessing the quality of 9 non-randomized studies included in systematic review and/or meta-analyses. The checklist is 10 divided into three groups that focus on different aspects: (1) study selection, (2) group scale used for measuring BS was not an inclusion criterion. Intervention studies were also excluded, 20 even though there was the possibility that they would have provided additional data; it was 21 considered that they would have provided a source of heterogeneous data, and thus considering 22 them would have been a conceptual error. All the studies that considered other specialties rather 23 than neurosurgery have been considered only if data related to neurosurgical specialty could be 24 isolated. The main objective of the conducted meta-analysis was to identify quantitative studies assessing the 14 burnout phenomena and gauge its prevalence among residents and neurosurgeons. The analysis was conducted through SPSS using as data input the sample size and the burnout rate 16 of every included primary study. Effect sizes were assessed through the computation of 17 dichotomous means and the gauging of variance, Z-values, to indicate the significance of the effect 18 in the overall sample, a 95% confidence interval, a p-value, and a standard error. Both a fixed-effect 19 model and a random effect model were conducted identifying a general prevalence and an effect 20 size for both neurosurgeons and residents. Moreover, a heterogeneity analysis was designed, testing 21 the null hypothesis and assessing the Q-value and Tau-squared to identify results' consistency. The papers search of the articles was carried out on PubMed, SCOPUS and Cochrane Library. The In the second step of screening, 16377 studies were excluded because the Full-text articles were not 28 available, or assessed for eligibility according to the following exclusion criteria: a laboratory study, 29 animal study and articles not in English. Not only in the general population imaginary but also among physicians, neurosurgery is known to 2 be a stressful yet rewarding profession 5 . This meta-analysis attempts to identify the stressfulness of 3 the profession, analysing the prevalence rates in the studies published about the presence of burnout 4 in neurosurgeons and neurosurgical residents. 5 Our study showed that the general prevalence of BS in the neurosurgical community is higher than 6 in the other medical specialties. A recent systematic review focused on estimating burnout among 7 different medical residency specialties found that the overall burnout prevalence in all specialties 8 was 35.1% (95% CI: 26.8% -43.5%), whereas the specialties that showed the higher prevalence of 9 burnout (general surgery, anaesthesiology, obstetrics and gynecology, orthopedics) presented an 10 average prevalence rate of 42.5% 3 . Burnout 12 It has been already showed by several studies that burnout syndrome is one of the main drivers of In the case of neurosurgery residents, personal characteristics, including age, marital status, and 9 involvement in sports activities or leisure, showed less influence on the development of burnout 9 . However, several factors affecting the stress level of neurosurgical residents, have been identified, 11 as an inadequate exposure to the operating room, hostile faculty, hostile co-residents, and feeling 12 underappreciated by patients or staff, poor control over one's schedule, and co-resident attrition 9 . In general, a high prevalence of burnout was found in both residents in neurosurgery (45.4%) and 14 neurosurgeons (51.1%), especially compared to the other medical specialties 3 . Regardless, given 15 that burnout correlates with high probabilities of medical errors and other work-related issues, such 16 as an increased risk of conflicts between work and home, and a greater predisposition to 17 depression 3,20 , it is has been emphasized that an early and regular assessment of burnout among 18 residents and surgeons in neurosurgery is essential to reverse this phenomenon 20 . Moreover, it is suggested that preventive actions can be adopted to reduce the occurrence of burnout 20 among neurosurgeons and residents in neurological surgery. In general, the present literature 21 showed that unstable routine work, high hourly workloads, and reduced time for family and leisure, 22 in addition to the great difficulty to seek professional help are some of the most influential factors 23 responsible for a predisposition to developing burnout 6,7,8,9 . Thus, changes in habits among 24 neurosurgeons, residents, and medical institutions are required so that standardization of hourly 25 workloads may be set, as this seems to be a more effective protective factor against burnout 23,24 . Creating support groups is important, where neurosurgeons and residents can exchange experiences, 27 receive information from an expert that will help them recognize the signs and symptoms of 28 burnout, besides strategies that help deal with severe burnout, as well as the foundation of wellness Burnout syndrome is a condition that affects all the medical and surgical specialties. According to 9 the present literature, neurosurgery showed to be the most affected specialties (48.4%); these results 10 remain also when we analysed separately neurosurgeons (51.1%) and residents in neurosurgery 11 (45.4%). Because of the severe consequences of the syndrome, institutions and departments should 12 be encouraged to develop and improve wellness programs. 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