key: cord-0277592-m2k146rt
authors: Kücükali, H.; Türkoglu, S. N.; Hasanli, S.; Dayanır Cok, F. N.; Culpan, H. C.; Hayran, O.
title: Comparison of the burnout among medical residents before and during the pandemic: not more exhausted but less accomplished
date: 2022-05-29
journal: nan
DOI: 10.1101/2022.05.28.22275707
sha: 3ea0e1ab7e6a2355982e0c5a22727c1c74b93bca
doc_id: 277592
cord_uid: m2k146rt

Objective: COVID-19 pandemic was anticipated to exacerbate burnout among healthcare professionals. This study aims to compare the level of burnout syndrome in medical residents before and during the COVID-19 pandemic and identify potential risk factors. Methods: This cross-sectional study was conducted on medical residents from three different university hospitals in Turkey in March 2021, one year after the pandemic hit Turkey. Burnout is measured by the Maslach Burnout Inventory which assesses three dimensions of it: emotional exhaustion, depersonalization, and personal accomplishment. Collected data were combined and compared with the data of a previous study which was held in the same hospitals in December 2019, three months before the pandemic. Results: A total of 412 medical residents from three universities participated in this study. The mean age was 27.8{+/-}2.4 and half of them were female. Compared to pre-pandemic levels, residents have a significantly decreased feeling of personal accomplishment one year after (from 20.8{+/-}5.1 to 10.9{+/-}5, p<0.001). No significant differences in emotional exhaustion (pre: 19.0{+/-}7.6 post: 18.8{+/-}7.8) and depersonalization (pre: 7.3{+/-}4.3 post: 7.2{+/-}4.4) scores were observed. Emotional exhaustion is higher in residents who are female, have more night shifts, live with someone at the risk of severe COVID-19 and experience personal problems during COVID-19. Depersonalization increases as the age, residency year, and the number of night shifts increases and it is higher in married residents. Residents of the state university hospital feel less personal accomplishment than those of foundational universities. Conclusion: Already high pre-pandemic levels of burnout and a relative decrease in demand due to social restrictions may explain not increasing emotional exhaustion and depersonalization. However, the substantial decrease in the feeling of personal accomplishment among residents is concerning. Without immediate action, it may lead to serious consequences on human resources and the quality of health care in the short to middle term.

In recent years, there have been national and international debates on whether medical residency years pose a risk to the mental health of physicians. The residency training period includes a general level of activation and coping with new situations that most physicians find stimulating and rewarding. In this period, when the increase in the body's response to stress is elongated in terms of time and intensity, insufficient adaptation leads to burnout or psychobiological exhaustion (Ironside et al., 2019; Navinés et al., 2016) .

Burnout has been a mental and physical syndrome characterized by emotional distress that usually occurs in individuals who need to use emotional resources as part of their work, such as healthcare workers (Maslach & Jackson, 1981) . Emotional exhaustion, depersonalization, and loss of sense of accomplishment resulting from prolonged exposure to work stress factors are noticed (Agha et al., 2019; Biksegn et al., 2016; Leiter & Maslach, 2014; Moreira et al., 2018) . Burnout in healthcare professionals is a global problem affecting healthcare practices and quality of care reaching epidemic levels (Elbarazi et al., 2017; Sanfilippo et al., 2017; Shah et al., 2019) . Although often overlooked, burnout remains a real problem in the medical profession and can lead to less job satisfaction, productivity, and patient care (Dyrbye et al., 2017) .

A 2019 report on burnout, depression, and suicide from the US suggests that clinicians experience burnout more often than other professionals and it affects residents' clinical judgments, their ability to communicate and the provision of quality care for patients (Kane, 2019) . In addition, burnout causes higher medical errors due to fatigue and reduced attention, which lead to neglect of personal safety precautions and patient safety (Dimitriu et al., 2020) .

It is vital to address burnout in the context of the COVID-19 pandemic. In addition to the economic crisis and high unemployment rate, pandemic stress also affected the physical and psychological health of people (Blustein et al., 2020; Xiong et al., 2020) . Countries confronted this period differently, so the impact of a pandemic on the quality of life varies according to the country and the individual (Suryavanshi et al., 2020) . While the primary focus of frontline healthcare workers is to minimize transmission and treat patients with COVID-19, the impact, and consequences of the pandemic on mental health are significant (Fiest et al., 2021) . During this period, mental health problems such as insomnia, anxiety, depression, burnout syndrome, and health-related quality of life were observed in healthcare workers (Barello et al., 2020; Brito-Marques et al., 2021; Pappa et al., 2020) .

Several recent studies have found an increased level of burnout in healthcare professionals and medical assistants exposed to the pandemic. A study on medical residents during COVID-19 indicated a burnout prevalence of 76% (Osama et al., 2020) . Compared to studies before the COVID-19 pandemic, higher results were observed regarding burnout in surgical residents during the pandemic period (Malik et al., 2016; Serenari et al., 2019) . Another study aimed to measure the impact of the COVID-19 pandemic on the mental health of anaesthesia residents, found burnout symptoms in 62% of residents (Mion et al., 2013) .

Although it is generally assumed that the incidence of burnout among physicians increased during the COVID-19 pandemic, we wanted to retest this hypothesis on medical residents in the context of the already high pre-pandemic level of burnout and the altered medical practice during the pandemic. It was our chance to have a study (Küçükali et al., 2022) that was conducted in three university hospitals in Turkey just before the pandemic. Using that study as a point of reference, the current study aims to compare the level of burnout syndrome in medical residents before and during the COVID-19 pandemic and identify potential risk factors.

This cross-sectional study is a replication of a previous study (Küçükali et al., 2022) which investigated the burnout level of medical residents in three university hospitals in Turkey in December 2019, just before the COVID-19 pandemic emerged. The current study was conducted in the same hospitals in March 2021, one year after the pandemic hit Turkey.

There were approximately eight hundred medical residents in three hospitals combined. The study aimed to reach all active medical residents in hospitals excluding non-clinical departments (basic medical sciences, medical pathology, and public health). Data was collected via a questionnaire including questions regarding COVID-19 in addition to inherited the questions on sociodemographic factors and Turkish adaptation of the Maslach Burnout Inventory (Ergin, 1992) from the previous study. Well-established Maslach Burnout Inventory measures burnout in 3 dimensions: emotional exhaustion, depersonalization, and personal achievement via 22 questions. Questions used to be scored in 5-level Likert style ranging from "never" to "every day". The inventory yields three scores from three sub-scales where burnout syndrome presented by high scores in emotional exhaustion and depersonalization, and low scores in personal accomplishment.

Researchers approached participants in their work environment (usually in doctors' rooms in their clinics), informed them about the study, obtained their consent and handed them a hard copy of the questionnaire. In the beginning, questionnaires were applied in a self-answered manner. However, researchers couldn't reach all residents due to their unstable shift schedules. For those who can not be reached after two rounds of visits in all departments, we sent online versions of the questionnaires via instant messaging applications.

Data were analysed via SPSS v25. Mean total scores and standard deviations for each of the three subscales were calculated. Mean scores were compared between groups formed by categorical variables using an independent samples t-test and analysis of variance (ANOVA). We build multiple linear regression models for each of the three sub-scale scores to eliminate possible confounding effects. To compare our results with the results of the aforementioned pre-pandemic study, we requested and obtained the data of the previous study. The combined dataset allowed us to make subgroup analyses and build multiple linear regression models. Statistical significance was assumed for the probabilities below 0.05 in statistical tests.

A total of 412 medical residents from three university hospitals participated in the study. Participants' characteristics including demographics and COVID-19 related variables were given in Table 1 . The mean age of the residents was 27.8±2.4 and half of them were female. The mean sub-scale scores by personal and COVID-19 related characteristics were given in Tables 2  and 3 . The emotional exhaustion was higher in females (p=0.005), those who live with someone at risk of severe COVID-19 (p=0.003), and those who have experienced personal problems during the pandemic (p=0.001). Those who have 6-10 night shifts per month had a higher emotional exhaustion score than those who have 1-5 night shifts (p=0.004). Residents who work both in inpatient and outpatient clinics had higher depersonalization than those who work in outpatient clinics only (p<0.001). The feeling of personal accomplishment was lower in males (p=0.045), and those who work at the state university hospital (p<0.001). However, having a COVID-19 history (p=0.032), or living with someone at risk for severe COVID-19 (p=0.013) was associated with higher scores in personal accomplishment.

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The determinants of emotional exhaustion, depersonalization, and personal accomplishment during the pandemic were assessed by multiple linear regression models and coefficients presented in Tables 4, 5, and 6 respectively.

According to Model 1 (R 2 =0.11 p<0.001) the emotional exhaustion score increases by 2.3 points (95%CI 0.7-3.9) for the female sex, by 0.5 points (95%CI 0.2-0.9) for each increase in the number of night shifts per month, by 2.4 points (95%CI 0.3-4.5) for living with someone under risk of severe COVID-19, by 3.3 points (95%CI 1.5-5.2) for having an experience of personal problems during the pandemic. However, it decreased by 2.4 points (95%CI 4.6-0.3) for having COVID-19 related duty either outpatient or inpatient. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Model 2 (R 2 =0.06 p=0.03) indicates that the depersonalization score decreases by 0.3 points (95%CI 0.5-0.02) for each increase in age. However, it increases by 1.2 points (95%CI 0.1-2.3) for being married and by 0.3 points (95%CI 0.08-0.5) for each increase in the number of night shifts per month. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2022. ; https://doi.org/10. 1101 /2022 Model 3 (R 2 =0.07 p=0.007) shows that the personal accomplishment decreases by 1.5 points (95%CI 2.6-0.4) for those who work in a state university. Burnout levels before and during the pandemic were compared in Table 7 . A significant (48%) decrease in personal accomplishment score was found (p<0.001). There was no statistically significant difference for other dimensions. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Then, we used multiple regression analysis, this time to eliminate the confounding effects of known variables on the possible effect of the pandemic on the burnout subscale scores. Included study time (before or after pandemic) in the previous models. Even after controlling for confounders, pandemic (i.e. study time) was still a plausible (B=10.3, 95%CI 11-9.6, p<0.001) explanation for the decrease in the feeling of personal accomplishment. Coefficients for Models 4, 5, and 6 are provided in the appendix (Table 8 ,9,10 respectively).

Subgroup comparisons of three subscale scores (Table 11 -13) and the comparisons of mean scores of each of the personal accomplishment items before and during the pandemic were also provided in the appendix (Table 14) .

The main objectives of our study were to compare the level of burnout in medical residents before and during the COVID-19 pandemic and identify risk factors that may be associated with burnout. Our findings suggest a significant decrease in the feeling of personal accomplishment while non-difference in emotional exhaustion and depersonalisation.

Burnout levels before and after the pandemic.

New tasks due to the pandemic, fear of illness, lack of knowledge on using personal protective equipment (PPE), inadequate PPE, faulty infection control measures, faulty communication and directives, lack of emotional support and preparation, low autonomy, lack of management support, low hospital management support, lack of appreciation from supervisors, job insecurity, perceived fatality, not being able to spare enough time for the patient, fear of mistakes, medical neglect, dissatisfaction with patient care, fear of carrying a disease to the family, staying in a place other than the family home for security measures, not being able to see the family, being young, isolation and stigma is one of the factors associated with the increase in burnout of health workers (Aba, 2022; Dumea et al., 2022; Kılıç et al., 2021; Sengul et al., 2021; Soares et al., 2022; Wilson et al., 2017) .

When the burnout levels of doctors in a metropolitan city in the north-eastern region of Turkey were examined before the pandemic, the results show that EE (emotional exhaustion) and DP (depersonalization) scores were lower and PA (personal accomplishment) scores were similar in our study (Levin, 2019) . This can be interpreted as EE and DP scores being affected by the city (population density, etc.) and the hospital (patient density, etc.) they work in. EE, DP, and PA scores in our study were similar to a burnout study in which doctors working in three metropolitan cities were in the majority during the early pandemic (April 2020) (Kılıç et al., 2021) .

Again, in a study conducted with anesthesiologists and intensive care unit nurses in Istanbul during the early stages of the pandemic (May 2020), EE and DP scores were like those in our study, and the PA score was higher than that of in our study (Sevinc et al., 2022) . Before the pandemic, it is known that despite the high workload, people who are better able to adapt to crises and cope with difficult situations may experience less burnout (Borusiak et al., 2022) . This may explain the difference between the PA scores of anesthesiologists, intensive care unit nurses, and other studies.

EE and DP scores of medical residents, whose workload was already high before the pandemic regardless of the hospital type, might not change that much depending on the changes in care provision during the pandemic. Or exacerbating effects of the pandemic may be balanced by the relative decrease in demand and imposed flexible work schedules. Further investigation of nondifference in EE and DP may shed light on what could help to solve the concerning problem of burnout in this population.

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When we look at the studies in other countries, in a study comparing the burnout of primary care physicians by years, it was shown that the biggest change was the decrease in PA, like in our study (Seda-Gombau et al., 2021) . As a result of the analysis, before the pandemic, an upward trend for EE and DP and a downward trend for PA were observed and then aggravated by the prolongation of the pandemic (Seda-Gombau et al., 2021) . Although we could not observe this trend with the data in our study, one year after the first case in Turkey (March 11, 2020), a decrease in PA was observed in our study, which can be explained by the prolongation of the pandemic.

From a psychological point of view, the increase in Forward-Looking Anxiety (cognitive processes such as anxiety, fear, panic, constantly and excessively reviewing possibilities and thinking about the possibilities caused by uncertainty about the future), Inhibitory Anxiety (Behavioral processes such as running away, freezing, or doing nothing in the face of uncertainty), False Emotions (Trying to show that the person feels emotions that they do not feel), Hidden Emotions (Hiding the emotions that would not be appropriate to be shown in a certain situation by the individual), and COVID-19 Threat Perception (low or high perceived threat relative to its real-world counterpart) sub-dimension scores associated with a decrease in the dimension scores during the pandemic (Aba, 2022) . In our study, the decrease in the PA score during the pandemic period can be explained in this way.

In a study examining the burnout rates of US doctors from 2011 to 2014, the PA score was classified as high/medium/low. According to this study, 66.6% of doctors scored high in 2011, while 61.2% scored high in 2014 (Shanafelt, Hasan, et al.) . One of the authors of this study (vice president of professional satisfaction at the AMA) stated that since the sense of providing good care to patients increases doctors' sense of personal satisfaction, anything that interferes with caring for patients distracts them from personal satisfaction (Henry, 2016) . The reasons that prevent the provision of quality health care services such as chaotic working environments and time pressure may have led to higher PA scores in studies conducted in other countries before the pandemic (Henry, 2016) . In the continuation of the same study, there have been changes in health institutions in the last 5 years and the changes in health service delivery (virtual care, etc.) during the pandemic. Therefore, although the burnout rate, which is handled with two sub-dimensions GE and DP, is lower than that of the prepandemic period, job satisfaction is higher (Shanafelt, West, et al.) . These results are promising in terms of things that can be done to reduce burnout in Turkey.

In studies, EE scores were found to be higher in women, single people, those with less professional years, with longer working hours, those who experienced sleep deprivation, and who worked in shifts (Kılıç et al., 2021; Seda-Gombau et al., 2021; Sengul et al., 2021) . The effects of work-home conflicts and maternal responsibilities on female health workers are known (Kılıç et al., 2021; Soares et al., 2022) . In our study, multiple regression analysis showed that being a woman increased the IE score. It is known that the high number of night shifts that cause sleep deprivation and poor-quality sleep increases burnout (Seda-Gombau et al., 2021; Sevinc et al., 2022) . In our study, multiple regression analysis showed that each increase in the number of night shifts per month increased the EE score. Personal characteristics of the participants such as age, marital status, professional year, and professional characteristics such as before or after the pandemic, department, and university type did not make a statistically significant difference in the EE score. In our study, the ages of the participants were young and close to each other. Therefore, we can claim that there is no relationship between age and EE score, but there is no relationship between them in the literature (Aba, 2022; Nituica et al., 2021) . In some studies, it has been observed that single/divorced people have higher EE scores than married people (Aba, 2022; Nituica et al., 2021) . Being single is considered an important risk factor for burnout (Maslach et al., 2001; Zarei et al., 2019) . It is stated that being married protects against EE and burnout by increasing perceived social support (Kılıç et al., 2021; Zarei et al., 2019) .

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However, there are studies in which marital status does not make a statistically significant difference in the EE score, as in our study (Nituica et al., 2021) .

It has been observed that the EE levels of healthcare professionals who have been in the profession for 1-10 years are significantly higher than those who have been in the profession for more than 10 years (Türkmen & Aslan) . In our study, since both the age and the experience (years) are close to each other and less than 10 years, there may not be a significant relationship with the EE score. No significant relationship was found between study time (before or after the pandemic), department and hospital type, and EE and DP. The absence of a relationship between the department and EE and DP is consistent with the literature (Nituica et al., 2021) . There are studies in which employees in private hospitals have higher EE and DP scores than those employees in other institutions (Sengul et al., 2021) . Before and during the pandemic, the work of resident doctors with similar intensity, regardless of hospital type and department, may have caused the lack of a predictor for EE and DP.

In our study, multiple regression analysis showed that each increase in age decreased the DP score, each increase in the residence year increased the DP score, and each increase in the number of night shifts per month increased the DP score.

Personal characteristics of the participants such as gender, marital status, and professional characteristics such as before or after the pandemic, department, and university type did not make a statistically significant difference in the DP score. In our study, although the DP score was high in younger, there are studies in the literature that are compatible with our finding, as well as studies showing that age does not make a significant difference (de Wit et al., 2020; Elhadi et al., 2020; Nituica et al., 2021; Wilson et al., 2017) . Studies show that the residency year does not make a difference in DP (Passos et al., 2022; Wilson et al., 2017) . It is known that exposure to criticism and violence increases DP scores (Passos et al., 2022; Wilson et al., 2017) . In our study, the fact that the DP score was high in the younger ones but the increase in residency year was a predictor of DP may be evaluated in this context. Night shift poor sleep quality increases the likelihood of being exposed to mobbing and violence, and it was found that the burnout levels (EE, DP, and PA) of night shift workers were significantly higher than those working the day shift (Hacimusalar et al., 2021; Sengul et al., 2021) . In our study, it was reported that DP scores were higher in shift workers, which was consistent with the literature. Although studies show that women generally have higher burnout rates and EE scores than men, there are also studies showing that men have higher DP scores than women (Aba, 2022; Nituica et al., 2021) . It has been reported that the reason for this may be that men use less emotional expression than women and lack empathy (Aba, 2022) . However, no significant relationship was found between gender and DP in our study. Studies in the literature show that married people have lower DP scores, but some studies do not show a significant relationship between marital status and DP, as in our study (Aba, 2022; Kılıç et al., 2021; Nituica et al., 2021; Zarei et al., 2019) .

In our study, multiple regression analysis showed that being in the pandemic period reduced the PA score, while the hospital type was foundation increased.

Personal characteristics of the participants such as age, gender, marital status, professional year, and occupational characteristics such as department, and night shift per month did not make a statistically significant difference in the PA score. It has been mentioned that health workers, whose job descriptions have changed with the pandemic, who feel inadequate in the fight against a new and unknown virus, and who feel guilty thinking that they are not enough in the treatment of patients, show symptoms of burnout (Levin, 2019) . When a study conducted on healthcare workers during the pandemic was evaluated psychologically, it was found that the Emotional Labor Scale's Concealed . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2022. ; https://doi.org/10.1101 https://doi.org/10. /2022 Emotions sub-dimension (the level of cognitive effort used by the healthcare worker to hide or hide the emotions he/she feels in the institution) and the COVID-19 Threat Perception predicted PA negatively (Aba, 2022) . It was found that the Deep Action sub-dimension of the Emotional Labor Scale (feeling the emotions in the display of the emotions requested by the Institution) predicted PA positively (Aba, 2022) . From this point of view, PA scores may have decreased so much since the institutions could not facilitate the pandemic process psychologically for the assistant doctors who participated in our study and could not manage it well. It has been shown that people with a high intolerance of uncertainty (suddenly announced curfews, revoked leave, and the right to resign, extra hours posted) have low PA scores (Aba, 2022) .

On May 27, 2020, a circular has been published by the Ministry of Health in Turkey orders that "personnel who request to resign from their duties during this process, for whatever reason, will not be accepted".

This may be one of the reasons why the PA score is lower both during the pre-pandemic and the pandemic periods compared to other countries. It has been observed that there is a significant relationship between trust in the health system and PA, and non-physician healthcare workers have higher PA scores (Aba, 2022) . The increase in distrust in the health system and the fact that the participants were only doctors may have caused the result of our study. There is a negative and significant relationship between the death of the patient cared for due to COVID-19 and the inadequacy of the measures taken during the pandemic and PA (Aba, 2022) . Maybe those working in state hospitals may have been more exposed to these situations. In a study conducted before the pandemic, it was found that the job stress levels of those working in a foundation university hospital were lower than those working in a state hospital, and their job satisfaction levels were higher than those working in a state hospital. This information in the literature may also have led to this difference (Şahin, 2011) . Although there are studies where it is stated that age positively predicts the PA score and those feelings of inadequacy that can be felt due to less experience, being new to business life, and being employed for a short time may affect the younger healthcare professionals more, there are also studies where no such relationship was observed between age and PA, as in our study are available (Aba, 2022; Nituica et al., 2021) . Different relationships were found between gender and PA (Aba, 2022; Sengul et al., 2021) . Although in some studies men had a higher average of PA than women, in other studies, it was the opposite (Aba, 2022; Kılıç et al., 2021; Sengul et al., 2021) . Like our study, some studies did not find a significant relationship between gender and PA (Nituica et al., 2021) . Gender has not been accepted as a strong predictor of burnout (Maslach et al., 2001) . In addition to studies showing that married people have higher PA scores, some studies did not show a significant relationship between marital status and PA, as in our study (Aba, 2022; Kılıç et al., 2021; Nituica et al., 2021; Zarei et al., 2019) . If we consider the sub-dimension of PA in our study, this dimension is thought to have a separate role from both EE and DP and represents perceived professional competence (López-Núñez et al., 2020) . For this reason, it is thought that employees reflect their personal characteristics, not their reactions to stressful situations. Therefore it is not a burnout dimension, but an individual psychological capital more like self-esteem, self-efficacy and optimism that develops independently of EE and DP (López-Núñez et al., 2020) . For this reason, some authors have excluded the PA dimension from their burnout studies (López-Núñez et al., 2020) .

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By 2021, global trends in the labour market presented an extraordinary phenomenon which is later called "The Great Resignation" (Sheather & Slattery, 2021) . Employees around the world quit their jobs due to low wages, high cost of living, and job dissatisfaction. It is acceptable to expect that economic difficulties combined with burnout could lead to mass resignations among doctors as well (Sheather & Slattery, 2021) .

Resident physicians in Turkey are more precarious than ever. Physician identity was wounded before the pandemic (Koytak, 2021) . The recent decrease in purchasing power and public disputes on physician wages did not do better. In this context findings of our study become more concerning. Resident physicians who will continue to feel low personal accomplishment are likely to leave their job and training given global economic trends. Turkey is already one of the countries with the lowest doctor per population (1.8/1000) among OECD countries (average of 3.5) (OECD, 2021) . A possible wave of resignation may intensify the problems arising from inadequate human resources, such as short consultation times and long waiting times. Because the residency program also works as a tool for distributing doctors after the training more equally among regions, this may also play a role in health inequalities. Lower completion of the residency program would mean fewer specialists in the following years. This may risk the achievements of universal health coverage in Turkey, particularly for some specialist care.

It is important to note that this study was not longitudinal, i.e., data is not necessarily collected from the same residents in the reference study. There is a constant change in residents in each hospital. Thus, this study does not show a causal relationship between the pandemic and burnout among medical residents. Still, the comparison in this study provides better evidence than existing studies in the Turkish context for both local decision-makers and global researchers. Although the study has achieved an approximate 50% participation rate, selection bias should be always kept in mind while interpreting the findings. Residents who experience burnout may be more or less willing to participate in the study than others. Lastly, 69 participants answered the online form, and they have a significantly higher mean EE score (21.9±7.5) than those who answered the paper form (18.2±7.7). When they are excluded from Model 1, female sex and experience of personal problems during the pandemic turn into non-significant (p=0.51, p=0.67 respectively). No difference was observed for other dimensions by mode of application.

This study indicates a remarkable decrease in the feeling of personal accomplishment among medical residents during the pandemic in Turkey compared to a similar pre-pandemic study. This was significant in female and state university residents. Surprisingly, our study does not support the hypothesis of an increase in emotional exhaustion and depersonalization dimensions of burnout. This can be explained by already high pre-pandemic levels of burnout and a relative decrease in demand due to social restrictions. Loss of feeling of personal accomplishment may lead to mass resignations given the global trends in the labour market and economic crisis. Even if they do not resign, it is well known that burnout will have an impact on the quality of health care. The health workforce in Turkey is not in a position where these concerns can be overlooked. Therefore, we are calling on decisionmakers at all levels of the health system in Turkey to act immediately, reform the medical residency training program, improve working conditions, and build back better after the COVID-19 pandemic.

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Burnout syndrome in personnel of an infectious diseases hospital, one year after the outbreak of the COVID-19 pandemic

Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care

Prevalence of and factors associated with burnout among health care professionals in Arab countries: a systematic review

Burnout syndrome among hospital healthcare workers during the COVID-19 pandemic and civil war: a cross-sectional study

Doktor ve hemsirelerde tukenmislik ve Maslach tukenmislik olceginin uyarlanmasi VII

Experiences and management of physician psychological symptoms during infectious disease outbreaks: a rapid review

The effects of working and living conditions of physicians on burnout level and sleep quality

The role of personal accomplishment in physician burnout

Resident and faculty perspectives on prevention of resident burnout: a Focus group study

Medscape national physician burnout, depression & suicide report

Factors affecting burnout in physicians during COVID-19 pandemic

The Changing Social Position of the Medical Profession in the Pandemic

Medical residents are facing burnout: who are at stake?

Burnout at work: a psychological perspective

Mental health care for survivors and healthcare workers in the aftermath of an outbreak

Psychological capital, workload, and burnout: what's new? the impact of personal accomplishment to promote sustainable working conditions

Burnout among surgical residents in a lower-middle income country

Factors influencing resilience and burnout among resident physicians -a national survey

Impact of COVID-19 on surgical residency programs in Pakistan; A residents' perspective. Do programs need formal restructuring to adjust with the "new normal"? A cross-sectional survey study

Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis

Burnout syndrome in resident physicians of a Federal University

Incidence and factors associated with burnout in anesthesiology: a systematic review

Impact of the COVID-19 pandemic on burnout in primary care physicians in Catalonia

The impact of changing processes in the COVID-19 pandemic on health care workers' burnout syndrome: web-based questionnaire study

Burnout and psychological distress between surgical and non-surgical residents

Anxiety and burnout in anesthetists and intensive care unit nurses during the COVID-19 pandemic: a cross-sectional study

Emotional exhaustion among anesthesia providers at a tertiary care center assessed using the MBI burnout survey

Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between

Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between

The great resignation-how do we support and retain staff already stretched to their limit?

Burnoutrelated factors in health professionals during the COVID-19 pandemic: an integrative review

Mental health and quality of life among healthcare professionals during the COVID-19 pandemic in India

Bir devlet hastanesinde çalışan hemşireler ile bir vakıf üniversitesi hastanesinde çalışan hemşirelerin iş stres ve iş doyumu düzeylerinin incelenmesi Maltepe Üniversitesi

COVID-19 pandemisi sürecinde sağlık çalışanlarının algılanan stres ve duygusal tükenme düzeylerinin incelenmesi International Black Sea Coastline

Quantifying burnout among emergency medicine professionals

Impact of COVID-19 pandemic on mental health in the general population: a systematic review

Prevalence of burnout among primary health care staff and its predictors: a study in Iran

Analysis of personal accomplishment items