BACKGROUND: Burnout, a state of physical and emotional exhaustion, in healthcare workers (HCWs) is a major concern The prevalence of burnout, due to COVID-19 pandemic in India, is unknown We therefore conducted this survey MATERIALS AND METHODS: A questionnaire-based survey using Copenhagen Burnout Inventory was carried out among HCWs looking after COVID-19 patients Questionnaire was sent to the HCWs, using WhatsApp Messenger, and voluntary participation was sought We received responses from 2026 HCWs Burnout was assessed in personal, work, and client-related (COVID-19 pandemic-related) domains Burnout was defined at a cut-off score of 50 for each domain RESULTS: The prevalence of personal burnout was 44 6% (903), work-related burn-out was only 26 9% (544), while greater than half of the respondents (1,069, 52 8%) had pandemic-related burnout Younger respondents (21-30 years) had higher personal and work-related burnout The prevalence of personal and work-related burnout was significantly (p < 0 01) higher among females The doctors were 1 64 times, and the support staff were 5 times more likely to experience pandemic-related burnout CONCLUSION: There is a significant prevalence of burnout during the COVID-19 pandemic among HCWs, in particular, doctors and support staff Female respondents had higher prevalence We suggest that the management should be proactive and supportive in improving working conditions and providing assurance to the HCWs The long-term effects of the current pandemic need to be assessed later HOW TO CITE THIS ARTICLE: Khasne RW, Dhakulkar BS, Mahajan HC, Kulkarni AP Burnout among Healthcare Workers during COVID-19 Pandemic in India: Results of a Questionnaire-based Survey Indian J Crit Care Med 2020;24(8):664-671

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Burnout among Healthcare Workers during COVID-19 Pandemic in India: Results of a Questionnaire-based Survey

Professional burnout among medical trainees has been identified as a national concern in need of attention. A significant challenge for residency programs is designing and implementing effective strategies to promote resident wellness and reduce burnout. Emerging evidence highlights the importance of developing organizational changes targeting physician burnout. To address this critical need, Harvard South Shore (HSS) Psychiatry Residency Training Program aimed to assess burnout among residents, identify areas for wellness-related growth, and implement strategies for organizational change to reduce burnout and increase wellness. We aligned closely to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines to systematically approach planning, conducting, and evaluating this quality improvement effort. We developed a wellness action team and assessed burnout using the Copenhagen Burnout Inventory (CBI). We also conducted a survey to investigate high opportunity areas for wellness-related growth and using this data we designed and implemented four organizational initiatives to (i) improve residents’ on-call experience, (ii) increase social activities, (iii) support preventative care, and (iv) promote wellness education. We then re-assessed burnout 1 year after implementation and performed two-sample t-tests to compare CBI scores. We additionally gathered and analyzed feedback from residents on the implemented organizational initiatives’ relevance to wellness and their well-being. There was an overall clinically meaningful reduction in burnout averaged among all residents that participated. Participants indicated that fitness-oriented activities were most likely to lead to change in wellness habits. Our implemented wellness program was resident-led and involved continuous feedback from both residents and leadership. Given that there may be multiple factors that affect resident burnout, future studies involving a control group could help reveal whether our intervention contributed to the change in burnout scores we observed.

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Resident-led organizational initiatives to reduce burnout and improve wellness.

Background: With increasing workload and dismal working conditions, healthcare professionals (HCPs) in India often suffer from burnout. Understanding the extent of these problems and the contributing factors is necessary to build a healthy workforce capable of serving the society. The purpose of this study was to systematically review and analyze: 1) the prevalence of burnout among HCPs in India and 2) the factors associated with burnout in this population. Methods: A systematic search of MEDLINE and EMBASE, from the inception of these databases to October 2019, was conducted using keywords. The search results were screened to identify studies evaluating burnout among HCPs in India using a standard burnout tool. Using a random effect model, the pooled prevalence of burnout was estimated using Maslach Burnout Inventory (MBI) in three domains: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Risk factors for burnout were assessed qualitatively. Results: A total of 15 studies assessing burnout in 3845 Indian HCPs were identified. The pooled prevalence of burnout was 24% in the EE domain, 27% in the DP domain, and 23% in the PA domain. Younger age, female gender, unmarried status, and difficult working conditions were associated with increased risk of burnout. Conclusion: Burnout is highly prevalent among Indian HCPs, with close to one-fourth of them suffering from burnout. A number of personal and professional factors are associated with burnout, and these should be considered while developing solutions to tackle burnout.

https://journals.sagepub.com/doi/pdf/10.4103/IJPSYM.IJPSYM_387_19

Prevalence and Factors Associated with Burnout among Healthcare Professionals in India: A Systematic Review and Meta-Analysis.

This prospective study explores the prevalence, associated characteristics, and trajectory of burnout over one academic year in a multidisciplinary sample of resident physicians using a relatively new burnout survey instrument. All residents from a U.S. academic health center (n = 633) were invited to complete the Copenhagen Burnout Inventory (CBI) three times, with 4-month time lags between invitations. A total of 281 (44%) provided complete CBI survey responses at least once, and 43 (7%) did at all three times. Descriptive statistics, cross-sectional analyses, correlations, and multivariable linear regression analyses were computed, as well as repeated measures ANOVAs and paired t tests, as appropriate, for each CBI domain (personal, work, patient-related burnout). About half had CBI scores indicating moderate-to-high levels of personal burnout (49–52%) and work-related burnout (45–49%), whereas patient-related burnout was less common (14–24%). However, patient-related burnout increased significantly from the beginning to the end of the year. Regression analyses indicated patient-related burnout was significantly higher for postgraduate year 1–2 residents compared to PGY 4+ residents, but was not significantly different by gender. Personal and work burnout scores were significantly higher for females. Persistently high burnout was observed in only 6% of respondents. In this study of resident physicians using the CBI, burnout was prevalent and higher levels of burnout were observed for females on the personal and work burnout domains, while junior residents had higher patient-related burnout. Persistently, high burnout was rare. The CBI demonstrated high reliability, was practical to administer, and produced similar results with existing burnout research.

A One-Year Institutional View of Resident Physician Burnout.

Background: Globally, burnout is an increasingly prevalent problem amongst young medical professionals. This review aims to understand the factors related to burnout in the early-career stage of medicine. Drawing on the widely used Job Demands-Resources Model, the antecedents of burnout were distinguished from its outcomes.Methods: The review adopted the PRISMA guidelines. Using specific search terms, peer-reviewed articles were obtained from a range of databases and assessed against selection criteria. To meet inclusion requirements, the study had to be published between 2000 and 2018, include a validated measure of burnout, and undertake empirical assessment of factors related to burnout in medical students and/or junior medical officers/residents. Additional studies were obtained and reviewed from the reference lists of selected articles.Results: Out of the 3796 studies that were initially found, 585 were assessed against the eligibility criteria leaving 113 studies for review. These studies highlighted the negative consequences of burnout in the early medical career. Also identified were work-specific and person-specific demands that likely lead to burnout and, work and person resources that appear to reduce burnout.Conclusion: This review provides a framework to explain the growing problem of burnout amongst early-career medical professionals. However, further research is necessary to overcome the current reliance on cross-sectional designs and small sample sizes.

A review of the factors related to burnout at the early-career stage of medicine

Background and Rationale: Residents work in emotionally demanding environments with multiple stressors. The risk for burnout is high in them and it has significant negative consequences for their career. Burnout is also associated with consequences in terms of physical and mental health including insomnia, cardiovascular disease, depression and suicidal ideation. Thus, the study aimed to study the prevalence of burn out and its correlates among interns and residents at Government Medical College, Thiruvananthapuram, Kerala, India. Settings and Design: Cross Sectional Study at Government Medical College, Thiruvananthapuram, Kerala, India. Methods: It was a cross Sectional study of 558 interns and residents of Government Medical College, Thiruvananthapuram, Kerala, India. Data was collected which included the Copenhagen Burnout Inventory [CBI]which assesses burnout in the dimensions of Personal burnout, Work burnout and Patient related burnout, with a cut off score of 50 for each dimension. Age, sex, year of study, department the resident belonged to, or an intern, junior resident or a super speciality senior resident (resident doing super speciality course after their post graduate masters degree) were the correlates assessed. Statistical analysis: Univariate analysis. Results: More than one third of the participants were found to have burnout in one or another dimension of the CBI. Burnout was found to be the highest among the interns in the domains of personal burnout (64.05 %) and patient related burnout (68.62 %) and in junior residents for work related burnout (40%). Super specialty senior residents had the least prevalence of burnout in all three dimensions. Among the residents, Non Medical/Non Surgical residents had the least prevalence of burnout in all three dimensions, whereas surgical speciality residents had the highest of personal burnout (57.92 %) and Medical speciality residents had the highest patient related burnout (27.13%). Both medical and surgical specialty residents had equal prevalence of work burnout. The study also showed that as the number of years of residency increased, the burnout also increased in all three dimensions. A between gender difference in burnout was not noticed in our study. Conclusions: Burnout was found to be present in a large number of residents in our study. Nationwide studies and assessment of more correlates will be needed to understand this phenomenon and also for formulating measures for preventing and managing it.

Prevalence of burnout and its correlates among residents in a tertiary medical center in Kerala, India: A cross-sectional study.

Back to table of contents Previous article Next article APA & MeetingsFull AccessWork Group Produces Primer on Structural Racism for TraineesBadr Ratnakaran, M.B.B.S., Weei LoAllen, M.D., Dhruv Gupta, M.D., Sanya Virani, M.D., M.P.H., Charles Dike, M.D., M.P.H.Badr RatnakaranSearch for more papers by this author, M.B.B.S., Weei LoAllenSearch for more papers by this author, M.D., Dhruv GuptaSearch for more papers by this author, M.D., Sanya ViraniSearch for more papers by this author, M.D., M.P.H., Charles DikeSearch for more papers by this author, M.D., M.P.H.Published Online:25 Feb 2022https://doi.org/10.1176/appi.pn.2022.03.3.26AbstractAPA/APAF fellows compile a list of resources for medical students and residents to increase their knowledge of the impact of structural racism on patients and clinical practice.iStock/wildpixelThe year 2020 was remarkably challenging as the COVID-19 pandemic shone a glaring and unflattering spotlight on health care disparities faced by minority communities due to the enduring legacy of racism and racial discrimination. Patients belonging to ethnic and racial minorities often face an uphill battle in obtaining the health care they deserve, enduring prejudices that pervade all levels of care and significantly limit access. Ethnoracial biases (implicit and explicit) and discrimination can occur during clinical encounters leading to disparities in diagnoses, medical decision-making, and interactions with patients. These contribute to stress and psychological trauma that increase the risk of psychiatric disorders in members of these vulnerable groups. Despite these facts, however, many medical schools and psychiatry residency programs in the United States do not provide adequate training regarding racially driven health care inequities.The disproportionate morbidity and mortality of COVID-19 among Blacks, Hispanics, and Native Americans is a direct consequence of long-standing historical injustice due to racism. Psychiatry is not immune from the structural racism that permeates the U.S. health care system as the history of psychiatry is deeply rooted in colonialism and racism. As APA president in 2020-2021, Jeffrey Geller, M.D., M.P.H., focused on confronting these issues. Dr. Geller constituted the Presidential Task Force to Address Structural Racism Throughout Psychiatry, which created courageous initiatives and educational resources on structural racism in psychiatry. A work group of APA/APAF fellows was established, and two of the authors of this article who served on the task force, Drs. Charles Dike and Sanya Virani, guided the fellows in developing projects to address structural racism in psychiatry training. The other authors proposed the creation of an educational resource on structural racism for medical students and trainees in psychiatry.With the goal of creating a beginner’s guide on the topic, we reviewed various online resources and scientific literature, and senior psychiatrists and APA/APAF fellows across the country provided feedback. The work group subsequently created “A Primer of Online Resources on Structural Racism in Psychiatry for Medical Students & Trainees in Psychiatry.” The primer was created as an easily accessible resource to help trainees understand core concepts and various subtopics of structural racism in psychiatry. The primer consists of a wide range of literature on structural racism, including studies, reviews, and meta-analyses.The core of the primer addresses topics related to the impact of structural racism on mental health. Examples of social determinants of mental health related to race include racial disparities in immigration policies, child welfare, criminal justice, access to mental health and substance use treatment, food insecurity, racial segregation of neighborhoods, and impact on physical health. The primer also provides resources for trainees to develop skills for addressing racism in clinical settings and other resources for in-depth learning on structural racism in psychiatry. ■The primer is posted here.Badr Ratnakaran, M.B.B.S., is an APA/APAF Leadership Fellow and a fellow in geriatric psychiatry at the Virginia Tech Carilion School of Medicine Carilion Clinic.Weei LoAllen, M.D., is an APA/APAF Public Psychiatry Fellow and a fellow in child and adolescent psychiatry at Keck School of Medicine at the University of Southern California.Dhruv Gupta, M.D., is an APA/APAF Diversity Leadership Fellow and a PGY-4 resident in psychiatry at Icahn School of Medicine at Mount Sinai, Elmhurst Hospital.Sanya Virani, M.D., M.P.H., is APA’s resident-fellow member trustee, a member of the APA Presidential Task Force on Social Determinants of Mental Health and the former APA Presidential Task Force to Address Structural Racism Throughout Psychiatry, and a fellow in forensic psychiatry at Alpert Medical School at Brown University.Charles Dike, M.D., M.P.H., is a member of the former APA Presidential Task Force to Address Structural Racism Throughout Psychiatry and an associate professor of psychiatry at Yale School of Medicine. 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Work Group Produces Primer on Structural Racism for Trainees

The Same Day on Repeat: A Unique Case of Persistent DÉjÀ Vu Phenomenon as a Long COVID Symptom in an Older Adult

Back to table of contents Previous article Next article Clinical & ResearchFull AccessStimulant Prescriptions for Older Adults Are on Rise: A Guide for Safe PrescribingBadr Ratnakaran, M.D., Antoinette Shappell, M.D.Badr RatnakaranSearch for more papers by this author, M.D., Antoinette ShappellSearch for more papers by this author, M.D.Published Online:27 Apr 2023https://doi.org/10.1176/appi.pn.2023.06.6.34AbstractBecause older adults have a greater risk for cardiovascular events associated with stimulant prescribing, clinicians should initially screen and then monitor patients’ blood pressure and heart rate. The number of stimulant medication prescriptions in the United States is rising for a variety of indications and among many patient populations, including older adults. The majority of stimulants being prescribed belong to the amphetamine and methylphenidate class of drugs. An observational cohort study appearing in The Lancet in August 2022 led by Shannon Brumbaugh, M.D., revealed that stimulant prescribing in the United States between 2010 and 2020 has increased in patients of all ages and that the average age of recipients increased throughout their study.The results further indicated that among adults 65 and older, there was an increase in stimulant prescriptions for people with multiple cardiovascular risk factors. Stimulants act on the central nervous system to increase attention, improve mood, and elevate energy. However, their effects on monoamine transmission may cause an increase in resting heart rate and systolic blood pressure, thereby increasing risk for those with preexisting cardiovascular disease. This concern is supported by findings from another cohort study—this one was led by Mina Tadrous, Pharm.D., Ph.D., and published in JAMA Network Open in October 2021. The team found a 40% increase in cardiovascular events among 6,457 older adults within 30 days of initiation of a stimulant.There are many reasons for increased prescribing of stimulants to older adults. Increased awareness and acceptance of attention-deficit/hyperactivity disorder (ADHD) have contributed to an increase in diagnoses; however, ADHD diagnoses alone do not account for the increase in stimulant prescribing. Some stimulant prescriptions are approved for treatment of narcolepsy and short-term adjunct treatment of weight loss in obese patients. Other conditions for which off-label use of stimulant medication may yield significant benefits include fatigue, traumatic brain injury, poststroke recovery, treatment-resistant depression, Parkinson’s disease, and major neurocognitive disorder.There is a dearth of studies on the use of stimulants in older adults, so it is challenging to predict adverse effects. But given the potential risks associated with stimulant prescribing in an older population that is inherently at greater risk for cardiovascular events, careful initial screening and monitoring of blood pressure and heart rate are recommended. Routine urine drug screening is also recommended to ensure compliance as well as to minimize prescribing to patients who are taking other controlled medications that may potentiate the risk for cardiovascular events. An electrocardiogram is not routinely needed before starting a stimulant unless the patient has a history of congenital heart disease, cardiac surgery, heart failure, heart murmur, palpitations, chest pain, hypertension, shortness of breath on exertion, and other medical conditions that increase cardiac risk.Stimulants are also relatively contraindicated in patients with severe vascular or cardiovascular diseases, hyperthyroidism, epilepsy, glaucoma, drug abuse, agitation, and psychosis. They can decrease the metabolism of many drugs, including tricyclic antidepressants, warfarin, phenytoin, primidone, and phenobarbitone. Co-administration of stimulants with monoamine oxidase inhibitors can cause life-threatening hypertensive crises and increase the risk for serotonin syndrome when combined with serotonergic drugs like most antidepressants.Gastrointestinal and urinary pH affects the absorption and elimination of the amphetamine class of stimulants. Gastrointestinal acidifying agents such as ascorbic acid and fruit juices and urinary acidifying agents such as ammonium chloride can lower amphetamine plasma levels; gastrointestinal alkalinizing agents such as sodium bicarbonate and urinary alkalinizing agents such as acetazolamide and thiazides can lower amphetamine plasma levels.To minimize adverse effects, clinicians should start stimulants in older adults at the lowest dose and gradually increase until potential benefits are reached while monitoring for side effects. For example, methylphenidate can be started at 5 mg in the morning and then increased by 5 mg weekly based on the improvement of symptoms. Lower doses of stimulants are usually therapeutic in older adults. A second dose can be given in the mid-afternoon to avoid insomnia.As required by the Drug Enforcement Administration, Schedule II stimulants (amphetamines and methylphenidates) can be prescribed by a qualified medical professional with multiple prescriptions to a total of up to a 90-day supply as long as the state laws are met and there is no undue risk of diversion or abuse. Each prescription must have written instructions for the earliest date on which the pharmacy can refill each prescription. Clinicians should also check the Prescription Monitoring Drug Program to ensure that patients are not misusing or overusing the stimulants. The risk of diversion and abuse of the stimulants should be evaluated during patient encounters.Clinicians should also conduct due diligence in monitoring medical comorbidities, medication changes in older adults, and patients’ ability to manage their medications. The dosage of stimulants should be re-evaluated for drug-drug interactions as well as for side effects and changes in physiology with aging. Patients with impaired liver and renal function should be prescribed the lowest possible dose. Drug holidays can be used to reduce the frequency of dosing.To discontinue the medications, clinicians should gradually taper the dose until it is stopped. Abrupt cessation of stimulants can cause withdrawal symptoms of dysphoria, depression, fatigue, and sleep disturbances. If the indication for which the stimulant was prescribed still needs to be addressed, nonamphetamine stimulants like modafinil and armodafinil and nonstimulant medications for ADHD like atomoxetine, guanfacine, clonidine, and bupropion can be prescribed. ■Resources“Trends in Characteristics of the Recipients of New Prescription Stimulants Between Years 2010 And 2020 in the United States: An Observational Cohort Study”“Assessment of Stimulant Use and Cardiovascular Event Risks Among Older Adults”Badr Ratnakaran, M.D., is a geriatric psychiatrist at the Center for Healthy Aging and medical director of CONNECT at Carilion Clinic in Roanoke, Va. Antoinette Shappell, M.D., is an adult and child and adolescent psychiatrist and Special Assistant to the Deputy Assistant Under Secretary for Health in Patient Care Services at the U.S. Department of Veterans Affairs in Washington, D.C. They are both members of the APA Council on Geriatric Psychiatry. ISSUES NewArchived 

B Ratnakaran

Papers

Prevalence of burnout and its correlates among residents in a tertiary medical center in Kerala, India: A cross-sectional study.

Work Group Produces Primer on Structural Racism for Trainees

The Same Day on Repeat: A Unique Case of Persistent DÉjÀ Vu Phenomenon as a Long COVID Symptom in an Older Adult

Stimulant Prescriptions for Older Adults Are on Rise: A Guide for Safe Prescribing

Climate Change and Older Adults: an Important Reason to Prepare Trainees for the Imminent Geriatric Mental Health Crisis