EMOTIONAL BURNOUT SYNDROME : EFFECT ON CLINICAL INERTIA AND MEDICAL PRACTICE STEREOTYPES

R.A. Khokhlov, E.V. Minakov, G.I. Furmenko, N.M. Akhmedzhanov* Chair of Hospital Therapy of Voronezh State Medical Academy named after N.N. Burdenko, Studencheskaya ul. 10, Voronezh, 394000 Russia Interregional Cardiology Center of Voronezh Regional Clinical Hospital No 1, Moskovsky prosp. 151-2, Voronezh, 394082 Russia State Research Center for Preventive Medicine of Rosmedtechnology, Petroverigsky per. 10, Moscow, 101990 Russia

Treatment compliance, following WHO definition, is conformity of patient's behavior with doctor's recommendations (drugs intake, diet observance, any other mode of life modifications) [1].Low compliance with cardiovascular disease therapy leads to early development of complications, disability and premature death which results in significant economical costs and negative demographic tendencies [2][3][4].
Patient's personality features, disease trends, choice of medical treatment, socio-economic aspects and cooperation between a doctor and a patient are the factors of great
The extreme degree of professional burnout is identified as emotional burnout syndrome (EBS).It means emotional exhaustion, depersonalization and personal progress reduction that take place in workers of social sphere whose job supposes intensive relations.The EBS can develop in professionals feeling overburdened with other people problems [8][9][10][11].
Differential signs of the EBS are ennui, estrangement from process and results of labour, callousness, inhumane and cynical attitude to patients, negative estimation of one's qualification and professional skills [7,9,11].The syndrome is spread widely among doctors of various specialties.Its occurrence in the USA and European countries varies from 25 to 76% depending on used survey techniques [7,10,[12][13][14][15].
Influencing almost all sides of clinical practice and work stereotypes, the EBS contributes to improper attitude to professional duties and worsens medical care quality.Besides EBS can cause such situations as stress-determined diseases, alcohol or drugs abuse, labour discipline decrease and low morality [7,9,11,16,17].
The aim of this study was to investigate EBS effect on medical practice and primary care physician's stereotypes.

Material and methods
Within educational project of the Society of Cardiology of the Russian Federation (SCRF): "Management of highrisk patients", which was lasting during 2006 -2007, anonymous questionnaire survey of 184 primary care doctors was carried out.Questions about physician's sociodemographic characteristics, their postgraduate education, work conditions and stereotypes of clinical practice were included in the questionnaire.The basic principles of cardiovascular disease prevention and treatment (according to SCRF guidelines) were tested as well.169 (92%) forms were given back.Six of them were excluded from the analysis because of insufficient information about respondents.Prevalence of the EBS was estimated using N.E.Vodopianova's questionnaire "Professional burnout" (PB) which is an analogue of Maslach Burnout Inventory method [8][9][10].The EBS was determined as severe emotional exhaustion and depersonalization with low professional achievements.The EBS risk (i.e.significant profes-их последипломной подготовки, условия труда, сложившиеся стереотипы клинической практики.Проверялось также знание основных принципов профилактики и лечения сердечно-сосудистых заболеваний, рекомендованных ВНОК.Было возвращено 169 (92%) анкет; 6 из них после проверки были исключены из анализа, поскольку не содержали полной информации о респондентах.
Medical care suboptimality was estimated by answers to 11 questions, that didn't contain any criticism and described mostly typical situations where improper actions or neglect attitude of a physician to a patient could become apparent.The form specially elaborated for this problem investigation was used as a base of the questionnaire [7,15].Respondents chose one of the following answers: "never", "very seldom", "several times a year", "monthly", "weekly".Medical care considered as suboptimal if improper actions or neglect attitude were revealed one time a month or more often.
The participants were divided into two groups according to survey results: the first one included 43 (26,4%) physician with active stereotypes of clinical practice and the second one included 120 (73,6%) physician with standard stereotypes of clinical practice.
Specialists with active stereotypes of clinical practice in contrast to their colleagues demonstrated lower clinical inertia due to regular medical literature reading, taking part in conferences and seminars.They also consulted their patients on nonmedical preventive measures, calculated cardiovascular death risk and explained the prescribed drugs effect [6].
There were 123 (75.5%) women and 40 (24.5%)men among those who answered the questions completely.Their age lied in the compass of 26 -76 years with the median 47 and the interquartile range 39 -53 years.The length of medical service ranged from 2 to 50 years with the median 21 and the interquartile range 14 -28 years.

Results and discussion
The analysis of 153 questionnaires allowed to determine burnout prevalence in primary care physicians.The Table 1 and Fig. 1 show the findings.
The average values of the all three subscales were in a reference values range which had been received for Russian population [9,10].The average values according to the emotional exhaustion subscale were 23.0±8.6 for the total sample, 19.9±7.4 for men and 24±8.8 for women.When using the depersonalization subscale the average values were 7.8±4.9for all of the respondents, 8.3±5.0 for men and 7.7±4.9for women.The average values according to the personal accomplishment subscale amounted to 31.5±7.1,31.8±5.9, and 31.3±7.4,respectively.The emotional exhaustion score was significantly higher in women than in men but it didn't reach the EBS level.
On the total the syndrome prevalence came to 13.1%.Besides, 49.7% of primary care physicians had got the high degree of burnout, i.e. threat of the EBS development, because of emotional exhaustion or depersonalization high scores.
The findings correspond to Russian and international study results [9,[12][13][14][15][16][17].Result discrepancies in this kind of studies are usually explained by different criteria of the EBS, special features of clinical practice in studied medical population and some cultural factors [9,11,19].For example, if the EBS was defined as extremely high level of emotional exhaustion, depersonalization and low professional achievements, its prevalence among Swiss general  practitioners was 3.5% and it was 8.1% among Russian dentists [12,13].When estimating the EBS only as high scores of emotional exhaustion or depersonalization its prevalence reached to 31.5% or even 76% as it was shown in Swiss general practitioners and American medical residents [7,13].The majority of authors note the higher degree of emotional exhaustion in women [9,11,14].Fig. 2 and 3 represents the manifest EBS and the high score of burnout prevalence standardized by age and length of service.
The manifest EBS prevalence as well as the high score of professional burnout was unrelated with physicians' age and length of service.Other researchers give the same results [12,13].However, in young specialists at the beginning of the career the higher frequency of this phenomenon can be marked which can be explained by emotional shock of collision with reality.After 45-50, when soul-searching takes place and behavior motives are changed, the inverse correlation between age (service length) and the EBS can be observed [10,11].
Such characteristics as marital status, having children, specialty, workplace, administrative position and the wages didn't impact on the EBS development.It can be explained by the small size of compared groups from the one side and by the lack of questions that evaluate personal and organizational EBS risk-factors more accurately from the other side, as it is known that work conditions and individual psyhophisiological features of a worker are the professional burnout fundamental reasons [9,11,[13][14][15]17].
The Table 2 represents demonstrations of improper medical care.More than 90% of respondents answered the questions more likely negatively: "never", "very seldom", "several times a year".At the same time improper actions (questions 1-4, 6-8, 10) were found in 27 (17.7%)cases and improper attitude to patients (questions 5, 9, 11) -in 15 (9.8%) cases only.The most often (in 9.8% cases) specialists didn't discuss the treatment choice with their patients and didn't answer completely to patients' questions.That reflected ineffective doctor-patient cooperation.At the total the prevalence of suboptimal medical care amounts to 24.2%.
Such starting characteristics as age, length of service, sex, marital status, the number of children, specialty, conditions of work didn't impact on suboptimal practice manifestation.
At the same time the portion of specialists with improper attitude to patients in the form of indifference to their social and financial problems and their sufferings related with a disease, feeling the blame because of diagnostics and treatment defects, was reliably more among the burned-out physicians [ 6 (30%) from 20 vs 9 (7%) from 133 accordingly; p=0.0055].There was slightly more the portion of physicians with improper actions among them also [7 (35%) from 20 vs 20 (15%) from 133; p=0.0525].At that any suboptimal care demonstration occurred more often in burned-out physicians [10 (50%) from 20 vs 27 (20.3%)from 133; p=0.009].T. Shanafelt et al. comes to the same conclusion: the EBS was considered as the main independent predictor of suboptimal medical care in their work [7].
The correlation coefficients matrix for values of the PB questionnaire subscales on improper actions and attitude to patients was made (Table 3).The significant correlation between scores of emotional exhaustion and depersonalization from the one side and the frequency of suboptimal medical care manifestations from the other has been revealed.In particular, at increasing of depersonalization score physicians could refuse from the examination of a quarrelsome patient, readdressed patients to other specialists, committed errors.They also prescribed drugs with not evident efficacy, didn't estimate side effects of remedies, avoided repeated consultations, were indifferent to sufferings.For the subscale of emotional exhaustion the same direct relationship has been determined, and for the subscale of personal accomplishment -the inverse one.Thus, increase of professional burnout worsened work stereotypes.The data are well agreed with T. Shanafelt's et al. study [7] which shown that relative risk of suboptimal medical care significantly rose in increase of depersonalization level.
Thus the EBS and changes preceding it, emerging during professional practice, can be considered as severe factors affecting clinical care stereotypes and work efficacy and consequently patients' treatment compliance.Taking into account the high prevalence of emotional burnout among primary care specialists, monitoring and preventive measures of this state must be an important concern aim of their labour management.

Conclusion
The manifest EBS prevalence among primary care specialists is 13.1%.However, almost half of the physicians have the risk of its origin.Presence of a family and children reduces the risk of the EBS development.
The level of emotional exhaustion in women is significantly higher than this in men.The most frequent manifestation of suboptimal medical care is improper attitude to patients and their problems related with a disease.The EBS contributes to development of improper attitude to patients, at the same time there is significant correlation between depersonalization score by the PB subscale and suboptimal medical care manifestations.The emotional burnout influencing clinical practice stereotypes can promote the clinical inertia.

Figure
Figure 2. Emotional burnout syndrome prevalence according to age

Figure 4 .
Figure 4. Emotional burnout profile in physicians with improper attitude to patients

Figure 5 .
Figure 5.The emotional burnout profile in physicians with different clinical practice stereotypes

Table 2 .
The frequency of physicians' improper actions and improper attitude to patients (n=153)