Assessment of pediatric residents burnout in a tertiary academic centre
To identify respondent characteristics for the survey, we searched the literature using MEDLINE and PubMed databases, as well as articles identified from the references of reviewed articles. We included only English language articles and excluded articles in other languages. We used keywords (MeSH) terms in our search: burnout, resident, pediatrics, residency, physician, residents working hours, Saudi residency program. We conducted a cross-sectional survey, that was administered to all pediatric residents enrolled in the Saudi Paediatric Board program (PGY1-PGY4) in a large tertiary academic hospital in the Western region of Saudi Arabia (King Abdulaziz University Hospital). E-mail was sent to trainees with a link to the survey. Survey was constructed using an online survey website (Survey Monkey TM ). The survey included a cover letter explaining the aim of the study and ensuring confidentiality. The survey took place over one week in May 2016 after obtaining the research committee approval at King Abdulaziz University. Two reminders were sent through e-mail 2 and 5 days from the initial e-mail to increase responses. With the last reminder, we mentioned that this was the last chance to participate and that the survey will be closed in 24 hours. We measured burnout using the Maslach Burnout Inventory Human Services Survey, a 22-item scale developed to assess burnout among professionals that work in emotionally stressful environments. This scale has been used extensively to measure burnout in medical team members and is regarded as the standard tool for assessing the construct. The scale included 3 domains: 1) emotional exhaustion, 2) depersonalization, and 3) personal accomplishment. Each item measured a specific domain, based on a 7-point Likert-type scale, ranging from “never” to “every day”. The total score for each domain was calculated by summing across domain-specific items. The standard scoring criteria for medical professionals are as follows: for emotional exhaustion 18 and below is low, 19 to 26 is average, and 27 and above is high; for depersonalization 5 and below is low, 6 to 9 is average, and 10 and above is high; and for personal accomplishment, 33 and below is low, 34 to 39 is average, and 40 and above is high. “High” scores on emotional exhaustion and depersonalization and “low” scores in personal accomplishment are considered indicators of burnou. , - Demographic characteristics were collected, including gender, marital status, and year of training, to evaluate if there were associations between these factors and the severity of burnout. All pediatric residents registered in the residency training program from PGY1-PGY4 were included. We excluded any incomplete surveys. The study was conducted in full accordance with the Declaration of Helsinki. Descriptive statistics were calculated to examine trends in survey responses and total scores within and across domains. T-tests were used to examine differences in mean domain scores across demographic characteristics, to investigate factors associated with burnout. Data compilation and analyses were conducted using Stata 14 (College Station, TX, Texas). 

There were 50 enrolled resident in the pediatric residency program during the 2015-2016 academic year. A total of 35 (70%) residents responded, with 32 (91.4%) residents who completed the survey. Incomplete surveys were discarded and results were not used in the analysis. summarizes the demographic criteria of participants. More than 70% of residents were classified to be experiencing severe burnout. Forty-three percent of our residents are suffering from severe emotional exhaustion compared to 71.8% experiencing depersonalization and low accomplishment in 40.6%. Data were further analyzed to see if there were any associations of burnout with gender, relationship status and/or year of training findings in greater detail. 

There have been a number of studies examining into burnout among residents of different specialties but non was pediatric specific. Our findings underscore the prevalence of burnout among pediatric residents, who were not protected from burnout and were suffering the consequences of this syndrome on both personal and career levels. More than 70% of our residents reported experiencing one type or more of burnout, which is comparable with national and international literature. - There are several key findings in this study. First, our pediatric residents suffered from high levels of depersonalization when compared with similar studies in Saudi Arabia and around the world. Depersonalization in our cohort group reached 71.8%. Several prior studies provide benchmark prevalence estimates. For example, the study by Baharoon et al, reported depersonalization of 23% among all specialty residents in a tertiary hospital in Riyadh, Saudi. Aldrees et al who studied burnout among ENT residents in the Saudi program across the Kingdom reported a depersonalization rate of 55%. Dyrbye et al described a 35.7% depersonalization among US residents and fellows of different specialties. The second notable observation is that we found statistically significant relationships between burnout and relationship status, where partner residents (engaged or married) suffered from higher emotional exhaustion and depersonalization. The relationship factor did not make any difference on the personal accomplishment scores. and Figures - illustrate these difference, which has not been described in prior Saudi or international studies. This finding is of particular importance as it is opposite to what other studies found. For example, Baharoon et al and Dyrbye et al found that there was no relation of relationship status and burnout; on the other hand, Aldrees found that being a single female is associated with higher burnout scores. However, it is also reasonable to infer that married residents will be more burned out trying to find a balance between work and home/family responsibilities. In this survey, there were no significant relationships between burnout and gender and no statistically significant difference of burnout score in different years of training which is comparable with other literature. There has been a similar study carried out by Alyoubi et al where they looked at burnout among pediatrician (residents, specialists, consultants) practicing in Jeddah, Saudi Arabia. Unfortunately, they used a different scoring system which made it impossible to compare our data to theirs. Burnout is a serious phenomenon that affect not only physician on multiple levels (health, mental and social aspects), but can also affect the quality of patient’s care directly. , , In order to understand this phenomenon further, a comprehensive study is needed, and we believe that this study provides such initial investigations. Health systems and different medical specialties vary significantly in their practice patterns. Therefore, we need to further study the impact of cultural and institutional factors that may have contributed to the discrepancy between our results and previous reports. Study limitation The study cohort is relatively small compared to other published literature. Efforts are underway to conduct a second version for all pediatric residents across the Kingdom to be able to say with confidence if it is program, personal or institute related. In conclusion, 70% of pediatric residents at King Abdulaziz University Hospital are suffering from burnout. There was a significant relationship between being engaged/married and worse burnout score (emotional exhaustion and depersonalization). Moreover, our residents experienced much higher levels of depersonalization than their peers, nationally and internationally. 

The study cohort is relatively small compared to other published literature. Efforts are underway to conduct a second version for all pediatric residents across the Kingdom to be able to say with confidence if it is program, personal or institute related. In conclusion, 70% of pediatric residents at King Abdulaziz University Hospital are suffering from burnout. There was a significant relationship between being engaged/married and worse burnout score (emotional exhaustion and depersonalization). Moreover, our residents experienced much higher levels of depersonalization than their peers, nationally and internationally. 

