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Abstract
Introduction: Emergency medicine (EM) residents are at high risk for burnout syndrome. The professional quality of life scale (ProQOL) is a validated survey that measures compassion satisfaction (CS) and compassion fatigue, which is comprised of burnout and secondary traumatic stress (STS) scales. This study sought to evaluate CS and fatigue among Turkish EM residents using the ProQOL survey. Methods: This was a cross-sectional study of Turkish EM residents who are part of the EM Residency Association of Turkey. The ProQOL survey version 5 was E-mailed in Turkish to all 150 EM residents. Participants were currently employed as EM residents. Demographics and satisfaction with quality of life were also collected. Results: Eighty residents completed the survey. Almost half of the respondents were either very dissatisfied or dissatisfied with their overall quality of life. Turkish EM residents not only had moderate levels of CS (scoring 33.9 ± 7.9), but also suffered moderate burnout (27.0 ± 5.9) and STS (24.7 ± 5.3). Conclusions: Turkish EM residents have moderate levels of CS and moderate levels of burnout and secondary traumatic stress.
Keywords: Compassion fatigue, emergency medicine, professional burnout, quality of life, secondary trauma
How to cite this article: Introduction 
A physician's job satisfaction is the outcome of both positive and negative contributors. The most widely used tool for the assessment of job satisfaction in caregiving occupations is the professional quality of life scale (ProQOL), which has been translated into many languages and used across many specialties.[1] The ProQOL utilizes survey questions to measure two key aspects of job satisfaction: Compassion satisfaction (CS) and compassion fatigue (CF).[1] For the purposes of the ProQOL, these two components may vary independently of one another and warrant individual exploration [Figure 1].
Figure 1: Schema of contributors to EM resident compassion satisfaction and compassion fatigue, including secondary traumatic stress and burnout. EM: Emergency medicineProQOL researchers define the negative contributor to job satisfaction, CF, as burnout along with secondary traumatic stress [STS, [Figure 1]].[1] According to the World Health Organization, “burn-out is a syndrome. Resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one's job, or feelings of negativism or cynicism related to one's job; and reduced professional efficacy.”[2] Burnout syndrome has been included in both the 10th and the 11th revisions of the International Classifications of Diseases.[2] Physicians experience burnout in excess of the general population regardless of physicians' subspecialty or geographic location.[3],[4],[5],[6],[7],[8],[9],[10],[11] Emergency medicine (EM) physicians are at even more risk, experiencing burnout rates in excess of 60%, as compared to 38% in physicians in general.[12],[13],[14] This is likely due to demanding work hours and shifting schedules, work-life imbalance, violence in the workplace, patient volume and acuity, high-stress situations, administrative burden, and interpersonal factors.[13],[14],[15],[16] Trainees in EM are likewise disproportionately affected relative to their peers, with burnout in excess of attending physicians.[13],[17],[18],[19],[20],[21],[22],[23] Risk factors for resident burnout include lack of autonomy, work-home conflicts, and high-risk decisions during times of clinical uncertainty, among others.[23]
The component of CF known as STS is incurred by the observation of stressful, disturbing, violent, or traumatic events in the workplace.[1] STS may manifest in sufferers through fearfulness, sleep difficulties, intrusive images, or avoidant behaviors. STS has become a diagnostic criterion for the diagnosis of posttraumatic stress disorder (PTSD) per the American Psychiatric Association.[24] Studies have shown that a significant number of emergency physicians experience STS as well as PTSD.[25],[26]
In spite of high rates of burnout and STS, 65% of US EM physicians report high rates of job satisfaction.[27] This relatively high satisfaction rate in spite of high rates of burnout and STS is likely related to what ProQOL researchers call “CS.” CS is deriving pleasure through one's work, whether by helping others, interacting with peers, or contributing to society.[1]
Although attention to physician wellness has brought increasing scrutiny to contributors of physician burnout and components of job satisfaction, few international studies have looked at these parameters in trainees. In Turkey, the previous research has elucidated some important features of the EM resident experience, which include workload, lack of social support, workplace violence, and work relationships.[8],[28],[29],[30] However, data are comparatively lacking regarding CS and CF in this group. The purpose of this pilot study is to evaluate CS and CF among Turkish EM residents who are members of the EM Residency Association of Turkey (EMRAT) using the ProQOL survey. It is our hope that increasing understanding of these components of job satisfaction will serve as a guide for future studies focused on improvement.
Methods Study design
This was a cross-sectional survey-based study of Turkish EM residents. The study was reviewed by the IRB and found to be exempt. The study number was 2018-122, and it was approved on October 23rd, 2018.
Study setting and population
The study included 150 residents who were part of the EMRAT during the study (academic year 2017–2018). All participants were age 18 or older and currently employed as EM residents. Participants were not consented, as survey completion was considered implicit evidence of consent.
Patient and public involvement
Patients and the public were not involved in the design of this study. The research question was developed in concert with graduate medical educators in EM in the US and Turkey.
Study protocol and measurements
The ProQOL survey version 5 was translated into Turkish by a native Turkish speaker, using the Turkish translation of the ProQOL version 4 as a basis, as per the ProQOL website.[1] This anonymous survey was E-mailed to all 150 members of the EMRAT. In addition to the components of the ProQOL survey, participants were queried regarding their age, marital status, caregiver status, workload, and quality of life. Participants completed the survey using Google survey.
Data analysis and handling
Survey data were imported from Google Sheets and analyzed with descriptive statistics (©1993-2013, Ostend, Belgium). Reference ranges for survey scores were provided at ProQOL.org.[1] In summary, for measures of burnout, STS, and CS, scores ≤22 are categorized as LOW, scores 21–41 are categorized as MODERATE, and scores ≥42 are categorized as HIGH.
Results Eighty residents completed the survey. Ninety-six percent of respondents were Turkish citizens, and most were under the age of 40 years. Remaining demographic information regarding participants is presented in [Table 1]. Most of the residents responding to the survey reported heavy workloads, with the majority reporting 60–80 h of work each week, seeing more than 3 patients per hour. Further details regarding the residents' clinical responsibilities are demonstrated in [Table 2].
When queried as to their satisfaction regarding work-related aspects of their lives, residents were generally dissatisfied. Residents were least satisfied in the financial aspects of their work, specifically income and medical student debt. They also felt very dissatisfied in their patient population, with mixed satisfaction in their work environment. Residents felt slightly more positive about the quality of their teaching faculty. Details of resident satisfaction as it pertains to work are presented in [Figure 2].
Figure 2: Resident levels of satisfaction with job-related elements of their livesResidents were slightly less dissatisfied with their personal lives, with more than half feeling at least neutral on query of their quality of life, health, and living environment. Residents were by and large dissatisfied with their amount and quality of sleep [Figure 3].
Figure 3: Resident levels of satisfaction with personal elements of their livesOn the ProQOL inventory, Turkish EM residents had moderate CS, with a mean score of 33.9 (standard deviation [SD] 7.9). They also scored moderately on indicators of CF, with a mean burnout score of 27 (SD 5.9) and a mean STS score of 24.7 (SD 5.3).
Discussion This study found that Turkish EM residents experienced moderate levels of CS and moderate levels of both components of CF (burnout and STS). These values demonstrate a lower quality of life relative to US residents utilizing the same survey instrument.[31] The reasons for this are likely multifactorial, and at least to a degree, correctable.
Compassion satisfaction
One component of CS is perceived positive impact of one's work. In our survey, residents had moderate CS, but were very dissatisfied with their patient population and moderately dissatisfied with their working environment, including their reimbursement [Figure 2]. The specialty of EM has struggled for recognition, fair wages, and fair representation in Turkey, which negatively impacts CS.[32] In Turkey, many EDs are being used as observation units, and patients can remain in the ED for days or weeks at a time.[32] It is possible that this extended nonemergent care may dampen residents' perceived positive impact on patients as well as contribute to their general dissatisfaction with their work. In a study of EM physicians in Turkey, avoiding the day-to-day challenges of working in the ED was a commonly cited reason for pursuing subspecialty training after completion of EM training.[33] This suggests a level of disillusionment, with trainees seeking to reduce time in their chosen profession. In addition, in a study of 41 residents who have left EM training in Turkey, one commonly cited reason was poor relationships between co-workers and supervisors.[29] It stands to reason that residents who feel undersupported, threatened, and under-reimbursed feel less pleasure from helping their patients.
Another component of CS is the feeling of effectiveness and mastery.[33] Turkish residents may have more challenges achieving these feelings due to faculty staffing and availability of resources as compared to their US peers. In an overview of EM in Turkey, training was described as suffering from understaffed teaching faculty and inadequate specialty supervision, with too few faculty in the nation to support the EM training programs.[32] Furthermore, one study identified group bullying from co-workers and supervisors as well as inadequate access to academic resources as significant detractors in EM residency training, which is unlikely to promote feelings of autonomy or mastery.[29] In our study, 27 trainees (34%) were dissatisfied with their academic teachers, 36 (45%) were satisfied, and the remaining were neutral. This is an area with potential for active intervention, and indeed the EM Association of Turkey is working to establish educational guidelines to create uniformity to training.
Compassion fatigue: Burnout
Burnout in EM physicians has been linked to high volumes of patients, shifting schedules, inadequate sleep, and struggles with work-life balance. Our study supports higher levels of burnout for Turkish EM residents relative to their US counterparts. Part of this is likely due to workload, both in terms of hours worked and patient volume. When volumes exceed provider comfort, errors are made and perceived positive outcomes can worsen. Our study found that 82% of Turkish residents are seeing greater than three patients per hour. This exceeds Accreditation Council for Graduate Medical Education (ACGME) expectations from even senior US residents, who see about 1.7 patients/h.[34] Although some of the differences in patient volume may be ameliorated by decreased documentation requirements and administrative burden for Turkish residents, ≥3 patients/hour is likely excessive.
Although we did not query residents regarding how their schedules shifted (circadian, back-scheduling, or block scheduling), most Turkish EM residents reported working >60 h per week. In the US in 2003, the ACGME introduced work hour restrictions for resident education, capping EM residents at 60 h and requiring at least one 24 h period off per week.[35] These restrictions have been shown to lower the rate of burnout and emotional exhaustion among medical trainees in the US.[36] As the time commitment for clinical responsibilities increases, residents have decreased time for other aspects of their lives, harming their work-life balance, impacting their sleep, and increasing their levels of burnout. Decreasing sleep has been shown to reduce self-compassion and resilience, as well, compounding burnout.[37] Our study shows that Turkish EM residents are generally dissatisfied with their leisure time and sleep [Figure 3]. Capping Turkish EM residency hours and/or providing dedicated leisure time or mandatory breaks for sleep would likely improve their measures of burnout.
Studies have also shown that wellness programs may reduce burnout rates among residents in several specialties, although the data are not completely clear.[38],[39] Nevertheless, institutional investment in reducing burnout and creating wellness is a critical first step in creating a supportive culture. In our cohort of residents, 91% stated their residency did not have a wellness program, and this would be a reasonable starting point for programs seeking to create a culture of wellness.
It has been suggested that overall, burnout and empathy worsen each year of residency training, with subsequent improvement after graduation.[40] Currently, the duration of Turkish training exceeds that of US residents by 1–2 years. Although we are not suggesting that the length of training is unnecessary (as training length is a combination of prior schooling as well as formal residency training, and differs based on health-care system), it is possible that the additional years with limited autonomy, reduced reimbursement, and long hours contribute negatively to burnout.
Secondary traumatic stress
The final component of CF is STS. In our study, 96% of Turkish EM residents reported being assaulted while working in the ED, which is echoed in a prior study demonstrating high rates of violence and assault among Turkish EM physicians.[30] Their study found that these episodes are not isolated and that more than half of the physicians reported multiple episodes of violence in the prior year.[30] In that study, being subjected to workplace violence was associated with younger physician age (0.008), working in an ED with a high patient admission rate (P = 0.018), current position (P < 0.001), working outside regular work hours (P < 0.001), working in a state hospital (P < 0.001), and level of experience (P < 0.001).[30] Another study demonstrated that increasing work hours also increases exposure to STS.[31] Most of these risk factors for violent exposure select for resident physicians, who work longer hours, more night hours, are by definition less experienced, usually younger, and frequently train at large, busy centers. This affect could be mitigated by strengthening security at training facilities, reducing number of visitors, and education of patients and visitors regarding behavioral expectations.
Implications
Increased CF and decreased CS are not just problems in themselves but have downstream effects such as decreased motivation and attrition from ED training. Attrition rates in Turkey are 3 times higher than in the US, with top-cited reasons of violence/security concerns (63.4%), busy work environment (53.7%), and inadequate training (46.3%).[14],[29],[41] Further, there is data to suggest that burnout can lead to increased medical errors, decreased patient safety, and decreased quality of care, including patient satisfaction.[14] Finally, CF increases negative coping mechanisms and mental health disorders in physicians, including substance abuse, depression, and suicidality.[14] Therefore, in the interest of providing an effective and vital workforce, it is imperative to take measures to reduce burnout and STS and improve CS in trainees.
Limitations
Our study is limited by its response rate. Fifty-three percent of members of EMRAT responded, and there may be nonrandom differences between those who chose to complete the survey and those who did not. We suspect those who did not participate are more likely to have been busy or overextended (and therefore have worse scores on CF), as completion of the survey took about 20 min, but that is conjecture. Our study results are in keeping with other studies of similar populations, and therefore we suspect the results are fairly accurate.
Our study is also limited by our study instrument. Although the ProQOL is widely used, some studies suggest that it is not entirely valid or might benefit from modification.[42] In spite of this, we feel that the ProQOL allowed us some insight into contributors to EM resident quality of life when training in Turkey.
Conclusions Turkish EM residents have moderate rates of CS and moderate rates of CF including burnout and STS. Training programs should focus on mitigation strategies to improve workforce vitality and patient care.
Research quality and ethics statement
This study was determined not to require the Ethics Committee review. The corresponding protocol approval number is 2018-22. The authors followed applicable EQUATOR Network (http:// www.equator-network.org/) guidelines during the conduct of this research project.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jets.jets_62_21
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