Department of Medicine, McMaster University, Hamilton, ON, Canada
Introduction Before the COVID-19 pandemic, reported physician burnout was endemic in North America, with rates as high as 51%. The pandemic placed an increased demand on physicians’ time both in their work and home lives. We sought to identify the frequency of burnout in a large academic institution and its impact on clinical practice, non-clinical work, and home life.
Methods All academic physicians and non-physician faculty members in the Department of Medicine (DOM) at McMaster University were invited to participate in an anonymous survey between January 22 and February 21, 2021. The survey elicited information on how clinical practice, work, and home life changed throughout the pandemic. Responses to questions were captured on a 1-to-5 Likert scale. Descriptive statistics were calculated and the Mann–Whitney U-test was used to determine statistical significance (p < 0.05). The results were compared to the 2019 DOM survey which included a question on burnout.
Results Among 330 faculty, 76.7% completed the survey. The reported burnout was high at 75.9%, affecting women to a greater extent than men (82.5% vs 70.4%, p < 0.01). Early career faculty also reported proportionally more burnout (83.5% vs 65.7%; p < 0.001). Medical-legal liability of phone-based care was a concern for 48% of physicians. The reported hours of work per day were significantly higher amongst women than men compared to pre-pandemic (80.4% vs 58.0%; p < 0.001). Loneliness (64.1% vs 51.4%; p < 0.05) and hours spent on caring for dependents (54.5% vs 31.1%, p < 0.01) were higher for women versus men. Both genders reported career fulfillment and research productivity were overall lower by 51.2% and 52.3%, respectively.
Conclusions The COVID-19 pandemic has increased burnout amongst DOM academic faculty, and disproportionately affected women and early career faculty. A thoughtful systems-level approach, with dedicated resources, is needed to address the impact of the COVID-19 pandemic on medical faculty.
Introduction Avant la pandémie de COVID-19, l’épuisement professionnel des médecins était endémique en Amérique du Nord, les taux de déclaration atteignant 51 %. La pandémie a exercé une pression accrue sur le temps des médecins, tant dans leur travail que dans leur vie privée. Nous avons cherché à déterminer la fréquence de l’épuisement professionnel dans un grand établissement universitaire et ses répercussions sur la pratique clinique, le travail non clinique et la vie privée.
Méthodologie Tous les médecins universitaires et les membres du corps professoral non-médecins du Département de médecine de l’Université McMaster ont été invités à participer à un sondage anonyme qui s’est tenu du 22 janvier au 21 février 2021. Le sondage a permis de recueillir des renseignements sur les changements survenus au cours de la pandémie en ce qui a trait à la pratique clinique, au travail et à la vie privée. Les réponses aux questions ont été consignées sur une échelle de Likert de 1 à 5. Des statistiques descriptives ont été calculées et le test U de Mann-Whitney a été utilisé pour déterminer la signification statistique (p < 0,05). Les résultats ont été comparés à ceux du sondage mené en 2019 auprès du Département de médecine qui comporte une question sur l’épuisement professionnel.
Résultats Parmi les 330 membres du corps professoral, 76,7 % d’entre eux ont répondu au sondage. Les déclarations d’épuisement professionnel sont élevées à 75,9 %, et les femmes sont touchées dans une plus grande mesure que les hommes (82,5 % contre 70,4 %, P < 0,01). La proportion de déclarations d’épuisement professionnel est également plus élevée chez les membres du corps professoral en début de carrière (83,5 % contre 65,7 %; p < 0,001). La responsabilité médico-légale de la prestation de soins par téléphone est une préoccupation chez 48 % des médecins. Le nombre d’heures de travail par jour déclaré est considérablement plus élevé chez les femmes que chez les hommes comparativement à avant la pandémie (80,4 % contre 58,0 %; p < 0,001). De la même façon, la proportion des femmes est plus élevée que celle des hommes en ce qui concerne la solitude (64,1 % contre 51,4 %; p < 0,05) et le nombre d’heures consacrées au soin de personnes à charge (54,5 % contre 31,1 %, p < 0,01). Les deux sexes font état d’une diminution globale de 51,2 % du sentiment d’accomplissement professionnel et de 52,3 % de productivité en recherche.
Conclusions La pandémie de COVID-19 a entraîné une augmentation des cas d’épuisement professionnel parmi le corps professoral du Département de médecine, et a touché d’une manière disproportionnelle les femmes et les membres du corps professoral en début de carrière. Une approche réfléchie à l’échelle du système, assortie d’une affectation de ressources, est nécessaire pour pallier les répercussions de la pandémie de COVID-19 sur le corps professoral en médecine.
Key words: gender equity, internal medicine, professional burnout
Corresponding Author: Sonia S. Anand: firstname.lastname@example.org
Submitted: 3 April 2022; Accepted: 4 May 2022; Published: 4 June 2022
Burnout is described as “an erosion of the soul caused by the deterioration of one’s values, dignity and spirit” and manifests as exhaustion, depersonalization, and a decreased sense of personal accomplishment.1,2 Burnout is endemic in medicine, with an estimated prevalence of 51% of physicians prior to the COVID-19 pandemic.3 Physician burnout is largely rooted in healthcare organizational and system factors including excess work-related stressors, but physician personal characteristics also contribute.4 Work factors, excessive workload, inadequate resources, loss of support from colleagues, and loss of control and autonomy within the healthcare environment (such as electronic medical records and clinic space restrictions) all contribute to burnout.2,5,6 Physicians who are self-critical, over-committed, and who have work–life imbalances are also more likely to experience burnout.3 Other characteristics that increase the risk of burnout include having a child under the age of 21, the female sex, and early career.7 The consequences of burnout can be dire for the health care system. Burnout is directly associated with an increase in serious medical errors.8 It also affects the capacity of the healthcare system by reducing the ability to deliver clinical care through increasing turnover, retirement, and decreasing productivity.9,10
The COVID-19 pandemic has compelled physicians to face unprecedented challenges in their ability to safely care for patients, themselves, and their families. Physicians were required to pivot their practices to virtual, participate in pandemic administrative planning, and adapt to new methods of delivering content to learners. Anxiety was provoked by challenges in obtaining personal protective equipment, the fear of contacting COVID-19 or exposing family members to COVID-19.11 Anxiety has further exacerbated burnout and it has been suggested that the pandemic has disproportionately affected women and people of color.4 Despite the perceived widespread ramifications of burnout, little is known about the impact of the COVID-19 pandemic on the extent of burnout and aspects of physicians’ lives being affected. We, therefore, aimed to address this knowledge gap by conducting a survey of physicians and non-physician faculty from the Department of Medicine (DOM), McMaster University. Our objective was to assess the proportion of our faculty experiencing burnout and to determine the impact of the COVID-19 pandemic on three key areas: clinical practice;, non-clinical work, and home life.
The survey used to assess burnout and the impact of -COVID-19 on academic physicians was developed by the McMaster Equity, Diversity, and Inclusion (EDI) advisory committee. This committee (listed at the end) is comprised of representatives across divisions of general internal medicine and other medical subspecialties, PhD scientists, department administrators, and an internal medicine resident representative. Questions were developed to capture the demographics of the DOM and the impact of COVID-19 on clinical practice, non-clinical work life, and home life. A formal burnout scale was not used. COVID-19 specific questions were assessed by the committee for face validity, and a Likert scale was used to obtain a range of responses. The survey was pilot tested by the EDI advisory committee members and modified based on this feedback. Further validation of the survey was not done due to time constraints.
The COVID-19 questions attempted to capture information on how clinical practice, work and home life had changed throughout the COVID-19 pandemic using an EDI-based perspective which focuses on gender, ethnicity, and sexual orientation. Responses to questions were captured on a 1-to-5 Likert scale and free text responses were also accommodated.
The COVID-19 survey questions were included as part of the 2nd biennial Department of Medicine Equity and Diversity Survey and distributed electronically to all full-time faculty in the DOM at McMaster University in Hamilton, Ontario, Canada. The survey used the REDCap electronic data capture system, hosted at McMaster University.12 It was administered between January 22 and February 21, 2021, and completed anonymously. Division directors were asked to encourage their division members to complete the study. As a financial incentive to complete the survey, potential respondents were offered Alternate Funding Points to complete the survey, which is a standardized academic merit system adopted by the DOM. The survey questions are detailed in Appendix 1.
A question regarding burnout of faculty was asked in the 2019 Department of Medicine Equity and Diversity Survey prior to the COVID-19 pandemic. This 2019 survey had a 46% response rate with 153/330 fully completing the survey, and the reported burnout results are used as a baseline measurement pre-COVID-19 comparison. The 2019 survey questions are listed in Appendix 1.
The intent of this survey was descriptive and exploratory, without a hypothesis-driven survey sample size. Descriptive statistics were calculated, and the Mann-Whitney U-test was used to determine statistical significance using a conventional p-value of <0.05. Univariate analysis was also performed to determine factors associated with feeling burnt out or overwhelmed. Chi-squared tests were used to determine the significance of the association between categorical variables (gender, person of color, faculty rank, academic position, age bracket, and self-reported ethnicity). A forward stepwise multivariable logistic regression model was formulated with increased burnout as the dependent variable, and type of Faculty (i.e., clinical vs research educator), gender (male vs female), and rank (assistant professor, associate, and full professor) entered to the test for independent effects. Statistical analysis was done using R version 3.6.1 in RStudio version 1.2.5019.13
Among 330 faculty who were invited by email to participate, 76.7% (n = 253) responded to the survey. Among the respondents, 40.7% (n = 103) self-identified as women and 91% (n = 224) had full-time faculty appointments. The breakdown of self-identified gender and subspecialties are provided in Figure 1. There were higher proportions of -clinicians (n = 159, 62.8%) and Canadian trained faculty (n = 192, 75.9%). Only 32.4% (n = 82) of the respondents self--identified as persons of color, 5.1% (n = 13) non-heterosexual, 4.3% (n = 11) self-reported as having a disability, and 2.8% (n = 7) non-cis-gendered.
Figure 1 Survey participants by subspecialty and gender*
*Note: Seven participants who did not identify as a man or woman are not included in this chart to maintain anonymity.
Burnout was reported as being somewhat or substantially higher among 75.8% of respondents overall, with significantly more women faculty reporting burnout compared to men (82.5% vs 70.4%, p < 0.01). Table 1 shows the reported proportion of burnout by gender, Faculty rank, academic position, age strata, person of color, and ethnicity. Those who were women, early-career (e.g., Assistant professors), clinician-educators, and those aged <50 years reported significantly more burnout than did men, higher academic ranks, clinician research-educators, and faculty aged >50 years, respectively. Women of color had the highest reported burnout compared to all other groups. In a multivariable analysis considering these factors, the female gender was independently and significantly associated with more burnout (p = 0.037) (Supplementary Table 1). Compared to the 2019 survey, where 49.7% of faculty reported feeling burnt out more often than a few times a year, the 2021 burnout rate was as high as 86.4%, representing a 35% increase from than pre-pandemic rates.
Table 1 Percent somewhat or substantially more burnt out by gender, rank, age, ethnicity, and person of color
|Demographic||Sub-group||Proportion burnt out||Association with a binary increase in the burnout (Chi2)||p-Value|
|Non-cis gender||6/7 (85.7%)|
|Gender × Person of color*||Woman and person of color||29/33 (87.9%)||8.8||<0.05|
|Man and person of color||32/47 (68.1%)|
|Woman and White||54/68 (79.4%)|
|Man and White||68/95 (71.6%)|
|Faculty rank||Clinical scholar||5/5 (100%)||16.8||<0.05|
|Assistant professor||47/58 (81.0%)|
|Assistant clinical professor||19/21 (90.5%)|
|Associate professor||67/85 (78.8%)|
|Associate clinical professor||6/11 (54.5%)|
|Clinical professor||N < 5|
|Emeritus||N < 5|
|Academic position||Clinician educator||122/158 (77.2%)||12.9||<0.01|
|Research educator – clinician||32/53 (60.4%)|
|Research educator – non-clinician||20/21 (95.2%)|
|Ethnicity||East Asian||18/21 (85.7%)||2.16||0.83|
|South Asian||29/41 (70.7%)|
|Other Asian||4/5 (80%)|
|Middle Eastern||9/12 (75%)|
|White European||112/151 (74.2%)|
*The two women missing in the Gender × Person of Color variable declined to respond to the person of color question. The univariate proportions reported include everyone who had data for both the burnout question and the demographic in question, so they were included in the gender proportions, but excluded from the intersectional person of color and gender proportions.
Multivariate regression with burnout as a dependent variable.
|Factor||Effect (Beta)||95% CI||p-Value|
Research educator – clinical
Research educator – non-clinical
vs All others
Assistant clinical professor
Associate clinical professor
vs Full professor
Sixty-six percent of the respondents (n = 149) reported having fewer in-person clinics and 18.6% (n = 44) reported being “concerned” or “very concerned” about the medical--legal risks of making their clinical practice virtual (Table 2). In terms of the financial aspects of clinical practice, 20.8% (n = 47) reported having substantial difficulty paying administrative assistant salaries and 25.1% (n = 59) perceived a substantial reduction in income from clinical work. Most physicians (82.1%, n = 207) were “very concerned” or “somewhat concerned” about the personal risk of acquiring an infectious disease like COVID-19 and/or passing it on to a family member. The impact of the pandemic on clinical practice was similar between women and men.
Table 2 Effects of COVID-19 pandemic on clinical practice, non-clinical work life and home life
|Overall||Female faculty||Male faculty||p-value|
Female versus Male
|Effect on clinical practice|
|Face to face clinic visits – Somewhat or Substantially Less||149/227 (65.6%)||57/88 (64.8%)||90/132 (68.2%)||0.32|
|Working from home – Somewhat or Substantially More||189/250 (75.6%)||81/100 (81%)||103/143 (72%)||0.18|
|Medical-legal risks of changing your clinical practice from face to face to virtual – Very concerned||44/237 (18.6%)||18/93 (19.4%)||25/137 (18.2%)||0.50|
|Reduction in patient billings – Substantial||59/235 (25.1%)||18/95 (18.9%)||39/133 (29.3%)||0.29|
|Difficulty paying administrative assistant salary – Substantial||47/226 (20.8%)||21/90 (23.3%)||25/130 (19.2%)||0.25|
|Personal risk of acquiring an infectious disease like COVID-19 and/or passing it on to your family – Very Concerned||129/252 (51.2%)||52/102 (51%)||73/143 (51%)||0.68|
|Effect on non-clinical work life|
|Hours per day spent doing your job – Somewhat or Substantially Higher||172/252 (68.3%)||82/102 (80.4%)||83/143 (58.0%)||<0.001|
|Interactions with colleagues – Somewhat or Substantially Less||166/250 (66.4%)||65/101 (64.4%)||99/142 (69.7%)||0.78|
|How has your attendance at educational rounds and/or CME changed since COVID-19? – Somewhat or Substantially more frequent||87/251 (34.7%)||35/101 (34.7%)||57/143 (39.9%)||0.53|
|Change in how you provide mentorship or supervise learners – substantial||118/247 (47.8%)||51/101 (50.5%)||65/140 (46.4%)||0.99|
|Research productivity – Somewhat or Substantially Lower||126/241 (52.3%)||54/98 (55.1%)||67/136 (49.3%)||0.73|
|Fulfillment of career – Somewhat or Substantially Higher||50/252 (19.8%)||27/103 (26.2%)||21/143 (14.7%)||0.95|
|Effect on home life|
|Care of dependents living in your household – Somewhat or Substantially Higher||101/243 (41.6%)||55/101 (54.5%)||42/135 (31.1%)||<0.01|
|Hours per day spent doing childcare/home schooling – Somewhat or Substantially Higher||118/231 (51.1%)||53/94 (56.4%)||61/132 (46.2%)||0.44|
|Feeling of being burnt out or overwhelmed – Somewhat or Substantially Higher||191/252 (75.8%)||85/103 (82.5%)||100/142 (70.4%)||<0.01|
|Loneliness – Somewhat or Substantially Higher||144/252 (57.1%)||66/103 (64.1%)||73/142 (51.4%)||<0.05|
Sixty-eight percent of faculty reported the hours per day spent doing their job was somewhat or substantially higher than prior to the pandemic; this was more frequent among women compared to men faculty (80.4% vs 58.0%; p < 0.001) (Table 2). Figure 2 depicts the perceived impact of COVID-19 on career fulfillment, research productivity, and attendance at educational rounds or CME. Notably, when compared to pre-pandemic, career fulfillment was reported by 51.2% (n = 129) as being substantially or somewhat lower, research productivity was reported as substantially or somewhat lower by 52.3% (n = 126), whereas attendance at CME (including rounds) was reported as somewhat or substantially higher by 34.7%. Interactions with colleagues were also perceived to be impacted by COVID-19, with 66.4% (n = 166) of respondents reported having fewer interactions than pre--pandemic, whereas 20% (n = 50) reported more interactions than pre-pandemic.
Figure 2 Effect of COVID-19 on non-clinical work
To elucidate the impact of the COVID-19 pandemic on home life, we asked respondents how their time spent caring for dependents, childcare, and home schooling were affected by the COVID-19 pandemic. We also asked about feelings of loneliness. The responses are detailed in Table 2 and Figure 3. Women faculty reported more time spent caring for dependents than men faculty (54.5% vs 31.1%, p < 0.01), while both genders reported somewhat or substantially more time spent on childcare/home schooling (51.1%). Over 50% of faculty reported an increase in the feeling of loneliness, more so reported by women faculty (64.1% compared to men 51.4%, p < 0.05).
Figure 3 Effect of the pandemic on home life
The results of this survey demonstrate the profound impact the COVID-19 pandemic had on clinical and non-clinical faculty members at a large academic institution. Our data demonstrate that burnout during the COVID-19 pandemic affected 86.4% of faculty members compared to the reported burnout rate of 49.7% 2 years earlier amongst our faculty. The higher rate of reported burnout during the pandemic reflects many negative pandemic-related changes in work and life on our faculty and should be a call to action. Factors associated with burnout included female gender, clinical and non-clinical factors, academic rank, as well as increased workload at home. COVID-19 stressors included inadequate resources, loss of control, fear of contracting COVID-19, loneliness, and excessive workload in the workplace and at home.
Using both the quantitative data and the written comments grouped and themed that we received from the 2019 and 2021 survey, the COVID-19 pandemic added additional stressors to our DoM faculty, in particular, due to reduced resources (i.e., people off sick, reduced residents support) and increased administrative duties. The transition to virtual rounds and meetings was positively received by many faculty, especially those with young children which enabled more flexibility in work–life integration.
Our survey had a high response rate (76.7%) and therefore is likely generalizable to our DOM faculty. It attempted to capture the challenges faced by physicians in clinical practice, non-clinical work life, and home life during the COVID-19 pandemic. With government-mandated restrictions on access and capacity imposed on clinics and operating rooms, it was not surprising that two-thirds of physicians reported having fewer in-person clinics. While many pivoted to virtual care, this was not an option for some procedurally based subspecialties such as interventional cardiology or gastroenterology. The effect on procedurally based specialties, reduced out-patient clinics due to COVID-19 restrictions, and drop in related elective hospital admissions during the pandemic could explain why 25.1% of respondents in our survey reported a substantial reduction in patient billings and 20.8% were concerned about their ability to financially compensate their administrative assistant.14 The shift in the modality of care delivery also engendered concern regarding the medical-legal risks of virtual care with 48% of physicians being very concerned about this.
Isolation, another known contributor to burnout, was imposed by the pandemic and impacted both home life and work–life for physicians.2 In home life, isolation came from public health restrictions, school closures, restrictions on social activities, and lockdowns. In the sphere of work–life, the move to virtual care and the cancellation of in-person gatherings (CME, patient care meetings, administrative meetings, and collegial gatherings) restricted opportunities for interaction with colleagues. The isolation in both spheres could explain why over half of physicians reported feeling more lonely.
The challenges experienced by faculty during the pandemic were not equal among genders with women physicians being on the frontlines both at work and at home. We also observed that non-white women reported higher burnout compared to white women, non-white, and white men. Prior literature among medical students and physicians is inconclusive regarding differences in burnout between racialized and non-racialized physicians.15 Regarding work-load, 80.4% of women respondents reported spending more hours doing their job, compared to 58% of men faculty (p < 0.001). Significantly more women than men faculty (54.5% vs 31.1%, p < 0.01) also reported spending more time caring for dependents. These COVID-19-related changes augmented the already widely recognized fact that women spend significantly more time on unpaid household and care work.16 Excess workload is a well-documented risk factor for burnout and likely explains why women reported higher rates of burnout or feeling overwhelmed in our survey.7 The impact of burnout on women’s academic careers is concerning. Gender differences have long been documented in academic medicine careers.17,18 This has been attributed to systemic factors that have been exacerbated by the pandemic such as career absences, work environment, and home life responsibilities.19–21 We have already seen significant concerns regarding the pandemic’s impact on women’s academic productivity with decreasing numbers of manuscript submissions by women authors and fewer first and last women authorship since the start of the pandemic.22,23 Younger women faculty are particularly at risk as the prime reproductive years coincide with the early-career period of academic medicine, and without publications and grants, academic promotion can be limited.24 The COVID-19 pandemic could have a lasting impact on these junior women faculty careers if burnout is not systemically addressed. A body of scholarly work is now emerging testing solutions to health care and academic burnout. A recent article in Nature suggested possible solutions to dealing with burnout in academia include: (i) communicate that feeling burnout does not equate with failure; (ii) encourage faculty to find ways to detach from stress (nature-based activities, cooking, book clubs, music groups), (iii) prioritize and normalize conversations about mental health, and (iv) minimize isolation (i.e., plan social events with colleagues).25 The recent white paper published by the Ontario Medical Association, “Healing the Healers: System-Level Solutions to Physician Burnout,” also suggested several strategies to address burnout.26 These included: (1) using scribes, medical technology, and frequent collaborative review of policies/procedures to decrease the burden of documentation and administrative work; (2) ensuring that digital health tools (such as EMRs) serve the needs of physicians, and provide ongoing support for these tools; (3) addressing the gender pay gap with fair and equitable compensation for all (such as ensuring pay reflects work required to perform a service). These and other programs will need to be implemented and tested to assess the effectiveness of such approaches.
The results of this cross-sectional survey should be interpreted with caution as it was designed to be exploratory. While the survey was pilot tested by the EDI advisory committee members and modified based on this feedback, no formal validation occurred. Furthermore, we asked physicians to self-report burnout, rather than using a validated tool such as the Maslach Burnout Inventory.1 While we asked a similar question regarding burnout in 2019, it is important to note that while the demographics between the two surveys were similar, the response rate in 2019 was much lower than in 2021 (45.1% vs 76.7%). Another limitation of our analysis was the lack of information on potentially confounding factors such as living situations, social support systems, and other non-work factors that could impact loneliness and isolation.
Pre-pandemic, burnout was a serious threat to the healthcare system and physician health. Based on our survey, this is now a critical issue at our institution, especially for women, and those who are in their early career. Our findings are similar to those at other large academic institutions in Canada.4 We will need to meet this challenge by developing and evaluating interventions at a system level to address the large proportion of faculty experiencing burnout, and to implement specific post-pandemic measures to address the COVID-19 related gender gap in academic productivity.
The McMaster EDI committee is Chaired by Dr. Sonia Anand and includes Andrew Folino, Annette Rosati, Dr. Betty Chui, Dr. Carys Massarella, Graeme Matheson, Dr. James Douketis, Dr. Madeleine Verhovsek, Dr. Manali Mukherjee, Dr. Michelle Welsford, Dr. Mimi Wang, Dr. MyLinh Duong, Dr. Patricia Liaw, Dr. Shamir Mehta, Dr. Smita Halder, Dr. Stephanie Garner, and Dr. William Harper.
Dr. Douketis is supported by David Braley and Nancy Gordon Chair in Thromboembolic Disease.
Dr. Anand is supported by the Canada Research Chair in Ethnic Diversity and Cardiovascular Disease, and the Heart and Stroke Michael G DeGroote Chair in Population Health Research.
No funding was received for the development, distribution, or analysis of the survey. This survey was supported by the Associate Chair of Equity and Diversity, Department of Medicine, McMaster University.
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In the 2019 survey, we asked two questions regarding burnout:
Regarding “burnout,” please select the response that best summarizes your experience:
I enjoy my work. I have no symptoms of burnout.
Occasionally, I am under stress. I don’t always have as much energy as I once did but I don’t feel burnt out.
I am definitely burning out and have one or more symptoms of burnout (e.g., physical and emotional exhaustion).
The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot.
I feel completely burnt out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help.
Prefer not to answer
I feel burned out from my work.
A few times a year or less
Once a month or less
A few times a month
Once a week
A few times a week
Prefer not to answer
Our definition of burnout:
If they responded “I enjoy my work. I have no symptoms of burnout.” To the first question, then we took that as no burnout. For the rest, we used their response to the second question (self-reported frequency of feeling burnt out)
In the 2021 survey, we asked:
List the impact of the adaptations you have had to make during the COVID-19 Pandemic: Feeling of being burnt out or overwhelmed
Prefer not to answer