background and importance : some of the frequently reported possible consequences of burnout among emergency medicine practitioners are decreased career satisfaction , low job performance and high prevalence of mental problems such as anxiety , depression , and suicide are ( 15 ) . furthermore , in residency training programs , burnout reduces the quality of residents education by decreasing motivation and job involvement , and leads them to leave their career ( 6 , 7 ) . burnout is defined as a state of excessive physical , emotional , and mental fatigue and frustration caused by chronic involvement in emotionally demanding situations ( 8) . it can be measured reliably by the maslach burnout inventory , in its three subscales : emotional exhaustion ( feeling of being emotionally exhausted and tired with work ) , depersonalization ( an impersonal feeling about clients which leads to a callous or dehumanized perception towards them ) , and a low sense of personal accomplishment ( decreased feeling of competency and dissatisfaction with one s work ) ( 3 , 9 ) . emergency physicians are reported to have high intensity and unhealthy stress in their work environment ( 2 , 3 , 10 ) . sleep disturbances , high patient load , insufficient administrative support , perceived inadequacy of resources , emergent decision making based on ambiguous information , fear of malpractice and litigation issues are some of the factors associated with burnout among emergency physicians ( 2 , 10 ) . american college of emergency physicians ( acep ) has reported five factors as most stressful for emergency physicians : 1 ) irregular schedule , 2 ) unreasonable patient demands , 3 ) fear of making mistakes , 4 ) threat of malpractice , and 5 ) problems with nursing staff ( 2 ) . kuhn et al reported a model for predicting burnout in emergency physicians and found that high anxiety caused by anticipating bad outcomes is the strongest predictor ( 11 ) . some additional factors are reported in residents such as : younger age and low experience , lack of role clarity , economic difficulties , safety issues , dealing with difficult patients , bureaucracy , dysfunctional systems , and political issues ( 6 , 7 , 12 , 13 ) . in spite of the significant consequences of burnout , both on emergency physicians themselves and on the quality of care they deliver to their patients , few studies have investigated predictive stressors in burnout development and efficient ways to prevent it . emergency medicine is a relatively young specialty in iran . since the establishment of emergency medicine residency training program in 2001 , no data is available about work related problems of this specialty in iran . we designed this study to investigate the prevalence of burnout in iranian emergency medicine practitioners and its correlation with their demographic characteristics and work related factors . moreover , we tried to assess a model of stressor predictors of high burnout in our population . identifying the major predictors of burnout among emergency physicians can be the first step to develop protective strategies . this was a questionnaire - based cross sectional study of all iranian emergency medicine residents and practitioners . all residents and practitioners of emergency medicine in iran ( except the first and second authors ) were eligible for this cross - sectional study ( 188 physicians ) . the main part of data ( 84% ) was collected by attending work place of emergency physicians , mainly during their weekly conferences . after a brief explanation about the study purpose , informed consent was obtained , and the participants were then asked to answer the questionnaires . for other practitioners ( 16% ) they were called and after receiving some explanation about the study , were asked to sign the consent form , complete and mail back the questionnaires . all data was collected in march and april of 2008 , to avoid any seasonal bias . all gathered information was confidential , the names and specifications were substituted by unique codes , and participation was completely voluntary . this study was approved by the ethics committee of tehran university of medical sciences in 2008 . a 75-item self - administered questionnaire , comprised of 3 sections was prepared by the authors : the first part was socio - demographic ( i.e. age , sex , marital status , smoking , exercise ) and work - related items ( i.e. resident or not , number of shift hours in emergency department during previous week , mean shift hours per week in previous 6 month , weeks off work in previous year ) . a list of all possible stressors was developed based on a review of medical literature and a focus group discussion with emergency medicine residents and practitioners in tehran university of medical sciences ( 1 - 7,10 - 13 ) . participants were asked to rate the frequency of experiencing each stressor on a likert - type scale ranging from 1 ( not at all ) to 5 ( in every shift ) . each stressor was written as a statement such as  i am worried about making mistake in my practice  or  terminally ill patients make problem for me  . the face validity of the questionnaire was assessed by three experts prior to administration , and it was implemented in a sample of 20 residents of internal medicine , as a pilot study to find and resolve any problem . mbi has been found to be reliable , valid and easy to use ( 9 ) . it has22 statements which measure the three burnout components : nine for emotional exhaustion ( ee ) , eight for personal accomplishment ( pa ) , and five for depersonalization ( dp ) . each statement is a sentence like  i feel like i m at the end of my rope  and participants are asked to rate the frequency of experiencing such feeling on a seven - point scale from  never  ( 0 ) to  every day  ( 6 ) . the score of each subscale is calculated by summing up the scores of its items . high , moderate , or low levels of burnout are determined according to standard cutoffs for medical staff . these three dimensions ( ee , pa , dp ) can not be combined and shown in one score ( 9 ) . the term  burnout  was avoided in the questionnaire and explanation to prevent any bias . the validity and reliability of the persian translation of mbi has been previously proved by filian ( 14 ) . for stressor questionnaire , we tested correlation between all 38 stressor items and combined them based on their correlation coefficient ( significant at p - value<0.05 , more than 0.5 ) and their content ; making 19 final categories for stressors , explained in the result section . the three dimensions of burnout were calculated for each participant and ranked as high , moderate , or low . the correlation between demographic and work - related factors with burnout level , also association between stressors with the score of burnout , was investigated using univariate analysis . to find the best model to predict high burnout level , logistic regression model was used to predict level of burnout for each dimension separately ( high vs. low or moderate ) . only significant factors in univariate analysis ( which had significant association with score or level of burnout ) were entered in the regression model . from 188 eligible residents and graduates , 165 participated in this study ( response rate : 88% ) . the score for each subscale of mbi was considered as  missing  if only one question related to that subscale has been left unanswered . demographic and work - related characteristics of participants table 2 shows the list of 19 categories of stressors ( reduced from a 38-item list ) , the mean score calculated for each item for all respondents , and for residents and graduates , separately . for all stressors , the stress score for residents was higher than for graduates , except patients economic problems , from which graduated emergency physicians reported experiencing more stress from . mean scores reported for work related stressors , based on frequency of experience , listed in descending order in total population . the minimum and maximum possible score for each stressor were 1 ( never experiencing ) and 5 ( experiencing in every shift ) by comparing stressors scores between the first , second and third year residents and graduated physicians , we found that first year residents reported to experience stress from 8 sources significantly more frequently than other participants , including fear of malpractice , relationship with other services , care of the old or terminally ill patients , insufficient skills , difficulties to balance professional and private life , violence in ed , educational issues ( morning reports , teaching rounds , etc . ) , and having to deal with new technologies . five items were reported significantly more frequent by first and second year residents in comparison with third year residents and graduated physicians ; these included work overload , physical environment at work , shortage of equipment , consultant unavailability , and work related fatigue . finally , 2 factors were similar in all residents and significantly higher than graduates : insecurity about future career in field of emergency medicine , and text needed to be read overload . the number of completely answered questionnaire was 158 for emotional exhaustion ( ee ) , 160 for depersonalization ( dp ) , and 155 for personal accomplishment ( pa ) . the mean score for the ee subscale was 22.94 ( sd=13.6 ; 95% ci=20.78 - 25.01 ; range from 19 - 26 is considered as moderate ) , the mean score for dp was 9.3 ( sd=6.8 , 95% ci=8.24 - 10.36 ; a score between 5 and 10 is considered as moderate and above 10 is high ) , and the mean score for pa was 31.47 ( sd=9.9 , 95% ci=29.87 - 33.07 ; scores below 33 is considered low ) . on individual level , 39% of the respondents had high depersonalization ( 95%ci : 31%-47% ) , 37% had high emotional exhaustion ( 95% ci : 29%-45% ) , and 46% had high burnout in personal accomplishment ( 95%ci : 38%-54% ) . some of the demographic and work - related factors had significant relationship with high level of burnout in each dimension . table 3 and 4 show the relationship of high burnout in three subscales and these demographic and work related factors . relative risk ( rr ) of demographic and work related factors for high burnout in emotional exhaustion ( ee ) , depersonalization ( dp ) and personal accomplishment ( pa ) subscales . ed : emergency department mean of work and demographic factors in high burnout group in emotional exhaustion ( ee ) , depersonalization ( dp ) and personal accomplishment ( pa ) subscales . mean age is higher for moderate and low dp ; and more weeks off work is associated with lower ee and dp table 5 shows correlation between stressors and score of burnout in each dimension . all stressors had a significant relationship with higher score of ee and dp , except for patients economic problems with dp . twelve out of nineteen stressors had significant correlation with the lower score of pa subscale ; although the strength of correlation between stressors and pa score was lower than of dp and ee scores . the model was significant for predicting high burnout in this subscales ( hosmer and lemeshow test p - value=0.609 ) . the model was also significant for dp ; but none of the variables had a significant odds ratio . the significant predictors for high ee were work overload , economic problems and insecurity of future career in field of emergency medicine , and difficulties to balance professional and private life . perception of more stress from new information technologies had a protective effect on high emotional exhaustion . together these factors explained 50% of the total variance in reporting a high degree of ee . correlation between stressors score and burnout score in three subscales ; for ee ( emotional exhaustion ) and dp ( depersonalization ) , higher score means higher burnout ; for pa ( personal accomplishment ) , lower score means higher burnout significant factors ( p - value<0.05 ) in predicting high level of emotional exhaustion the results of this study showed that a high percentage of these physicians are suffering from moderate to high degrees of burnout ( 56% of on emotional exhaustion , 66% on depersonalization , and 78% on personal accomplishment subscale ) . other studies from different countries reported almost the same percentage ( 1 , 15 , 16 ) ; for example a study found 60% of moderate to high burnout in a large population of 1,272 american emergency medicine practitioners ( 10 ) . in a nationwide survey in romania , the level of occupational stress and burnout in emergency medicine professionals was reported to be the highest among all medical specialties ( 17 ) . considering the serious adverse effects of burnout on physician s health and job satisfaction , and its effect on quality of care for patients , also new establishment of emergency medicine and possibility for amendment in its future development , it is essential to pay more attention to its predicting factors in order to find ways to prevent it . the highest percentage of reported burnout is on personal accomplishment level and then depersonalization subscale . more severe burnout on depersonalization dimension has been reported in previous studies on emergency physicians ( 1 , 2 , 15 ) . it is suggested that the nature of emergency medicine , which involves a short - term relationship between physician and patient , may contribute to the development of this problem higher depersonalization or it may result from use of this attitude as a protective defense mechanism ( 2 ) . some researchers have proposed the probability that some other factors , apart from burnout , may contribute to this negative impersonalized attitude towards patients ( 18 ) . the importance of this attitude is even more obvious when considering the reports of its association with self - reported sub - optimal care of patients ( 19 ) . the feeling of low personal accomplishment among emergency medicine practitioners may reflect the perception of emergency medicine in relation to other specialties , which leads to low satisfaction and sense of not being efficient enough . since the specialty is very new , this may be a temporary problem that will be resolved in future . when analyzing the association between high burnout and demographic and work - related factors , results showed that high ee was not associated with any of the demographic factors . however , higher dp was found in men , younger physicians , and those who were living alone . on pa dimension , generally our results are consistent with previous studies ( 5 , 10 ) , which have reported no relationship between age , gender , and marital status with level of burnout . however , higher levels of burnout had been reported in those physicians who were smoking and not doing exercise . comparing different years of residency , higher level of ee and dp were found in first year and higher level of burnout on pa was seen in third year residents . higher level of stress in first year of residency had been reported in previous studies ( 20 ) . on the other hand , third year of emergency medicine residency may be a crucial time for residents to evaluate themselves and get ready to leave education setting and enter job market , where they are supposed to work independently ( 7 ) . low sense of personal accomplishment in third year residents may reflect their stress and low self esteem in evaluating themselves . interestingly , number of weeks off work is significantly associated with lower level of burnout in ee and dp subscale . considering no official off weeks has been considered in residency program and curriculum , this may be a required change that may be effective . overall the strongest stressors were shortage of equipment , problems with work environment , and relationship with other services ( including nursery , lab and other medical services ) . again , considering the recent establishment of this specialty in iran , it could reflect the organizational and financial problems of these new departments . difficulties to balance professional and private life , work overload and fatigue associated with it , and fear of malpractice had strongest relationship with high ee , while image of emergency medicine in media and perceived stress from violence in emergency department were stronger in physicians with higher dp . our result is consistent with previous studies which reported anticipated process failure ( 6 ) , patient load , interaction with patients and families , and lack of administrative support ( 21 ) , number of shifts per month ( 10 ) , insufficient staffing and work load ( 22 ) , economic and financial issues , individual malpractice ( 23 ) , quality of team work and work - family conflict ( 24 ) to have association with high burnout . generally , these factors were found to create higher score of stress in residents , compare to graduates ; this indicates the importance of more support for residents . our model for predicting burnout showed that the strongest predictors for high ee were work overload , economic problems and insecurity of future career in field of emergency medicine , and difficulties to balance professional and private life . interestingly , after controlling for other stressors , participants who perceived more stress in dealing with new technologies had less probability of being highly emotionally exhausted . this may reflect that more available sources of information and technology , or putting pressure on residents to search and use the latest information , can lead to tiredness with work . in summary , we can list the predictors of high burnout as follow : economic problems , personal life and work overload , and fear of having not enough skills in emergency departments . as a result , any intervention to prevent burnout in our population should focus mainly on these components . even though the results of our study reflects the situation in emergency physicians and residents in iran , not only the methodology and approach can be generalized , but also the results can be used to predict and overcome short - comings and problems in establishment of emergency medicine specialty , which is a very new specialty in developing world and expected to grow and be established in other countries in the future . limitations : our study is a cross sectional study and can not assess any change in variables over time . moreover , it can not prove cause - and - effect relationship between associated variables . thus , we could not assess whether , for example , high dp is a result of living alone , or is its cause , as these people prefer to live alone ; or it is not clear whether high burnout is consequences of stressors or people who are exhausted and frustrated perceive more stress from the environment . although we conducted our study in all iranian emergency physicians and residents and had a high response rate , our sample size was too small to assess our predictive model of burnout in residents and graduates separately . in addition , because of a small percentage of women practitioners in our study , our results should be regarded with caution in this population . we used a validated outcome in the maslach burnout inventory , but the predictors have not been similarly validated , although we piloted them and their face validity was checked . additionally we utilize multivariable logistic regression modeling to evaluate for associations with burnout , but considering the number of predictors , our sample size was inadequate for the number of predictor variables . our results suggest an alarming high rate of burnout ; especially in residents in recently established emergency medicine specialty in iran . since this is the first study performed to investigate burnout in physicians and residents in iran , it can contribute to improvement of health care quality , resident education efficacy and patient satisfaction by preventing burnout . our result can also be utilized to adjust the interventions suggested by previous studies in other countries to be more effective in iranian medical education system . we also determined some major stressors that interventions can be focused on ; these interventions can include improving organizational relationship with other services , stronger financial , emotional and educational support for residents and training them how to make a balance between life and work . the next step will be evaluating em residents and practitioners personality traits and coping mechanisms used by them in stressful situations and the impact of these factors on preventing burnout . ethical issues ( including plagiarism , informed consent , misconduct , data fabrication and/or falsification , double publication and/or submission , redundancy , etc ) have been completely observed by the authors .
abstractbackgroundemergency physicians are at risk of burnout , which can affect their mental health , as well as patient care . 
 we assessed burnout level among iranian emergency physicians and investigated demographic , work - related factors and stressors associated with higher burnout.methodsin a cross - sectional study , we surveyed all 188 emergency medicine residents and practitioners in iran . 
 we measured burnout using 22-item maslach burnout inventory assessing emotional exhaustion , depersonalization and personal accomplishment , also demographic factors , work related factors and sources of stress in emergency department using anonymous self - administered questionnaire . descriptive analysis , univariate analysis to evaluate association with higher score of burnout , and multivariate logistic regression analysis to predict high burnout in 3 subscales was performed.resultstotally , 165 questionnaires were filled ( response rate : 88% ; mean age : 33.6 years , 91% male ) . 
 mean burnout scores were 22.94 for emotional exhaustion ( 95% ci=20.78 - 25.01 ; moderate ) , 9.3 for depersonalization ( 95% ci=8.24 - 10.36 ; moderate to high ) , and 31.47 for personal accomplishment ( 95% ci=29.87 - 33.07 ; moderate to high ) . 
 frequent reported sources of stress were shortage of equipment , problem with work physical environment , and relationship with other services . 
 all 19 sources of stress were associated with higher score of emotional exhaustion and depersonalization ; while twelve out of 19 were significantly associated with lower level of personal accomplishment . in logistic regression model , 
 the significant predictors for high emotional exhaustion were work overload , feeling of insecurity for future career and difficulties to balance professional and private life.conclusionburnout is high among iranian emergency medicine practitioners and some interventions can be proposed to reduce stress .