Knowledge, Attitude, And Practice Towards Burnout and Anxiety Among Family Medicine Residents in Family Medicine Programs in Tabuk City, Saudi Arabia, 2023, Cross-Sectional Study

Abstract

Stress and burnout are increasingly recognized as significant issues affecting resident physicians, impacting their performance, mental health, and patient care. This study aimed to assess the prevalence and contributing factors of stress and burnout among family medicine residents in Tabuk City, Saudi Arabia. A cross-sectional study was conducted between December 2023 and June 2024 among 100 family medicine residents from the Ministry of Health and King Khalid Military Hospital programs in Tabuk. A self-administered online questionnaire, distributed via social media platforms, was used to collect data on sociodemographic variables, work-related characteristics, and stressors. Stress was assessed using 24 validated binary (Yes/No) items across five domains. Stress levels were categorized as low (0–8), moderate (9–16), or high (17–24). Data were analyzed using SPSS version 28, and chi-square or exact probability tests were used to explore associations. Among the 100 residents, 47.0% reported moderate stress levels, 30.0% low, and 23.0% high. Common stressors included fear of making mistakes (77.0%), time pressure (76.0%), and work-life imbalance (73.0%). Statistically significant factors associated with higher stress included being single (p = 0.027), having a distinction-level academic record (p = 0.049), longer duration of residency (p = 0.048), high-stress rotations such as Obstetrics & Gynecology (p = 0.001), working ?72 hours per week (p = 0.035), and smoking (p = 0.001). A considerable proportion of family medicine residents in Tabuk experience moderate to high levels of stress and burnout, influenced by both personal and systemic factors. Targeted interventions, such as workload regulation, improved mentorship, and psychological support, are recommended to enhance resident well-being and program sustainability.

Keywords

Introduction

Table 3 illustrates the stressors among family medicine residents across different domains. Within the Clinical Practice Stressors, the most frequently reported stressors were fear of making mistakes (77.0%), time pressures and difficulty meeting deadlines (76.0%), and work demands affecting personal and home life (73.0%). For Workplace Environment Stressors, residents most commonly reported lack of adequate, comfortable restrooms and facilities (76.0%), lack of incentives and promotions (59.0%), and feeling underpaid (45.0%). In the Interpersonal & Supervisory Stressors domain, the leading stressors were lack of support and unfair assessment from supervisors (54.0%), difficulty maintaining relationships with supervisors (44.0%), and working outside one’s competence (41.0%). Under Psychological & Emotional Stressors, residents predominantly experienced fear of making mistakes (73.0%), fear of infection (66.0%), and worries about finances (42.0%). Finally, in the Workload & Career Progression Stressors, the most reported stressors included work overload (68.0%), career-related worries such as insecurity and financial instability (50.0%), and on-call duties (41.0%).

Figure 1. The Overall Stress / Burnout Level Among Family Medicine Residents in Tabuk City, Saudi Arabia (2023) (N=100)

Figure 1 shows the overall stress and burnout levels among family medicine residents in Tabuk City. Nearly half of the residents, 47 (47.0%), experienced a moderate level of stress or burnout. About 30 residents (30.0%) reported a low level, meanwhile 23 residents (23.0%) experienced a high level of stress or burnout.

Table 4 outlines the factors associated with stress and burnout levels among family medicine residents. Marital status was significant (p = 0.027), with a higher proportion of single residents (31.7%) experiencing high stress compared to married residents (10.0%). Graduate qualification also showed a significant association (p = 0.049), where all residents with distinction were in the high stress group. Duration of residency training was linked to stress levels (p = 0.048); residents with ≤12 months of training were more likely to report low stress (47.1%), while those with longer training durations had higher moderate and high stress levels. The current rotation had a strong impact on stress (p = 0.001), notably with 100% of residents in Obstetrics & Gynecology reporting high stress, while rotations such as Dermatology and Surgery had residents predominantly in the low stress group. Work hours per week were also significant (p = 0.035), as those working 72 hours weekly had the highest proportion of high stress (42.1%) compared to just 7.7% in residents working less than 40 hours. Smoking status was strongly associated with stress (p = 0.001); all smokers (100%) reported high stress, while none were in the low or moderate groups. Other factors like age and gender did not show significant associations with stress or burnout levels.

DISCUSSION

The study on burnout and anxiety among family medicine residents in Tabuk City, Saudi Arabia (2023), included 100 participants with different sociodemographic characteristics. The majority of residents were over 27 years old, with a higher proportion of females than males. Most participants were single, and a significant number had graduated from local public universities. Considering academic achievement, most residents had passed their qualifications, while a smaller proportion graduated with honors or distinction.

The findings on residency-related factors reveal some variations in training duration, current rotations, workload, and lifestyle habits among family medicine residents in Tabuk City. A substantial proportion of residents had been in training for over 24 months, indicating that long-term exposure to residency demands may influence burnout and stress levels. The distribution across rotations varied, with family medicine being the most common, followed by emergency medicine and pediatrics, which may reflect differing stressors based on specialty-specific demands. Workload patterns also differed, with a majority working extended weekly hours, a known risk factor for burnout. Interestingly, smoking was rare, and alcohol consumption was absent, matching with cultural norms in Saudi Arabia.

The study identifies key stressors among family medicine residents in Tabuk City that align with global and regional findings. High rates of fear of making mistakes and time pressures reflect common anxieties in medical training, consistent with previous research highlighting workload and patient safety concerns [13, 14]. Work demands affecting personal life further confirm links to emotional exhaustion in demanding medical environments [15]. Systemic issues such as inadequate facilities, underpayment, and lack of incentives mirror challenges reported in Middle Eastern residency programs, emphasizing the need for institutional reforms [16, 17]. Interpersonal stressors, including poor supervisory support and difficult relationships, resonate with findings that hierarchical, unsupportive supervision increases burnout risk [18, 19]. Psychological stressors like fear of infection and financial worries echo global post-pandemic concerns and economic strains among trainees [20, 21]. Lastly, workload pressures, career insecurity, and on-call duties match with established burnout factors tied to job instability and sleep deprivation [22, 23]. Together, these results highlight complex stress sources requiring comprehensive strategies to improve resident well-being [24].

Generally, our study reveals that about half of family medicine residents experienced moderate stress/burnout, while one-fourth reported high levels, consistent with global trends but showing some regional variations. Comparable studies demonstrate wide-ranging burnout prevalence among medical residents, from 18% to 82% [25], meaning that institutional and cultural factors significantly influence these rates. The 30% low-stress group in Tabuk contrasts with findings from Aseer, Saudi Arabia (84.2% burnout prevalence) [17] and British Columbia (70% burnout) [26], possibly due to differences in workload, support systems, or measurement tools. However, the high-stress level (23%) simulates reports from Ontario, where residents experienced elevated anxiety (12%) and depression [16], reinforcing that medical training universally poses psychological risks.

Notably, studies in South Carolina [27] and East Tennessee [28] found lower stress levels, attributing this to strong social support and stress-management programs, factors that may be underdeveloped in Tabuk. The moderate-stress majority suggests partial resilience, possibly due to protective factors like mentorship and work appreciation, but also highlights unmet needs in workload management and emotional support.

As for factors associated with stress/burnout, single residents experienced significantly higher stress compared to married peers, supporting literature on the protective role of marital support [29], though differing from Alghamdi’s Saudi findings that linked marriage to greater emotional exhaustion [26]. High stress among residents with distinction-level academic achievement is in line with research identifying perfectionism as a burnout risk factor [25], suggesting high achievers may face greater internal pressure. Longer residency duration was associated with increasing stress, supporting evidence that burnout accumulates over time during training [30, 31]. A strong association between smoking and high stress raises concern, potentially reflecting stress-driven smoking behaviors or reduced coping capacity in smokers.

CONCLUSION

This study revealed that stress and burnout are highly prevalent among family medicine residents in Tabuk City, with nearly half experiencing moderate levels and almost a quarter facing high levels of stress. The most common stressors were clinical, such as fear of making mistakes and time pressure, as well as environmental issues like inadequate facilities and lack of incentives. Psychological stress and concerns about career progression also played a major role in residents’ well-being. Certain groups were particularly vulnerable: single residents, those with high academic achievement, residents working long hours, and those in certain high-demand rotations such as Obstetrics & Gynecology. It is recommended that residency programs implement structured mental health support, promote a more supportive supervisory environment, and consider rotation and workload balancing. Additionally, improvements in infrastructure, transparent promotion pathways, and targeted interventions for high-risk groups, such as new residents or those working excessive hours, could reduce stress and enhance overall resident well-being.

REFERENCES

1. Demerouti E. Burnout: a comprehensive review. Zeitschrift für Arbeitswissenschaft. 2024 Nov 6:1-3.
2. Schaufeli WB, Enzmann D, Girault N. Measurement of burnout: A review. Professional burnout. 2017 Jun 26:199-215.
3. Schaufeli WB, Bakker AB, Hoogduin K, Schaap C, Kladler A. On the clinical validity of the Maslach Burnout Inventory and the Burnout Measure. Psychology & health. 2001 Sep 1;16(5):565-82.
4. Alahmari MA, Al Moaleem MM, Hamdi BA, Hamzi MA, Aljadaani AT, Khormi FA, Darraj MA, Shrwani RJ, AlOmar AA, Tahhah MK, Alyousefy MA. Prevalence of burnout in healthcare specialties: a systematic review using Copenhagen and Maslach burnout inventories. Medical science monitor: international medical journal of experimental and clinical research. 2022 Dec 20;28:e938798-1.
5. Kobyakova OS, Deev IA, Kulikov ES, Khomyakov KV, Tyufilin DS, Zagromova TA, Balaganskaya MA. The professional burnout of physicians of various specialties. Health ?are of the Russian Federation. 2017;61(6):322-9.
6. Low ZX, Yeo KA, Sharma VK, Leung GK, McIntyre RS, Guerrero A, Lu B, Sin Fai Lam CC, Tran BX, Nguyen LH, Ho CS. Prevalence of burnout in medical and surgical residents: a meta-analysis. International journal of environmental research and public health. 2019 May;16(9):1479.
7. Alanazy AR, Alruwaili A. The global prevalence and associated factors of burnout among emergency department healthcare workers and the impact of the COVID-19 pandemic: a systematic review and meta-analysis. InHealthcare 2023 Aug 7 (Vol. 11, No. 15, p. 2220). MDPI.
8. Prentice S, Dorstyn D, Benson J, Elliott T. Burnout levels and patterns in postgraduate medical trainees: a systematic review and meta-analysis. Academic Medicine. 2020 Sep 1;95(9):1444-54.
9. Charoentanyarak A, Anothaisintawee T, Kanhasing R, Poonpetcharat P. Prevalence of burnout and associated factors among family medicine residency in Thailand. Journal of medical education and curricular development. 2020 Jul; 7:2382120520944920.
10. AlNahedh A, BinRusayyis A, Al-Tannir M, AlFayyad I. Prevalence of Depression and Burnout among Family Medicine Residents in Riyadh City, Saudi Arabia. Health Psychology Research. 2023 Dec 28; 11:90620.
11. Boštjan?i? E, Kocjan GZ, Stare J. Role of socio-demographic characteristics and working conditions in experiencing burnout. Suvremena psihologija. 2015 Jul 20;18(1):43-60.
12. Togia A. Measurement of burnout and the influence of background characteristics in Greek academic librarians. Library management. 2005 Apr 1;26(3):130-8.
13. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout among US medical students, residents, and early career physicians relative to the general US population. Academic medicine. 2014 Mar 1;89(3):443-51.
14. Alosaimi FD, Kazim SN, Almufleh AS, Aladwani BS, Alsubaie AS. Prevalence of stress and its determinants among residents in Saudi Arabia. Saudi Medical Journal. 2015 May;36(5):605.
15. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. Journal of internal medicine. 2018 Jun;283(6):516-29.
16. Alosaimi FD, Almufleh A, Kazim S, Aladwani B. Stress-coping strategies among medical residents in Saudi Arabia: A cross-sectional national study. Pakistan journal of medical sciences. 2015 May;31(3):504.
17. Abdulrahman KB, Alnosian MY, Alshamrani AA, ALassaf HI, Aldayel AS, Alaskar YA, Alshehri MA. Job satisfaction among family medicine physicians in Saudi Arabia. Journal of Family Medicine and Primary Care. 2021 Aug 27;10(8):2952-7.
18. Aldubai SA, Aljohani AM, Alghamdi AG, Alghamdi KS, Ganasegeran K, Yenbaawi AM. Prevalence and associated factors of burnout among family medicine residents in Al Madina, Saudi Arabia. Journal of family medicine and primary care. 2019 Feb 1;8(2):657-62.
19. Rotenstein LS, Torre M, Ramos MA, Rosales RC, Guille C, Sen S, Mata DA. Prevalence of burnout among physicians: a systematic review. Jama. 2018 Sep 18;320(11):1131-50.
20. Al-Mansour K. Stress and turnover intention among healthcare workers in Saudi Arabia during the time of COVID-19: Can social support play a role?. PloS one. 2021 Oct 7;16(10):e0258101.
21. Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Di Angelantonio E, Sen S. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. Jama. 2015 Dec 8;314(22):2373-83.
22. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, West CP, Sloan J, Oreskovich MR. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of internal medicine. 2012 Oct 8;172(18):1377-85.
23. Barger LK, Ayas NT, Cade BE, Cronin JW, Rosner B, Speizer FE, Czeisler CA. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS medicine. 2006 Dec;3(12): e487.
24. Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, Dawson S, Van Marwijk H, Geraghty K, Esmail A. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA internal medicine. 2017 Feb 1;177(2):195-205.
25. Prins JT, Gazendam-Donofrio SM, Tubben BJ, van der Heijden FM, van de Wiel HB, Hoekstra-Weebers JE. Burnout in medical residents: a review. Med Educ. 2007 Aug;41(8):788-800.
26. Al-Ghamdi MA, Nahar S, Siddiqui AF, Al-Saleem SA. Burnout and its correlates in Saudi family medicine residents: An observational study from Aseer, Saudi Arabia. Journal of Family Medicine and Primary Care. 2021 May 1;10(5):1904-11.
27. Earle L, Kelly L. Coping strategies, depression, and anxiety among Ontario family medicine residents. Canadian Family Physician. 2005 Feb 1;51(2):242-3.
28. Woodside JR, Miller MN, Floyd MR, McGowen KR, Pfortmiller DT. Observations on burnout in family medicine and psychiatry residents. Academic Psychiatry. 2008 Jan; 32:13-9.
29. Chen YH, Lou SZ, Yang CW, Tang HM, Lee CH, Jong GP. Effect of marriage on burnout among healthcare workers during the COVID-19 pandemic. International Journal of Environmental Research and Public Health. 2022 Nov 28;19(23):15811.
30. IsHak WW, Lederer S, Mandili C, Nikravesh R, Seligman L, Vasa M, Ogunyemi D, Bernstein CA. Burnout during residency training: a literature review. Journal of graduate medical education. 2009 Dec 1;1(2):236-42.
31. Heppe D, Baduashvili A, Limes JE, Suddarth K, Mann A, Gottenborg E, Sacro Y, Davis L, Chacko K, Connors G. Resident burnout, wellness, professional development, and engagement before and after new training schedule implementation. JAMA Network Open. 2024 Feb 5;7(2): e240037-1.