ABSTRACT
Objectives: To evaluate the prevalence of work-related burnout among neurosurgeons at multiple neurosurgical centers in Riyadh, Kingdom of Saudi Arabia.
Methods: A cross-sectional study was undertaken involving neurosurgeons in Saudi Arabia. From June 2023, to September 2023, a self-administered questionnaire was utilized to gather data from the neurosurgeons in Riyadh hospitals. This data pertained to their quality of life, exhaustion, frustration, and patient-doctor relationships.
Results: Out of 120 potential participants, 95 completed responses were collected, yielding a response rate of 79.2%. A significant positive correlation was revealed by correlation analyses between on-call hours and weekly working hours on one side, and burnout and poor quality of life on the other. Principle Component Analysis (PCA) revealed four components with eigenvalues greater than 1, accounting for 32.6%, 16.9%, 11.1%, and 7.8% of the total variance. The overall Kaiser-Meyer-Olkin (KMO) measure was 0.77, falling into the ‘middling’ category, with individual KMO measures ranging between 0.6 and 0.9.
Conclusion: The study revealed a job-related impairment of the work tolerance among neurosurgeons in Riyadh, which may be due to the limited number of neurosurgeons. Further measures are required to enhance the quality of life for neurosurgeons and, ultimately, patient care.
Burnout is a psychological condition that arises due to ongoing stress at work. It consists of overwhelming exhaustion, detachment from the job and cynicism, and a decreased sense of effectiveness and accomplishment, which leads to altered personal perceptions about oneself and others.1 It warrants a context-specific definition and argument, highlighting the social and interpersonal aspects of mental strain and distress. However, the syndrome is enigmatic and lacks adequate medical categorization.2
Neurosurgery is a surgical specialty focused on the prevention, diagnosis, and treatment of pathologies of the brain, spine, and nerves. It is one of the most challenging and complex medical specialties, requiring medical students to undergo an extensive number of exams and practice hours throughout medical school and their postgraduate studies.3 Furthermore, neurosurgeons play a pivotal role in every phase of the treatment journey, from the clinic and emergency room to the operating theater and rehabilitation. Unlike other specialties where a segmented approach can be implemented, neurosurgeons find themselves involved in every step due to the complex nature of neurosurgical cases.4
In May 2020, a study conducted on French neurosurgeons and residents showed that burnout among neurosurgeons has been a significant issue for many years. Several investigations have been conducted to identify the factors associated with burnout. Work addiction, long working hours, and conflicts with family life were found to have negative effects.5 A cross-sectional study conducted in Kuwait in January 2022, identified a higher prevalence of burnout among neurosurgeons compared to otolaryngology and cardiothoracic surgeons, who had the least severity of burnout respectively.6 Being a critical and serious subspeciality in surgery, and due to the little knowledge about neurosurgeons’ stress and exhaustion in Riyadh city, the current study explores the relationships between lifestyle and severity of professional burnout among neurosurgeons working in governmental and private health centers.
Methods
Research design
A sample of neurosurgeons from Riyadh City, Saudi Arabia participated in the present observational cross sectional study.
Data sources
The research data was obtained using a self-administered questionnaire, completed by neurosurgeons from multiple centers in Riyadh, Saudi Arabia during the period from June 2023, to September 2023. This questionnaire was disseminated via the Internet. Designed in both Arabic and English using Google Forms, the sections of the questionnaire were structured based on the research goals and reviewed by experts in neurosurgery. To ensure the questionnaire’s validity, face-to-face validation was conducted. Additionally, a pilot study involving 50 participants was launched to develop and revise the questionnaire, with all further comments duly considered. Furthermore, the survey items were investigated by Cronbach’s alpha to measure the reliability of the questionnaire. We included residents, specialists, fellows, general consultants, and subspecialized consultants of neurosurgery in Riyadh. We excluded all neurosurgeons outside Riyadh and neurosurgery temporary trainees. The questionnaire incorporated an informed consent form, and a paragraph was added to clarify to potential participants that their contribution was entirely at their discretion.
Ethical issues
The proposal received approval from the Institutional Review Board of King Abdulaziz City for Science and Technology in Saudi Arabia, under the registration/protocol number: VCR-23-016. Also, the study was in compliance with the Declaration of Helsinki. Given the cross-sectional nature of the data collection, the Institutional Review Board (IRB) waived the need for informed consent.
Statistical study
Descriptive statistics (such as percentages, means, and standard deviations) were used to discern the demographic as well as other traits of the participants. Principal Component Analysis (PCA) was utilized as shown in the results. Relationships among study outcomes were examined; the Pearson correlation was employed to identify the correlation amidst continuous variables, whereas Spearman’s correlation was applied to ascertain the correlation when one variable was ordinal. The t-test or One-way ANOVA was conducted to identify any significant disparities between either 2, 3, or more groups, respectively. The normal distribution was initially verified using the Kolmogorov-Smirnov test and scrutiny of the Normal Q-Q plots. The records are denoted as the mean±standard deviation. The results were deemed significant whenever p<0.05. Data analysis was conducted using the statistical program SPSS (IBM SPSS Statistics for Windows, V23.0, Armonk, USA).
Results
The survey included 25 questions, categorized into 3 sections: 9 questions related to sociodemographic data, 11 related to burnout assessment, and 5 questions focused on quality of life assessment.
Demographic data
A total of 120 neurosurgeons were contacted for the survey. From these, 95 valid and complete responses were received from government and private hospitals in Riyadh City, resulting in a 79.2% response rate. The participants ranged from residents, specialists, fellows, general consultants, or subspecialized consultants, aged between 21 and 70, who were working in Neurosurgery Departments at primary (5.3%), secondary (11.6%), tertiary (55.8%) government, and private (27.4%) Saudi hospitals in Riyadh. Sixty-eight point four percentage of the participants were male neurosurgeons, and 31.6% were female. The demographic features of the participants are presented in Table 1.
- Demographic characteristics.
Principle component analysis
A survey of 16 questions regarding the quality of life, burnout, and work-related stress was analyzed using PCA. The survey consisted of 14 questions based on the Likert scale. Before executing the analysis, the appropriateness of PCA was evaluated. All test variables produced at least one correlation coefficient greater than 0.3, which was indicated by the correlation matrix. The Kaiser-Meyer-Olkin (KMO) measures were employed to assess sample adequacy. The overall KMO measure was 0.77, falling into the ‘middling’ category, with individual KMO measures ranging between 0.6 and 0.9, categorized as ‘mediocre’ to ‘marvelous’. Bartlett’s test of sphericity was utilized. It yielded a statistically significant result (p<.0005), implying that the data analyzed were likely factorizable.
The PCA revealed four components with eigenvalues greater than 1, accounting for 32.6%, 16.9%, 11.1%, and 7.8% of total variance, respectively. As indicated by scree plot examination, all 4 components were maintained. The 1st component comprises four Likert-scale items, the second encompasses,3 the third contains another three, and the 4th involves two questions. This is detailed in Table 2. Correlation analyses were conducted for component-related scores.
- Illustrates the Rotated Component Matrix for the PCA of the survey questions.
The four-component solution accounted for 68.3% of the total variance. We applied Varimax orthogonal rotation to improve interpretation. The interpretation of data matched with the quality of life and burnout factors the questionnaire was created to evaluate. Strong loadings of ‘Poor Quality of Life’ items were revealed in Component 1, ‘Feel Exhausted, Tired, Disappointed’ items in Component 2, ‘Less Smooth, Successful, Energetic’ items in Component 3, and ‘Unkind and Tough with Patients’ items on Component 4.
The ‘Poor Quality of Life’ component had an average of 42.04±24.45 (mean±SD). The ‘Feel Exhausted, Tired, Disappointed’ component had an average of 47.63±24.72 (mean±SD). The ‘Less Smooth, Successful, Energetic’ component had an average of 39.56±23.19 (mean±SD), and the ‘Unkind and Tough with Patients’ component had an average of 33.95±26.84 (mean±SD). Figure 1 illustrates the four components, while Figure 2 provides details on the participants’ perception of each component.
- Neurosurgeons’ perception about the principal components of the Stress and Burnout questionnaire showing the mean of each component with reference to the ‘normal’ value (dotted line).
- Neurosurgeons’ perception about the principal components of the Stress and Burnout questionnaire showing the frequency distribution of the four components, a) poor quality of life, b) feeling exhausted, tired, and disappointed, c) less smooth, successful, and energetic, d) unkind and tough with patients.
Variance based on demographic attributes
An independent-sample t-test and a one-way ANOVA were conducted to determine if burnout and stress levels differed among participant groups of varying gender, marital status, offspring statuses, and workplace sector types. Gender comparisons included 65 male and 30 female participants. No significant gender-based differences were observed. When considering marital status (Figure 3a), participants were classified into three groups: single (n=40), married (n=49), and divorced (n=6). The ‘Less Smooth, Successful, Energetic’ component showed an increasing trend from married (32.14±23.01) to divorced (45.83±11.49) to single (47.71±22.01) groups, exhibiting statistical significance: F (2, 92)=5.717, p=0.005. A Tukey post hoc analysis revealed that the increase from married to single status (15.57, 95% CI (4.34 to 26.79)) was statistically significant (p=0.004), but there were no other significant differences among the groups.
- Assessment of burnout and stress with regard to a) the study participants’ marital and b) parental status. Bars with patterns and asterisks represent group means with significant difference. Dotted line represents the ‘normal’ reference.
Participants were almost equally divided in terms of having offspring: 48 did have children, while 47 did not. After conducting the independent-samples t-test (Figure 3b), it was observed that participants without offspring had a higher level of the component ‘Feel Exhausted, Tired, Disappointed’ (52.84±25.67) compared to participants who were parents (42.53±22.89); this difference of 10.30 was statistically significant (95% CI, 0.40 to 20.21), t (93)=2.066, p=0.042. Similarly, participants without offspring also had a higher average of the ‘Less Smooth, Successful, Energetic’ component (45.21±21.96) than their counterparts (34.03±23.24); this difference of 11.19 was statistically significant as well (95% CI, 1.97 to 20.40), t(93)=2.410, p=0.018.
In terms of the employment sector, participants were employed in either governmental (n=69) or private (n=26) hospitals. The t-test revealed a significant statistical difference between the 2 groups. The former had a higher average score on the ‘Poor Quality of Life’ component (45.83±23.98) compared to the latter (31.97±23.21), demonstrating a statistically significant difference of 13.86 (95% CI, 3.00 to 24.73), t(93)=2.534, p=0.013.
Correlation analysis
A Spearman correlation analysis was conducted to discern potential correlations between each of the 4 components of burnout and stress assessment on the one hand, alongside the professional attributes of the participants on the other (Figure 4). There was a significant positive correlation discovered between the ‘Poor Quality of Life’ component and the number of on-call days, rs(95)=0.329, p=0.001. Similarly, this component also correlated positively with the workload in terms of weekly hours, rs(95)= 0.529, p<0.0005. However, it was negatively correlated with age, rs(95)=-0.223, p=0.030.
- Bubble chart illustrating a correlation analysis between each component of the burnout perception and the participants’ attributes. Bubbles above the horizontal axis indicate a positive correlation. Bubble size is proportional to Spearman correlation coefficient. Solid bubbles, statistically significant correlation; empty bubbles, insignificant trend.
Regarding the ‘Feel Exhausted, Tired, Disappointed’ component, a statistically significant, positive correlation was observed with the number of on-call days. The correlation coefficient rs(95) was 0.218, with a p-value of 0.033. Similarly, this component also demonstrated a significant positive correlation in relation to the workload in terms of weekly hours, with a correlation coefficient of rs(95)=0.415 and a p-value less than 0.0005.
The component “Unkind and Tough with Patients” showed a positive correlation with the workload in terms of weekly hours, with rs(95)=0.214, p=0.038. Finally, the feeling of being “Less Smooth, Successful, Energetic” was negatively correlated with years of experience, with rs(95)=-0.222, p=0.030. There was no significant correlation between professional status (such as resident, consultant, etc.) and any of the stress components.
Discussion
The current study sought to evaluate the degree of burnout and quality of life among neurosurgeons in Riyadh hospitals, in Saudi Arabia. The results revealed impaired work tolerability, some degree of stress, exhaustion, and a poor quality of life among the participants related to their roles as neurosurgeons. Regarding data analysis, this study utilized PCA in addition to existing literature studies, to reduce dimensionality in a comprehendible manner, thus providing an accurate and simple data demonstration.7 Consequently, 4 components were identified, all of which were interrelated and served the study’s objectives. The first component is referred to as “Poor Quality of Life”. The second referred to the “Feeling of Exhaustion, Tiredness, and Disappointment”. The third was titled “Less Smooth, Successful, Energetic”, and the fourth was “Unkind and Tough Relationship with Patients”. Additionally, a correlation analysis was performed between each of the 4 components and the professional attributes of the participants.
This study’s findings revealed that the first component’s perception had a recorded average of 42.04±24.45%. Presumably, this level of perception is higher than the expected perception of a usual ‘unstressed’ professional. This perception is assumed to fall within the scale of ‘Never’ to ‘Rarely’, which equates to ‘0%’ to ‘25%’ of the total scale of poor perception, grounded on the questionnaire’s design.
Concerning the second component, a mean of 47.63±24.72% was documented, signifying a certain level of exhaustion and fatigue. The third component registered at 39.56±23.19%, revealing that participants felt less energetic during their free time, faced difficulty in smoothly managing their assigned duties, and struggled with postoperative complications. With regard to the fourth component, participants exhibited an average perception of 33.95±26.84%, suggesting a sense of being harsh and hard on patients.
The current findings were bolstered by a correlation analysis which indicated a significant positive correlation between some principal components and participants’ professional attributes. It revealed that an increased workload and additional on-call days for neurosurgeons are related to a lower quality of life, elevated burnout and fatigue levels, reduced energy, and increased difficulty in managing potential postoperative complications. Conversely, the more seasoned and experienced the neurosurgeons, the better their quality of life and sense of seamless management. This may be a sound finding, as increased work experience is typically associated with self-confidence and reduced distress.
The impact of demographic characteristics on the components of burnout was examined to ascertain if burnout varied among neurosurgeons with differing genders, marital status, offspring status, and types of workplace sectors.
The results indicated that the workplace sector had a significant impact on the quality of life among respondents. Neurosurgeons employed in governmental hospitals reported a poorer quality of life compared to those working in private hospitals. This discrepancy may be attributed to the higher patient flow rate in governmental hospitals as opposed to private institutions. Similarly, studies conducted by Yu et al8 and Ribeiro et al9 found a consistent effect of the workplace on burnout among Iranian nurses and Chinese neurosurgeons, respectively. Furthermore, neurosurgeons without offspring experienced higher levels of exhaustion, tiredness, and frustration compared to those with children, possibly indicating the stress-relieving effect of a family environment. Single neurosurgeons, compared to their married counterparts, were less energetic during leisure time, encountered more difficulty managing their assigned tasks, and were less equipped to handle postoperative complications. This highlights the potential stress-alleviating impact of a family atmosphere on work-related burnout. Our findings align with Ma et al10 who reported a mediating effect of family and social relationships on occupational stress among Chinese physicians. Correspondingly, Chen et al11 and Meng and Yang12 stated that marital relationships can provide satisfaction and support, thereby enhancing the ability of married individuals to cope with job-related stress.
Overall, the study presented interesting findings, however various confounding factors should be taken into account that may influence physical and mental well-being. These factors may include the community culture, staffing/workloading, scope and nature of the practice, work values, team dynamics, and work policies and organizations.13 According to Jamjoom et al,14 the number of neurosurgeons in Riyadh city stands at 84, serving approximately 8.2 million individuals. This data is based on a 2017 survey administered by the KSA General Statistics Authority. Thus, the region’s neurosurgeon to general population ratio is approximately 1:100,000, a figure significantly lower compared with other countries. The limited number of neurosurgeons in such a large geographical area inevitably increases their daily workload, potentially to the detriment of their mental health, resulting in decreased workplace tolerance and increased burnout. Furthermore, the uneven and diverse distribution of neurosurgeons within neurosurgical centers, coupled with an increase in their medical responsibilities and high expectations for professional excellence, are identified as risk factors for decreased workplace tolerance and burnout. This notion aligns with the suggestions put forth by.15
Interestingly, a cross-sectional study in China8 revealed that 45% of Chinese neurosurgeons experienced burnout, with significantly higher rates amongst those working in regional hospitals as opposed to tertiary hospitals. A recent study in KSA16 reported an average work-related burnout rate of 55.26±24.4 amongst urology residents. This level of burnout was attributed to the limited number of physicians available, resulting in an overwhelming workload and extended working hours.
Our study has its limitations
This study lacks the comparison of burnout between neurosurgery and other surgical or medical specialties. This study was confined to Riyadh, which does not include other regions of Saudi Arabia. Other limitations that may be related to the conduction of the study include sampling bias, non-response bias, and the cross-sectional design.
Conclusion and recommendations. The current findings, which are supported by the results of previous studies8 and,16 underline the critical need for prompt intervention and new strategies among surgeons, particularly neurosurgeons, to prevent further potential burnout. The work environment for neurosurgeons should be adjusted to make their job and career development less stressful. Introducing a work-life balance through stringent rules on working hours is a vital step for improving the quality of life of neurosurgeons and for hindering further burnout cases. Also, strict measures for early diagnosis and management of burnout among neurosurgeons should be implemented across all health facilities. This can help prevent the harmful effects of work-related depression and burnout, and it can enhance job satisfaction and work engagement. Comparing the prevalence of work-related burnout among neurosurgeons with other clinical specialties could provide valuable data for future investigations and the development of improvement plans by health administrations.
Acknowledgments
We would like to thank American Manuscript Editors (www.americanmanuscripteditors.com) for English language editing.
Footnotes
Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.
- Received September 26, 2024.
- Accepted March 19, 2025.
- Copyright: © Neurosciences
Neurosciences is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC). Readers may copy, distribute, and display the work for non-commercial purposes with the proper citation of the original work.
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