Is Dentistry Turning into Weary Profession? Dimensionality of Experienced Professional Burnout among Dentists in Central India

Objective: Dentistry has been considered as an inspiring and rewarding profession but it is also equally challenging because of the physical and mental adversity it produces on the dentists. Dentists experience a variety of stressful factors all through their career resulting in professional burnout. The study was conducted to measure the level of burnout and implicated risk factors among dentists working in dental colleges of Central India. Methodology: A total of 178 dentists working with at least 1 year of working experience were invited for the study, with a response rate of 87.5%, a total of 155 dentists participated. Information about demographic and professional details from the dentists was recorded and were also asked to rate the Maslach Burnout Inventory (MBI). Results: Mean MBI score was 60.38 ± 9.95. Mean scores for Emotional fatigue, Personal fulfillment, Depersonalization were 24.76 ± 3.99, 19.66 ± 4.29 and 15.94 ± 3.44 respectively. Among 22 factors of MBI Scale, four factors were extracted with eigenvalues above 2.0 by employing Factor Analysis with principal component analysis and varimax rotation. Conclusion: In conclusion, the study highlights that over all burnout among the dentists was low and it was seen that dentists maintained a good relation with their recipients creating a favourable working environment. The study emphasizes the need to appraisal of burnout in diverse professions for a better understanding of personal, social and institutional variables, leading to attenuation of burnout.


Introduction
Dentistry has been considered an inspiring and rewarding profession but it is also equally challenging because of the physical and mental adversity it produces on the dentists. Dentists experience a variety of stressful factors all through their career resulting in professional burnout. Various organizational and individual stress factors at dental school, in clinical practice building up all the way through, are responsible for professional burnout [1][2][3]. Burnout is a persistent, negative work-related state of mind in "normal" individuals, primarily characterized by emotional exhaustion and accompanied by distress, a sense of reduced effectiveness, decreased motivation, and the development of dysfunctional attitudes and behaviors at work [4]. Burnout leads to negative outcome on quality of work, affecting both professional and personal interests of a dentist. Recent studies have shown that professional workload, time constraint, and role conflicts are the important stressors in the development of burnout. Therefore, burnout risk assessment deserves continuous deliberations for subsequent prevention and intervention [5][6][7].
Several instruments have been used to measure burnout in health professionals but the Maslach Burnout Inventory (MBI) is considered to be the gold standard for assessing the burnout [8]. The MBI has three components: emotional exhaustion, depersonalization and personal accomplishment. Emotional exhaustion is considered a typical stress reaction due to prolonged exposure to work demands, whereas depersonalization is believed to be a way of coping with exhaustion by mentally isolating oneself from one's work particularly in relationship to the service recipient. As a consequence of exhaustion and depersonalization, a sense of reduced professional accomplishment or inefficacy might develop. Thus, burnout is considered to be a sequential process that develops over time [9][10].
Literature is not available from central India on the prevalence of burnout among dentists and hence the present study was conducted to assess level of burnout and implicated risk factors among dentists working in dental colleges of Bhopal.

Methodology
All the participating dentists in the study had completed five years graduation (Bachelor of Dental Surgery/BDS). In addition to this, the post graduate faculty had completed three years of Maters (Master of Dental Surgery/MDS) in any of the nine specialties after graduation. With the highest number of dental schools in the state, Bhopal has maximum number of dental faculty and hence dentists working in all the six dental schools of different universities were approached for the study. A total of 178 dentists working with at least 1 year of working experience were invited for the study, with a response rate of 87.5%, a total of 155 dentists participated. The questionnaire was self-administered had two sections; the demographic and professional details were recorded in the initial part and Maslach Burnout Inventory (MBI) in the latter. The professional information included the participating dentist's qualification (graduation/post-graduation), nature of practice, whether academic or private and the dentists' experience in these areas. The Maslach Burnout Inventory (MBI) which measures 22 various aspects of professional burnout was applied in the present study. The items are measured on a with 5-point Likert scale (1=never burnout to 5=everyday burnout) [11]. The study has been conducted in full accordance with the Helsinki declaration by World Medical Association. Institutional Ethical Committee (IEC code 2014PHD18) gave the approval for conducting the study and verbal informed consent from all the dentists was also obtained prior to the survey. Information from all the participating dentists was collected by a single investigator, ensuring anonymity of the information provided.

Statistical Analysis
Analysis of the data was done using SPSS (Statistical Package for the Social Sciences) version 22 (SPSS Inc., Chicago, IL, USA). Univariate and bivariate analysis was carried out to establish the association between independent variables on burnout. Further, Factor analysis (principle components, varimax rotation) was used to determine the association between the subsets of the burnout inventory. Significance was assumed at <0.05 (Table 1). Table 2 presents percentage distribution of dentist's burnout level for different domains of Maslach Burnout Inventory. Under Emotional fatigue domain, 48.4% of the dentists never felt stressed out while working with people, while majority of dentists (43.9%) agreed that they could easily create a relaxed atmosphere with recipients every day. Under Personal fulfillment domain, dentists never felt that they need not care about what happens to the recipients while a majority (34.8%) of the dentists dealt with emotional problems very calmly every day. In Depersonalization domain 43.9% of the dentists agreed that the recipients never blamed them for any of their problems while one third of the dentists dealt very effectively with the problems of their recipients every day.    Personal characteristics of the dentists were compared with total MBI scores and professional qualification was found to be significantly associated with total score of Maslach Burnout Inventory (Table 4).

Discussion
Dentistry is certainly one of the most stressful professions with difficult and uncomfortable working conditions leading to professional burnout [12]. The present study is the first to be conducted among dentists of Central India to assess their professional burnout. With a mean age of 33.20 ± 6.70 years, the sample of dentists represented a young dental manpower. More than half of the dentists (54.8%) were academicians with private practice. In the present study post graduate faculty (76.1%) were thrice the graduate faculty, indicating improved professional opportunities for them.
More than one third of the dentists (41.3%) felt very energetic and agreed that they could easily create a relaxed atmosphere with their recipients every day. Also, working with people never put too much stress on them and that they never worried every day that job was hardening on them emotionally, indicating less emotional fatigue among the dentists. The dentists dealt with emotional problems very calmly and positively influenced others people's lives through their work. More than half of the dentists agreed that they never treated the recipients as impersonal 'objects' and never had careless attitude towards recipients, but dealt very effectively with their problems everyday and hence never experienced being blamed by recipients for their problems.
Professional qualification emerged to be significantly associated with total MBI score, with more than half of the faculty (54.8%) who were postgraduates having higher burnout than the remaining 45.2% graduate faculty indicating busy practice schedule leading to emotional stress. This could be also due to the need to cope with dual workload of academic work and private practice. Marion Vogt observed that a key factor influencing the risk of job burnout is working time [13]. Academicians who also had private practice were having longer working schedules as they have to balance both. Whereas the dentists who are only academicians tend to have a specified working time, thus they tend to have more time for themselves.
Studies conducted in other countries including the UK, the Netherlands and Finland concluded that about 12%-16% of the dentists were at risk of burnout [14][15][16][17]. Maslach and Jackson [18] reported higher level of burnout among females as compared to males which might due to role difference; women being in giving roles, eventually makes them susceptible to emotional exhaustion.
The factors which emerged with maximum loading were related to personal fulfilment domain with dentists positively influencing others through their work and easily creating a relaxed atmosphere with their recipients. The dentists feeling of burn out from work and feeling fatigued in the morning to face another day also had high factor loadings. This indicates the need to address these problems which might effectively decrease the burnout among dentists improving the overall work efficiency.
Apart from the above mentioned factors, burnout can also be seen as an indicator of the discrepancy between one's character or personal values and one's duties at work. So, there are, however, other factors related to our working life which contribute to burnout including lifestyle and certain personality characteristics like insufficient time for relaxation and social life, lack of close, supportive relationships which also need to be addressed. This is an essential aspect which needs to be addressed to help build the capacity of people within the working environment improving overall quality of work.
In conclusion, the study highlights that over all burnout among the dentists was low and it was seen that dentists maintained a good relation with their recipients creating a favourable working environment. The study emphasizes the need to appraisal of burnout in diverse professions for a better understanding of personal, social and institutional variables, leading to attenuation of burnout [19]. Such information will have the practical benefit the system of recruitment, professional training and work environment modification so as to lessen the burden.