Lincoln's famous quotation quite aptly focuses our attention on the increasing worldwide prevalence of burnout among doctors, which moved the World Health Organization and the European Forum of Medical Associations to issue a joint statement in February 2003, urging all national medical associations to heighten awareness of and monitor the problem, to evaluate causative factors and develop preventive strategies accordingly. Much research data has since emanated from the West, but on the Eastern front, we have been greeted with silence as if standing pensively in front of the Wailing Wall in Jerusalem. Cultural and political differences may have been responsible for the dearth of information in the Orient.

Burnout is the stress syndrome comprising the triad of emotional exhaustion, depersonalization and low personal accomplishment. it can affect any profession or trade, but is especially common in the healthcare sector,¹ encompassing general practitioners,^2,3 physicians,^4-6 dentists,⁷ nurses^8,9 and other paramedical groups.^10,11 The phenomenon is a distinct entity from anxiety or depression, with which burn-out may often be associated, because of the work-related rather than physical or biological symptoms.¹² Burnout is often assessed using the Maslach burnout inventory (MBi)¹² and stress is generally assessed with the general health questionnaire (GHQ).¹³ The causal relationship between burnout and stress has been clarified by a well-designed 3-year longitudinal study.¹⁴ Whilst two components of burnout, namely, personal accomplishment (efficacy) and emotional exhaustion, were found to increase stress, depersonalization (cynicism) was found to decrease stress. To further complicate the issues, emotional exhaustion was also increased by personal accomplishment (efficacy) and stress. The scenario presented is that of an intertwining vicious cycle that can hopefully at least be partially broken by correction of extrinsic work-related stressors such as excessive workload,^6,15 bad organizational work culture,¹⁶ "mismatch between what doctors were trained for and what they are required to do",¹⁵ exaggerated patient expectations versus doctors' awareness of their limitations,¹⁵ imbalance between professional and private life,³ etc..........

Another 12-year longitudinal cohort study of United Kingdom medical graduates shows correlation between personality traits and the development of stress, burn-out or career satisfaction in these doctors.¹⁷ Furthermore, doctors' perception of workload and workplace climate were predictable both by their approaches to work and by measures of stress, burnout and career satisfaction; whilst their approaches to work were predictable by study habits and learning styles at the time of application to medical school as well as in the final year.¹⁷ Greater workplace empowerment has been strongly correlated with increased job satisfaction that in turn leads to a lower level of burnout in nurse educators,¹⁸ so that it is not unreasonable to extrapolate such findings to the medical establishment. Poor job satisfaction and frustration with organizational culture have also been shown to lead to stress and burnout manifesting as long sickness absence,⁸ whilst better job satisfaction has been found to lower the risk of burnout.⁶

Attempts have also been made to understand burnout in biochemical terms since free oxygen radicals have been implicated in ageing and many disease processes. A group of Spanish researchers¹⁹ studied the relationship between burnout (as measured with the MBi) and the antioxidant activities of two scavenging enzymes that form part of the body natural defence mechanisms. These two enzymes are superoxide dismutase (SOD) and catalase, which were respectively measured by Minami & Yoshikawa and Aebi methods according to their research protocols. This controlled cohort study involved 111 physically healthy workers of a pre-hospital emergency service, and both sexes were represented. Gender was found to be an insignificant variable, but significant differences (P < 0.001) were found in SOD activity between the pre-hospital emergency service workers and the control group. Workers on night and evening shifts were also found to have higher levels of SOD activity, which was statistically significant (P < 0.001). Although they all exceeded the control group in burnout subscales' scores, statistical significance was not obtained.

interestingly, another study⁹ of 141 University hospital nurses found that night shifts more readily caused burnout symptoms and that a minimum of 3 hour exposure to daylight per day could reduce work-related stress (which on its own can lead to burnout) and engender greater job satisfaction. Seasonal mood disorder is a widely accepted clinical phenomenon associated at least partially with daylight-mediated neurochemical dysfunction, which also correlates well with the Turkish⁹ and Spanish¹⁹ findings as regards night shifts. Job satisfaction is probably of overriding importance in the prevention or minimalization of burnout, as has been shown in an italian study involving 137 medical and 207 nursing respondents.⁶ The significance of job satisfaction was also demonstrated in an American study²⁰ using HiV/AiDS healthcare workers who, at the time of the survey, had a lower level of stress and burnout in comparison to the pre-HAART (so-called cocktail therapy) era because they were able to provide better care to patients and more equipped to deal with emerging challenges, thus deriving much more satisfaction from their work.

Focusing on the primary care level, what can family physicians do to ameliorate or minimize stressors that predispose to the development of burnout? As job satisfaction is of prime importance, efforts can be directed towards attaining it though we all know too often how difficult it is to balance professional and family life. introducing minor specialty interests into our daily work may help to relieve monotony and boredom that can lead to burnout. Becoming involved in part-time teaching or academic research can also add spices to what has become a rather dry and insipid professional life. Returning like prodigal sons and daughters to academia for short courses can also blow a freshening breeze over one's professional career. Re-appraisal of ideals and goals may add an enlightening spark. Revisiting and appreciating the importance of empathy, mutual respect and effective communication should reduce the stress of dealing with difficult patients or situations. The multifarious ways of fulfilling one's career and enhancing job satisfaction have always existed, and it is up to us as individuals to tap into the available resources. The grandeur of Rome was not built in one day, nor can preventive measures against burnout be effectual overnight. Let the ingenuity and innovativeness of the medical mind prevail!