Introduction

Burnout syndrome was first described in 1974 by Herbert Freudenberger as a psychological condition that gradually develops due to prolonged exposure to chronic workplace stressors, especially those related to interpersonal interactions [1]. It was officially recognized by the World Health Organization in 2019 as an occupational phenomenon in the International Classification of Diseases (ICD-11), characterized by chronic workplace stress that has not been successfully managed. [2] Burnout has become highly prevalent among both physicians and residents, with reported rates often reaching or exceeding 50% [3].

Emotional exhaustion and irritability at work can contribute to various mental health issues, notably burnout, which includes key components such as emotional exhaustion, depersonalization, and reduced sense of personal achievement [4]. Four key contributors to burnout among primary health care workers have been identified: [1] limited autonomy in managing work conditions and making decisions; [3] time constraints that make physicians feel valued mainly for their productivity; [4] disorganized and inefficient workplaces where physicians are burdened with administrative or routine tasks; and misalignment between physicians and leadership in terms of values, goals, mission, and financial recognition [5].

Burnout has been linked to various physical health issues such as cardiovascular diseases, type 2 diabetes, musculoskeletal pain, chronic fatigue, and gastrointestinal and respiratory problems. Psychologically, it is associated with insomnia, depression, use of psychiatric medications, and even suicidal ideation. These serious outcomes highlight burnout as a critical public health concern that requires urgent preventive efforts in the workplace [6].

In Syria, years of conflict have repeatedly targeted the health sector: by March 2025 only 57% of hospitals and 37% of primary health centers were fully functional, 246 facilities faced imminent closure, and up to 70% of the workforce had fled abroad, forcing the remaining clinicians to cover extensive service gaps with constrained resources [7]. Intensified violence since November 2024 displaced over 882,000 Syrians and coincided with 37 documented attacks on health premises, amplifying the trauma load on the residents who remain on the front lines [8]. More than 16.7 million people now depend on humanitarian health support, meaning residents routinely provide care in overstretched, emergency-driven environments where burnout carries immediate population-level consequences [9].

On the other hand, in Syria, the prolonged crisis and ongoing conflict have had a profound impact on all aspects of life, including healthcare and education, leading to a general decline in living conditions. These challenges have placed additional pressure on medical residents and physicians, who are not only endured the effects of war but also had to compensate for the collapsing healthcare system by taking on extra responsibilities as care providers [3]. While burnout is a global concern among healthcare professionals, its impact in conflict-affected settings like Syria is especially critical. Therefore, considering these challenges, it has become essential to assess burnout syndrome among medical residents in Syria.

To achieve this, we employed the Burnout Assessment Tool (BAT), a recently developed and validated instrument that offers a more precise evaluation of burnout compared to traditional measures. The BAT allows for assessing the syndrome, along with its core dimensions and secondary symptoms [10]. By adopting this updated conceptualization of burnout, the purposes of this study were to investigate the prevalence of burnout syndrome among resident physicians of all specialties in Syria and to identify the factors influencing its occurrence among resident physicians.

Methods

Results

A total of 550 medical residents participated in this study. The majority were female (56.9%) and single (63.1%). Most participants specialized in internal medicine (52.9%), followed by surgical (30.2%) and clinical specialties (6.9%). The most common specialties included General Internal Medicine and Pediatrics (15.3% each), and Gynecology and Obstetrics (11.8%).

Participants were mainly from Aleppo (32.0%), Idlib (26.0%), and Damascus (14.0%). Nearly all participants worked in governmental hospitals (97.5%), with 56.9% affiliated with the Ministry of Higher Education (MOHE) and 43.1% with the Ministry of Health (MOH).

In terms of training, the largest proportion of participants were in their 2nd year of residency (36.5%), followed by those in their 3rd year (27.1%). The median age across the cohort was 27 years (interquartile range [IQR] = 2), and the typical number of night shifts per month was 9 (IQR = 4), suggesting a moderate to high workload Table 1.

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Table 1. Baseline characteristics.

https://doi.org/10.1371/journal.pone.0350426.t001

Burnout was assessed using the Burnout Assessment Tool (BAT23), with scores categorized into three zones: Green (low), Orange (moderate), and Red (high).

Overall Burnout (BAT23): 50.0% of participants fell in the red zone, 21.5% in the orange, and 28.5% in the green.

Exhaustion: A high proportion (76.7%) were in the red zone.

Mental Disturbance: Most (66.7%) were in the green zone, indicating fewer symptoms.

Cognitive Impairment: Distribution was more even (38.7% green, 26.5% orange, 34.7% red).

Emotional Impairment: 48.5% were in the green zone, while 22.9% were in the red Table 2.

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Table 2. Main results.

https://doi.org/10.1371/journal.pone.0350426.t002

Sex: No significant difference in BAT23 red zone prevalence between males (52.3%) and females (48.2%) (p = 0.634). However, males reported more emotional impairment (28.3% vs. 18.8%, p = 0.016).

Province: Although regional differences were noted (e.g., Idlib 58.7%, Damascus 58.4%, Aleppo 46.0%), they were not statistically significant (p = 0.108).

Marital Status: No significant differences in BAT23 (p = 0.424). Divorced individuals had 100% red-zone rates in all subcategories, but their sample size was small.

Residency Year: Burnout was more common in mid-level residents (years 2–4). Spearman’s rho showed a weak but significant negative correlation (r = −0.095, p = 0.025) hence burnout is more likely in young residents, but percentages tended to be higher in the middle years (years 2–4) compared to early or late years

Specialty: Strong associations were found (p < 0.0001). Internal medicine specialties had the highest BAT23 red zone rates (56.4%), followed by surgery (44.6%) and clinics (39.5%), in a more detailed look Pediatric surgery showed lower percentages of red zone in Cognitive Impairment and Emotional Impairment (27.3% each), whereas specialties like pulmonology, anesthesia, and neurology showed higher BAT23 red zones (above 78%).

Involvement in multiple centers: Residents working in more than one center had similar BAT23 distributions (p = 0.968). Hospital Type and Recruitment: No significant differences were found based on type of recruitment (p = 0.435) or hospital affiliation (p = 0.282) Table 3.

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Table 3. Relationship between baseline characteristics and burnout.

https://doi.org/10.1371/journal.pone.0350426.t003

The median age was similar across the three groups (Green, Orange, and Red), with a median of 27 years and no statistically significant difference (p = 0.96). However, the number of shifts worked in one month differed significantly between groups (p = 0.0011). The median number of shifts increased progressively from the green group (7 shifts, IQR 6) to the orange group (8 shifts, IQR 5), and was highest in the Red group (9 shifts, IQR 4), indicating a trend of Red > Orange > Green in terms of monthly workload Table 4.

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Table 4. Age and number of shifts effect on burnout level.

https://doi.org/10.1371/journal.pone.0350426.t004

Significant differences were observed in both the ranking of the work environment and work satisfaction across the three groups (p < 0.0001 for both). The Green group reported the highest median ranking for work environment (6, IQR 2), followed by the orange group (5, IQR 8), and the red group reported the lowest (4, IQR 3). Similarly, work satisfaction rankings followed the same pattern, with the green group scoring highest (median 7, IQR 2), then Orange (median 6, IQR 2), and Red lowest (median 5, IQR 3) Table 5.

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Table 5. Ranking work environment & satisfaction.

https://doi.org/10.1371/journal.pone.0350426.t005

Several factors related to burnout and stress were explored among participants across four burnout subcategories: Exhaustion (Ex), Mental Distance (MD), Cognitive Impairment (CI), Emotional Impairment (EI), in addition to the main BAT23 scores.

Dropping out and psychological consultation due to burnout showed highly significant associations with all burnout dimensions (p < 0.0001). A notably high percentage of individuals in the Exhaustion Red group reported considering dropping out (94.1%) and seeking psychological consultation (87.6%).

Ways to destress varied, with social support being the most reported method (75.6%), followed by walking (70.7%). Although these trends were observed, the association with burnout dimensions did not reach statistical significance (p = 0.056).

Experiencing improper treatment showed strong associations across all burnout dimensions (p < 0.0001), with 85.5% of those in the Exhaustion red group reporting improper treatment noting that improper treatment isn’t significantly related to year of residency (Fisher’s p = 0.534)

A lack of time for family and friends, poor training, and work overload were all significantly associated with higher burnout scores (p < 0.0001). For example, only 56.6% of Exhausted Red participants felt they had time for family and friends, and just 69.1% felt they were receiving decent training.

The perceived fairness in workload distribution was also linked to burnout (p = 0.044), with lower agreement among high burnout subgroups.

Migration due to work conditions was significantly associated with burnout (p = 0.034), with 80.4% of those in Exhaustion red zone considering migration.

Regarding factors affecting stress, workload, lack of support, and work environment were most strongly linked to burnout dimensions, all showing statistical significance (p < 0.05), particularly workload and lack of support (p < 0.0001). Other factors like administrative tasks were also associated (p = 0.038).

Finally, days off per year were inversely related to burnout, although the correlation was weak (Spearman’s rho = −0.057, p = 0.181) for the total BAT score, however those reporting fewer days off showed higher cognitive impairment levels (Spearman’s rho = −0.126 p = 0.003) Table 6.

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Table 6. Association of Burnout Dimensions with Work-Related Factors, Coping Strategies, and Wellbeing Indicators.

https://doi.org/10.1371/journal.pone.0350426.t006

Discussion

Prolonged exposure to war has been associated with mental health. Physicians in crisis-affected regions may face elevated risks of stress conditions, like Burnout, due to healthcare system collapse, economic instability, resource shortages, and overwhelming patient loads identified as contributing factors in the literature.

In our study, the BAT was selected for comprehensive clinical assessment of burnout, integrating core dimensions (exhaustion, cognitive/emotional impairment, mental distance) and secondary manifestations (psychological distress, psychosomatic complaints). This contrasts with the Maslach Burnout Inventory (MBI), historically the dominant tool operationalizing burnout through three subscales (emotional exhaustion, depersonalization, reduced efficacy). [11,12] While the MBI has been widely used for decades in occupational and psychological research, its fragmented structure, lack of a unified diagnostic score, and exclusion of critical cognitive/emotional deficits limited its clinical utility [10].

The BAT was employed to overcome these limitations, offering a syndromic framework with validated psychometric robustness for precise evaluation of burnout severity and progression.

Although the questionnaire did not ask about individual experiences of violence or displacement, the national-level evidence of facility damage, workforce exodus, and humanitarian demand described above [7–9] shows that the remaining residents now practice within a collapsing infrastructure. We therefore relate our findings to the systemic stressors of the conflict rather than to direct exposures for each respondent.

Our study identified a comparable prevalence of physician burnout (50.0%) to that reported by Shenoi et al. among U.S. physicians (49.0%) [13]. However, this numerical equivalence requires careful interpretation, as the two studies employed fundamentally different measurement tools with distinct conceptual frameworks. Shenoi et al. used the Maslach Burnout Inventory (MBI), which operationalizes burnout through three subscales—emotional exhaustion, depersonalization, and reduced personal accomplishment—and classifies burnout as scoring high on at least one subscale [13]. In contrast, our study employed the Burnout Assessment Tool (BAT-23), a more recent instrument that conceptualizes burnout as a syndrome comprising four core dimensions (exhaustion, mental distance, cognitive impairment, and emotional impairment) and provides a unified composite score for determining burnout risk. The BAT was specifically designed to address limitations of the MBI, including its fragmented structure and lack of a unified diagnostic score [10].

Consequently, while the headline prevalence rates appear similar, the underlying constructs and thresholds for classification differ substantially. Notably, the rate of severe burnout in the Shenoi et al. study—defined as high emotional exhaustion combined with high depersonalization or low personal accomplishment—was 21%, whereas 50% of our participants fell into the highest-risk (Red) category on the BAT-23 composite score. This discrepancy underscores that direct cross-study comparisons of burnout prevalence are methodologically challenging when different instruments are used.

Beyond measurement differences, the numerical similarity obscures profound disparities in underlying drivers, systemic contexts, and clinical implications. The U.S. study identified regular physical exercise as protective and noted Sex differences in burnout risk, but did not find strong associations with organizational factors [13]. In contrast, our findings in Syria reveal burnout tightly linked to systemic healthcare collapse, resource scarcity, excessive workloads, and inadequate training—factors shaped by over a decade of conflict, workforce attrition, and infrastructural deterioration. Thus, while the prevalence figures may appear equivalent, the etiologies, manifestations, and potential solutions for burnout in these two contexts are likely vastly different.

The burnout profile revealed striking disparities across subdomains. Exhaustion emerged as the most severe dimension, with 76.7% of residents in the red zone (high risk)—a finding that reflects extreme physical and mental depletion. In contrast, mental disturbance showed relative resilience; 66.7% of participants were in the green zone (low risk), suggesting preserved psychological stability among most residents. Cognitive impairment displayed a tripartite distribution: 38.7% (green), 26.5% (orange), and 34.7% (red), indicating moderate-to-severe deficits in memory, focus, or decision-making for over 60% of residents. Emotional impairment was predominantly green (48.5%), though 22.9% fell into the red zone, highlighting vulnerabilities in emotional regulation among a subset.

Conclusion

This study reveals a concerning prevalence of burnout among Syrian medical residents, with 50% demonstrating severe symptoms, particularly in exhaustion and cognitive impairment. The highest rates were observed among mid-level trainees and those in high-intensity specialties, consistent with the compounded impact of systemic healthcare collapse, excessive workloads, and inadequate training. These findings highlight potential targets for structural reforms, including workload redistribution, improved training, and enhanced mental health support. Future research is needed to evaluate whether such interventions may reduce burnout and support the sustainability of Syria’s healthcare system. To our knowledge, this is the first multi-governorate application of the Burnout Assessment Tool within Syria’s residency programs, offering a comprehensive baseline of exhaustion, cognitive, and emotional domains to inform monitoring and intervention planning moving forward.

Supporting information