FULL TEXT (html)
Issue: 2022, June, Volume 16, No 2
issue id: 2022_6_16_2
article id: 2022_6_16_2_16

Original Research



Original Research / Orijinal Araştırma


Burnout and Job Satisfaction Among Family Physician

Aile Hekimlerinde Tükenmişlik ve İş Doyumu

Özden Gökdemir1, Gamze Dağbağlı2, Olgu Aygün3, Ülkü Bulut Batur4, Azize Dilek Güldal5


Abstract
Aim: Burnout syndrome is a major problem, especially among health care workers. The higher the sense of individual skills and achievement, the lower the likelihood of burnout syndrome. The objective of the study is to measure the level of burnout and job satisfaction of family physicians. Methods: Both data of the Family Physicians (FPs) who are working in rural and urban has been included in the study. The study is designed to measure their level of burnout and job satisfaction using the Maslach Burnout Inventory, Minnesota Work Satisfaction Questionnaire. Their relationship with the working area and other factors is also analyzed. Results: Maslach depersonalization subscale was found to be significantly higher in those who lived alone, those who defined their location as rural, and those who did not participate in continuing medical education (CME) (p=0.02, p=0.01, p=0.03). While Maslach personal achievement score was low in those who define their location as rural (p=0.01) it was found to be higher in women and those who did not participate in CME (p=0.02, p=0.03). In addition, as age increases, Maslach emotional burnout and depersonalization scores decrease and personal success scores increase (r =-0.169, -0.205, 0.163 and p=0.00, p=0.00, p=0.00). Conclusions: Emotional and total burnout scores decreased with age, and that attending CME increased personal achievement. CME could be a beneficial tool not only to support FPs but also to prevent burnout.
Key words: family physicians, burnout, job satisfaction.


Özet
Amaç: Tükenmişlik sendromu özellikle sağlık çalışanları arasında önemli bir sorundur. Bireysel beceri ve başarı duygusu ne kadar yüksekse, tükenmişlik sendromu olasılığı o kadar düşüktür. Araştırmanın amacı, aile hekimlerinin tükenmişlik ve iş doyum düzeylerini ölçmektir. Yöntemler: Çalışmaya kırsal ve kentsel alanda çalışan aile hekimlerinin verileri dahil edilmiştir. Çalışma, Maslach Tükenmişlik Envanteri, Minnesota İş Doyum Anketi kullanılarak tükenmişlik ve iş doyum düzeylerini ölçmek için tasarlanmıştır. Çalışma alanı ve diğer etmenlerle ilişkileri de incelenmiştir. Bulgular: Maslach duyarsızlaşma alt ölçeği, yalnız yaşayanlarda, bulunduğu yeri kırsal olarak tanımlayanlarda ve sürekli tıp eğitimine (STE) katılmayanlarda (p=0,02, p=0,01, p=0,03) anlamlı olarak daha yüksek bulundu. Maslach kişisel başarı puanı, bulunduğu yeri kırsal olarak tanımlayanlarda düşük (p=0,01) iken, kadınlarda ve STE'ye katılmayanlarda daha yüksek bulundu (p=0,02, p=0,03). Ayrıca yaş arttıkça Maslach duygusal tükenmişlik ve duyarsızlaşma puanları azalmakta ve kişisel başarı puanları artmaktadır (r =-0,169, -0,205, 0,163 ve p=0,00, p=0,00, p=0,00). Sonuçlar: Duygusal ve toplam tükenmişlik puanları yaşla birlikte azalmaktadır. STE'ye katılmanın kişisel başarıyı artırdığı görüldü. STE, yalnızca aile hekimlerini desteklemek için değil, aynı zamanda tükenmişliği önlemek için de yararlı bir araç olabilir.
Anahtar kelimeler: aile hekimleri, tükenmişlik, iş doyumu.



Geliş tarihi / Received: 03.08.2021    Kabul tarihi / Accepted: 08.04.2022

1Izmir University of Economics, Faculty of Medicine, Department of Family Medicine / Türkiye
2İzmir Bayraklı 7 Nolu Fuat Edip Baksı ASM / Türkiye
3İzmir Bozyaka Eğitim ve Araştırma Hastanesi / Türkiye
4Aksaray Üniversitesi Tıp Fakültesi Aile Hekimliği Anabilim Dalı / Türkiye
5Dokuz Eylül Üniversitesi Tıp Fakültesi / Türkiye

Address for Correspondence / Yazışma Adresi: Özden Gökdemir, Izmir University of Economics, Faculty of Medicine, Department of Family Medicine, Türkiye
gokdemirozden@gmail.com

Gokdemir O, Dagbagli G, Aygun O, Batur UB, Guldal AD. Burnout and Job Satisfaction Among Family Physician. TJFMPC, 2022;16(2): 376-384

DOI: 10.21763/tjfmpc.977985





Introduction
The term 'Burnout' was first defined by Freudenberger in 1974; as a state of mental and physical exhaustion caused by one's professional life.1
It is also emphasized that 'Burnout is a global concern and work-related stress has the potential to negatively affect the individual’s psychological and physical health, as well as an organization’s effectiveness'.2,3,4,5
Burnout is a social situation that negatively affects individuals, their institutions, and their environment. Studies on this issue show that burnout causes serious problems, leading to job loss, various social problems, and even psychiatric diseases.6 Many factors related to burnout are related variously to individual, social, and work issues. It has been determined by various studies that factors affecting burnout include age, gender, marital status, education, family structure, social support level, workload, and structure of the working system.7,8,9 The exhaustion of those working in the field of health has special importance due to the particular group they serve. The exhaustion of physicians may cause misjudgments in the treatment of patients, which lowers the quality of healthcare. Studies report that burnout is intense among healthcare professionals.10,11 Among the causes of burnout in healthcare professionals are factors such as dealing with patients, the intense nature of the work, workload, excessive responsibility, insufficient numbers and qualifications of staff working with patients of internal medicine, lack of time for self and private life, and unrealistic expectations.11,12

According to a meta-analysis of health workers in Turkey, women experience burnout more than men, shift workers more than day workers, singles more than married people, and nurses more than doctors.13 In another study among the nurses it was found that 52.80% of them had continuous sleep problems and 76.90% had chronic tiredness.14

Family physicians (FPs) in rural areas work in more isolated conditions and may receive consultations, referrals, etc. with more complicated cases. This is because life expectancy is shorter in rural areas, mortality rates are higher, and injuries, circulatory and respiratory diseases, diabetes, and suicide deaths are more common.1,12 The fact that they have to work alone with limited resources may also make patient management difficult and increase their workloads.

In Turkey, most of the researchers revealed that 'burn-out' is a significant problem for physicians.15,16,17 Yılmaz et all reported that 'physicians working under the family medicine system, a new primary care model, are at greater risk of emotional exhaustion, but that no change has occurred in terms of personal accomplishment or depersonalization, despite this new system'.18 Atik et al. revealed that 'working conditions' were the main reason for burnout of chest physicians.19

Job satisfaction is defined as the satisfaction of employees with their job, and the positive emotional relating to their self-assessment of themselves and their work. Absence of job satisfaction may a facilitating factor, and, correspondingly, its presence may be protective against burnout syndrome.20 Pehlivanoğlu et al. revealed that 'younger pathologists are less satisfied' and 'job satisfaction increases with the physical and technical quality of the pathology laboratory/institution, and years of experience'21 According to Yilmaz, 'the work satisfaction level of family physicians, who are on call and whose financial income expectation is not satisfied, was found low. It is seen that there is a strong correlation between the inadequacy of work satisfaction with burnout and anxiety, depression'.22 Kare et al. reported that rural healthcare workers in the study area were dissatisfied with their jobs. It is recommended that strategies to stimulate and strengthen management recognition, supportive supervision, performance-based regular salary increments, and career development be implemented.23

Considering all these factors, this study was planned to investigate the burnout and job satisfaction levels and related factors of family physicians, including working field.

Material and Method
A descriptive cross-sectional study was planned.
Turkey Statistical Regional Units Classification was utilized to guarantee a balanced distribution of participation. This classification led to the division into 12 statistical zones, from which 643 people were randomly chosen. The respondents of at least 10% were intended after establishing the number of participants to be reached for each statistical region, as previously stated. For each region, the number of provinces that will meet 10 times the number of people to be reached is chosen at random.
Karakoç et al. reported as 3262 new units were defined, but 53,9% were not fulfilled.24 Study was conducted by electronic mail system. Reminders were sent to participants 10 and 20 days after the initial request. online data survey (survey monkey) sends and collects questionnaires The emails were sent before the daily practice had begun and had been sent six/ four times a month. There were no inclusion or exclusion criteria, the sample included all those who volunteered.

Data Collection Tools
'Age, gender, how many years you have been working in your profession, total population of the area you work in, how would you describe the area you work in (rural-urban), number of years working in rural areas, average number of patients seen per day, population in your unit' were the questions for the sociodemographic data and also open-ended questions were added to better understand the level of job satisfaction and burn-out.

Maslach Burnout Inventory (MBI): This inventory, developed by Maslach and Jackon, was used. Turkish version of the inventory was conducted by İnce and Şahin (consisting of 22 items and 3 dimensions - emotional exhaustion, depersonalization, and personal success).25 The level of burnout is calculated by evaluating each score obtained from the subscales separately, rather than with a single score.
Cronbach Alpha coefficient, calculated separately for each dimension, was 0.88 for emotional exhaustion, 0.78 for the depersonalization dimension, and 0.74 for the personal success dimension.25,26
In the scoring key of the inventory, the emotional fatigue dimension has the highest score of 54, followed by the personal achievement dimension with 48 points and the depersonalization dimension with 30 points. In terms of personal achievement, the low-level burnout is the inverse of high scoring. In other words, participants who score low on this dimension are more likely to get burned out. personal achievement. It is also characterized as a sense of failure or diminished personal success due to the inverse relationship between the scoring and interpretation of the It is also characterized as a sense of failure or diminished personal success due to the inverse relationship between the scoring and interpretation. The item's lowest possible score is '0,' and its best possible value is '6.'26

Minnesota Job Satisfaction Survey (MSQ): This was developed by Weiss et al. in 1967, and the number of questions on the scale was later reduced from 100 to 20 by combining items related to internal and external satisfaction. The scale was translated into Turkish in 1988, and its validity and reliability studies were conducted and used to determine the job satisfaction levels of those working in the industry.27,28 Minnesota Job Satisfaction Scale is a five-point Likert-type scale, scored between 1 and 5, as follows: 'not satisfied at all, 1 point; not satisfied, 2 points; undecided, 3 points; satisfied, 4 points; very satisfied, 5 points'. The scale consists of 20 items with characteristics that determine the level of internal, external, and general job satisfaction. The overall job satisfaction score is obtained by dividing the total scores obtained from 20 parameters by 20, the internal satisfaction score by dividing the total scores obtained from the parameters that constitute the internal factors by 12, and the external satisfaction score by dividing the total scores obtained from the parameters that constitute the external factors by 8. All subgroups point averages are calculated as a value between 1.0 and 5.0. As a percentage value, 25% and below represents low job satisfaction, 26-74%, medium, and 75%, higher.29

Data Analysis: Data is analyzed by using SPSS 22.0 package program. In data analysis, frequency and percentage distributions, chi-square analysis, and t-test were used, p <0.05 value is accepted as a statistical significance level.

Results
522 respondents’ answers were obtained from the online survey database in total. Although there weren’t any exclusion criteria; 26 participants who did not complete the online questionnaire, and four participants with extreme values were excluded from the dataset. As a result, 492 participants were included in the study.

Participants’ mean age was 43.67±8.39, and 23.6% were female (n=116). Mean number of years in profession was 18.31±8.59, and number of daily consultations was 53.88±22.18, and number of registered patients was 3408.63±740.53. Other sample characteristics are shown in Table 1. Participants were also asked about factors that might affect their job satisfaction and burnout. The results of these questions are shown in Table 2.








Participants’ Minnesota Satisfaction Questionnaire scores, Maslach Burnout Inventory scores, and score rates are shown in Table 3 and Table 4.








Comparative Analysis
1. Maslach Burnout Inventory:
Maslach depersonalization subscale was found to be significantly higher in those who lived alone, those who defined their location as rural, and those who did not participate in continuing medical education (CME) ((p=0.02, p=0.01, p=0.03)). While Maslach personal achievement score was low in those who define their location as rural (p=0.01), it was found to be high in women and those who did not participate in CME (p=0.02, p=0.03).
Maslach emotional load score was also found high in those who did not participate in CME.
No significant difference was observed between the scale scores in terms of the item which defined location as rural or urban, according to the population size and the amount of time spent outside urban areas.
Maslach depersonalization, and emotional burnout scores were low and personal achievement scores were high for those whose expectations of primary care work were met, those without language problems with their patients, and those in their preferred locations. Similar results were obtained when these parameters were compared for those in rural and urban areas.
In addition, as age increases, Maslach emotional burnout, and depersonalization scores decrease and personal success scores increase, although the relationship is weak (r =-.169, -.205, .163 and p=0.00, p=0.00, p=0.00).
2. Minnesota Job Satisfaction Scale:
Those who have their expectations met by primary care work, who have no local language problems with their patients, and those who are happy with their location scored high on Minnesota total and subscales (p=0.00 p=0.00, p=0.00).There is a strong negative relationship between Minnesota job satisfaction scale subscales and total scores and Maslach emotional burnout and depersonalization subscales ( r and p values, and there is a strong but positive relationship with personal success score (emotional burnout r=-0.574, r=-0.487, r=-0.568 p=0.00, p=0.00, p=0.00; depersonalization r=-0.435, r=-0.368, r=-0.430 p=0.00, p=0.00, p=0.00; personal success r=0.475, r= 0.380, r=0.459 p=0.00, p=0.00).
The comparative analyses are shown in Table 5.





Discussion
1. In Turkey, the Turkish medical association reported that, emotional exhaustion scores were higher among physicians aged 35-44, and that the desensitization score was highest in the 25-34 age group and decreased with age.30 In Öztürk's study, the burnout scores of young and short-term physicians were shown to be higher31. Our results were aligned with these studies. In the study of Bugdayci, it was determined that desensitization and emotional exhaustion scores decrease with increasing age.32 All these studies show that young physicians are more prone to burnout. Similarly, in our study, it was shown that emotional and total burnout scores decreased with age.
2. CME In the research of Babbot et al., one of the reasons for high burnout scores and low job satisfaction scores was excessive paperwork.33 In contrast, in our study, one of the main associations was being single and not attending CME. Aygun et al. revealed that attending CME and being competent were protective factors for burnout syndrome among FPs.34 Reedy et al. reported that palliative care physicians who participate in CME were more likely to avoid burnout than those who did not.35 In our study, FPs who actively participated in CME had lower desensitization, higher personal achievement, and lower emotional load scores. This result is expected because, in addition to developing medical knowledge and skills, CME has the effect of reinforcing feelings of belonging and social relationships. Opportunities for attending CME could be one solution for preventing burnout.

However, it is noteworthy that the personal success is high in those who do not participate in CME. A possible interpretation is that those who regard themselves as personally successful do not feel the need to participate in these activities. However, in environments without much competition, it is uncertain how objectively people will be able to evaluate their success.

In Turkey, the 'rural definition' of the participants did not accord with the 'Village Law of 1924', according to in which, settlements with a population of less than 20,000 were defined as rural areas.36 51% of them described their working place as rural, while in fact, only 33.9% lived areas with less than 20,000. We know that there are rural areas within cities. Physicians’ definition of rural may be places with limited opportunities to reach other health or social facilities and share their workload. In our study: the issue of participants’ definition of the location of their work was based on this concept. Thus, the definition of the countryside should be reviewed in line with physicians’ perceptions. Rural burnout is a problem for healthcare workers, Pinikahana and Happell reported that most rural psychiatric nurses’ emotional exhaustion and depersonalization scores were low. The same root reason was reported for the nurses as ‘workload’ and ‘inadequate preparation’.37 In our study, Maslach desensitization subscale was found to be significantly higher in those who defined the place they live in as rural, and their achievement score was similarly low.

Social determinants of health (income, expenses, housing, safety, language, literacy, hunger, etc) are very important in achieving health equity, and family physicians share these with their communities throughout the health journey.38,31 FPs without no language problems with their patients where they live were more satisfied with their job, their emotional burnout scores were low, and personal achievement scores were high. Appropriate communication is another key factor in preventing burnout. Communication skills and intercultural competencies are important not only for patients’ health but also for the physicians’ well-being.39

In our study, those who have their expectations met by primary care work, and who have no language problems with their patients, scored higher on the Minnesota Job Satisfaction Scale (total and subscale). These results seem to reflect the accuracy of Maslow’s theory.40
In our study, time spent working in a rural area was not found to be an effective factor in burnout scores. However, an important result of our study is that emotional exhaustion and depersonalization subscales’ scores decrease with service time increase.

Conclusion
In our study, it was shown that emotional and total burnout scores decreased with age, that attending CME increased personal achievement and decreased the emotional load, and that desensitization increases with longer service time, causing a decrease in emotional exhaustion and depersonalization subscales’ scores. Continuing Medical Education (CME) may be effective to facilitate physicians. Besides providing learning outcomes, CME has long-term benefits in the prevention of 'burnout'.






Kaynaklar
1. Freudenberger HJ. Staff Burn-out. J Healthc Qual. 1982;4(4):6-8. doi:10.1111/j.1945-1474.1982.tb00486.x
2. Vázquez-Cabrera FJC-A and C. Burnout Syndrome in an International Setting. Burn Expert Prev Context Living Work. 2013;(July):1-257. doi:10.1007/978-1-4614-4391-9
3. Metlaine A, Sauvet F, Gomez-Merino D, et al. Sleep and biological parameters in professional burnout: A psychophysiological characterization. PLoS One. 2018;13(1):1-15. doi:10.1371/journal.pone.0190607
4. Tan S, Zhen E, Amatullah T, Mohd MT. Mental Health Status of Healthcare Workers in Primary Health Clinics in Sepang.
5. Vachon M, Papineau M, Dupuis G, Roberge P. Associations Between Systemic Quality of Life and Burnout Among French Canadian Workers. Soc Indic Res. 2019;142(3):1193-1210. doi:10.1007/s11205-018-1944-x
6. Balcıoğlu İ, Memetali̇ S, Rozant R, et al. Tükenmişlik Sendromu Burn out Syndrome. 2008;83.
7. Jiang H, Huang N, Jiang X, Yu J, Zhou Y, Pu H. Factors related to job burnout among older nurses in Guizhou province, China. PeerJ. 2021;9:e12333. doi:10.7717/peerj.12333
8. Kim SO, Moon SH. Factors influencing turnover intention among male nurses in Korea. Int J Environ Res Public Health. 2021;18(18). doi:10.3390/ijerph18189862
9. Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care-associated infection. Am J Infect Control. 2012;40(6):486-490. doi:10.1016/j.ajic.2012.02.029
10. De Hert S. Burnout in healthcare workers: Prevalence, impact and preventative strategies. Local Reg Anesth. 2020;13:171-183. doi:10.2147/LRA.S240564
11. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. [Summary for patients in Ann Intern Med. 2002 Mar 5;136(5):I29; PMID: 11874329]. Ann Int Med. 2002;136(February 2001). www.acponline.org/careers/catalog_resources.htm.%0Ahttps://doi.org/10.7326/0003-4819-136-5-200203050-00008
12. Kondro W. The view from the North. CMAJ. 2012;184(13):895-896. doi:10.1503/cmaj.109-4262
13. Çakır, Özlem; Tanğ Y. Türkiye’de Sağlık Çalışanlarında Tükenmişlik Sendromu: Bir Meta Analiz Çalışması. 'İş, Güç' Endüstri İlişkileri ve İnsan Kaynakları Derg. 2018;20:39-59.
14. Erdoğan P. İş tatmini ile tükenmişlik ilişkisi : B ir meta - analiz çalışması The relationship between job satisfaction and burnout : A meta - analysis study. 2021;9:405-425.
15. Hacer TY, Ali A. Burnout in physicians who are exposed to workplace violence. J Forensic Leg Med. 2020;69(October 2019):101874. doi:10.1016/j.jflm.2019.101874
16. Elay G, Bahar I, Demirkiran H, Oksüz H. Severe burnout among critical care workers in Turkey. Saudi Med J. 2019;40(9):943-948. doi:10.15537/smj.2019.9.24520
17. Dinibutun SR. Factors associated with burnout among physicians: An evaluation during a period of COVID-19 pandemic. J Healthc Leadersh. 2020;12:133-134. doi:10.2147/JHL.S284907
18. Yılmaz S, Calikoglu EO, Kosan Z, Aras A. Burnout among family physicians in Turkey: A comparison of two different primary care systems. Niger J Clin Pract. 2019;22(September):1070-1077. doi:10.4103/njcp.njcp
19. Atik M, Uçan ES, Ellidokuz H, Alptekin K. Burnout in chest physicians after health care reforms: A cross-sectional study in Turkey. Turkish Thorac J. 2019;20(1):18-24. doi:10.5152/TurkThoracJ.2018.18041
20. Özder G, Pak H, Gokdemir O. İş doyumu , stresle başaçıkma stilleri ve iş gören profilleri arasındaki ilişkinin kesitsel bir incelemesi [ A cross-sectional investigation of the relationship among job satisfaction ... 2020;(February). https://www.researchgate.net/profile/Ozden_Gokdemir/publication/339127608_Is_doyumu_stresle_basacikma_stilleri_ve_isgoren_profilleri_arasindaki_iliskinin_kesitsel_bir_incelemesi_A_cross-sectional_investigation_of_the_relationship_among_job_satisfaction_st
21. Pehlivanoglu B, Hassoy H, Gul G, Aykutlu U, Doganavsargil B. How does it feel to be a pathologist in turkey? Results of a survey on job satisfaction and perception of pathology. Turk Patoloji Derg. 2021;37(1):37-39. doi:10.5146/tjpath.2020.01513
22. Yilmaz A. Burnout, job satisfaction, and anxiety‑depression among family physicians: A cross‑sectional study. J Fam Med Prim Care. 2018;7:952-956. doi:10.4103/jfmpc.jfmpc_59_18
23. Kare AP, Gujo AB, Yote NY. Job Satisfaction Level and Associated Factors Among Rural Health Extension Workers of Sidama Region, Southern Ethiopia. Heal Serv Res Manag Epidemiol. 2021;8:1-7. doi:10.1177/23333928211051832
24. Karakoç FY, Emek M. The vacancy of the family practice units openıng for the inter-provincial placement and the factors affecting vacancies in Turkey. Türkiye Aile Hekim Derg. 2019;23(3):118-127. doi:10.15511/tahd.19.00318
25. Maslach C, Goldberg J. Prevention of burnout: New perspectives. Appl Prev Psychol. 1998;7(1):63-74. doi:10.1016/S0962-1849(98)80022-X
26. İnce NB, Şahin AE. Maslach Tükenmişlik Envanteri-Eğitimci Formu’nu Türkçe’ye Uyarlama Çalışması. Eğitimde ve Psikolojide Ölçme ve Değerlendirme Derg. 2015;6(2):385-399. doi:10.21031/epod.97301
27. Weiss DJ, Dawis R, England G, Lofquist L. Manual for the Minnesota Satisfaction Questionnaire. Man Minnesota Satisf Surv. Published online 1967:125.
28. Tözün M, Çulhacı A, Ünsal A. The Job Satisfaction of Physicians That Working in Primary Health Care Institutions in Family Medicine System (Eskişehir). TAF Prev Med Bull. 2008;7(5):377-384.
29. Soler JK, Yaman H, Esteva M, et al. Burnout in European family doctors: The EGPRN study. Fam Pract. 2008;25(4):245-265. doi:10.1093/fampra/cmn038
30. Aslan DDD, Kiper PDN, Karaağaoğlu PDE, Topal DF, Güdük DM, Cengiz DÖS. Türkiye’de Tabip Odalarına Kayıtlı Olan Bir Grup Hekimde Tükenmişlik Sendromu Ve Etkileyen Faktörler.; 2015. https://www.ttb.org.tr/kutuphane/tukenmislik.pdf
31. Manhire-Heath R, Cormack D, Wyeth E. ’ ...but i just prefer to treat everyone the same... ’: General practice receptionists talking about health inequities. Aust J Prim Health. 2019;25(5):430-434. doi:10.1071/PY19026
32. Buğdaycı R, Kurt AÖ, Şaşmaz T, Öner S. Mersin İlinde Pratisyen ve Uzman Hekimlerde Depresyon Sıklığı ve Etkileyen Faktörler. Toplum Hekim Bülteni. 2009;26(1):3-6.
33. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: Results from the MEMO Study. J Am Med Informatics Assoc. 2014;21(E2):100-106. doi:10.1136/amiajnl-2013-001875
34. Aygun O, Mevsim V. The impact of family physicians’ thoughts on self-efficacy of family physician’s core competencies on burnout syndrome in İzmir: A nested case-control study. Niger J Clin Pract. 2019;22(2):167-173. doi:10.4103/njcp.njcp_77_18
35. Reddy SK, Yennu S, Tanco K, et al. Frequency of Burnout Among Palliative Care Physicians Participating in a Continuing Medical Education Course. J Pain Symptom Manage. 2020;60(1):80-86.e2. doi:10.1016/j.jpainsymman.2020.02.013
36. Eldem H. Yerel Yönetimler Reformunun Bir Parçası Olarak Köy Kanunu Tasarı Taslağı. Optim Ekon ve Yönetim Bilim Derg. 2015;2(1):39-61. doi:10.17541/oeybd.01543
37. Pinikahana J, Happell B. Stress, burnout and job satisfaction in rural psychiatric nurses: A Victorian study. Aust J Rural Health. 2004;12(3):120-125. doi:10.1111/j.1440-1854.2004.00572.x
38. Artiga S, Hinton E. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity | The Henry J. Kaiser Family Foundation. Kaiser Fam Found. 2018;(May). https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
39. Wakuma C, Teresa E. Language as a Barrier to Health Care for Oromo Speaking Patients in Hospitals: A Case Study on Jimma and Wollega Public Hospitals. Int J Multicult Multireligious Underst. 2020;6(6):693. doi:10.18415/ijmmu.v6i6.1304
40. McLeod S. Maslow ’ s Hierarchy of Needs Maslow ’ s Hierarchy of Needs. Business. Published online 2018:3-5.

















TJFMPC
Turkish Journal of Family Medicine
& Primary Care

e-ISSN: 1307-2048
© 2016 www.tjfmpc.gen.tr

Browser?
44.192.114.32
07.07.2022 / 10:09