According to the World Health Organization’s classification, physician burnout is an occupational phenomenon (WHO, 2019) that is common among doctors, generally caused by long-term workplace stress and occupational injury. It is characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment. Occupational burnout is recognized through impulsivity toward work and one’s professional life. It has a major overlap with major depressive disorder, and it can manifest in many ways including fatigue, exhaustion, cynicism, anxiety, depression, irritability, insomnia, and the inability to concentrate (Van Dierendonck et al. Reference Van Dierendonck, Schaufeli and Sixma1994; Gundersen, Reference Gundersen2001; Kalani et al. Reference Kalani, Azadfallah, Oreyzi and Adibi2018; Schwenk & Gold, Reference Schwenk and Gold2018; Oquendo et al. Reference Oquendo, Bernstein and Mayer2019).
Physician burnout is one of the major problems in healthcare and medical education systems around the world. Different studies show the widespread and increasing trend of physician burnout. This can lead to threats to the doctor’s health; and consequently, it lowers their quality of life, reduces the efficiency of their work, damages the economy, increases medical errors, and also impacts negatively on the patient’s outcomes (Halbesleben & Rathert, Reference Halbesleben and Rathert2008; Azam et al. Reference Azam, Khan and Alam2017; Rothenberger, Reference Rothenberger2017).
Burnout in healing professionals is a phrase that was introduced in 1974 by Herbert Freudenberger, an American psychologist. It has, since then, attracted a lot of attention in the medical world (Freudenberger, Reference Freudenberger1974; Rothenberger, Reference Rothenberger2017). Although the term ‘burnout’ has been around for about 50 years, this does not mean that this phenomenon did not exist before. Some cases of job-burnout in earlier writings have been described (Maslach et al. Reference Maslach, Leiter, Schaufeli, Cartwright and Cooper2008). Furthermore, some researchers suggest that the understanding of this concept has probably existed since the time of Aristotle and Hippocrates (Holoshitz & Wann, Reference Holoshitz and Wann2017). It is also believed by some researchers that the concept of equilibrium in order to prevent burnout in Freudenberger’s thoughts is related to the concept of equilibrium in the humoral theory of the ancient Greeks (Friberg, Reference Friberg2009). On the other hand, in ancient times, doctors were respected and they received special economic and social support. One of the possible reasons for this may be the understanding of the importance of physician burnout in ancient times. They wanted to prevent it. Despite the many studies conducted on physician burnout, a few studies have been found on the history of physician burnout in ancient times. Thus, the present article aimed to study physician burnout from a historical point of view.
Adab al-Tabib (Practical Ethics of the Physician) is a historic and well-known work of Ishaq ibn Ali al-Ruhawi (9th century AD), a pioneer in medical ethics, who wrote significant content on medical ethics, law, and social medicine (Levey, Reference Levey1967; Padela, Reference Padela2007; Chamsi-Pasha & Albar, Reference Chamsi-Pasha and Albar2016). This book is one of the first works which made a reference to the physician burnout close to 11 centuries ago, with a detailed and accurate discussion of physician burnout and the ways of preventing it.
For the first time, this study presents historical evidence about physician burnout in the medieval Islamic golden age from the perspective of Ruhawi in his book Adab al-Tabib. In this article, through the simultaneous review of the Arabic version of Adab al-Tabib (Al-Ruhawi, Reference Al-Ruhawi2008) and its English (Levey, Reference Levey1967) and Persian translation (Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011), the concept of physician burnout, its causes and preventive strategies from the perspective of Ruhawi were reviewed and subsequently compared with findings from the new studies.
A brief biography of Ishaq ibn Ali al-Ruhawi and his brilliant work, Adab al-Tabib
Based on limited historical evidence about Ishaq ibn Ali al-Ruhawi, he was a physician and an author in the early Islamic golden era. He was born in the city of Ruha, a historical city in Mesopotamia area which is today called Urfa, in the second half of the 3rd century AH (9th century AD) (Levey, Reference Levey1967; Sadeghi & Ghaffari, Reference Sadeghi and Ghaffari2017). Al-Ruhawi is the author of the precious book Adab al-Tabib written in Arabic with a version translated to English by Martin Levey in 1967 (Levey, Reference Levey1967).
Adab al-Tabib is a historical and valuable book on the subject of medical ethics, which is recognized as one of the most valuable historical books that examines the major issues of medical ethics in depth. In this book, al-Ruhawi, with a problem-centered view, discussed the ethical, legal, and social issues related to physicians in that era, and some matters are valid today (Padela, Reference Padela2007; Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011; Sadeghi & Ghaffari, Reference Sadeghi and Ghaffari2017). According to the preamble of Adab al-Tabib, Ishaq ibn Ali al-Ruhawi provided the necessary ethical rules and proper behavior of doctors as well as the preventive measures to be followed to maintain health (Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011: 38, 39). The book Adab al-Tabib consists of 20 chapters which covers areas like medical and health sciences, the role of medicine and physicians, the sanctity of physicians, the principles of professional medical ethics, the responsibilities of the community toward doctors, and the recommendations to patients’ companions and visitors (Padela, Reference Padela2007; Sadeghi & Ghaffari, Reference Sadeghi and Ghaffari2017).
Physician burnout in Adab al-Tabib
Al-Ruhawi in Adab al-Tabib considered a sacred and unique position for the physician who was his original focus. He examined issues related to the individual, occupational, and social life of the physician from a problem-based perspective and in each case, he presented practical solutions to the challenges that a physician may come across (Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011).
From Ruhawi’s point of view, physician’s health is a remarkable issue and thus he emphasized the various aspects of the health of physicians, including their physical, mental, and spiritual health, and required them to adhere to the principles of healthy lifestyle (Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011).
While there is no exact vocabulary equivalent to physician burnout in Adab al-Tabib, it is nonetheless almost impossible to find an equivalent term for 20th century physician burnout from a book written a thousand years ago, evidence is presented below that shows Ruhawi’s understanding of job-related stress and physician burnout.
In a statement from the second chapter of Adab al-Tabib, Ruhawi talked about occupational diseases and their impact on human health. He stated thus:
The physician must know how each craft affects the human complexion – how it affects the sick and healthy, the maintenance of health by suitable means, and the cure of the sick from what is harmful. (Levey, Reference Levey1967: 45)
In the 19th chapter of Adab al-Tabib, Ruhawi narrates some stressful scenarios of physicians that may result from aggressive behaviors and reactions of patients and companions (Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011). This is probably one of the first descriptions of job-related stress. More specifically, in the final chapter of the book, Ruhawi talks about doctor’s self-care, an exceptional topic which is probably one of the first descriptions, and predicted the physician situation that is almost similar to what we now call physician burnout. Then, Ruhawi suggested ways to prevent doctors from getting into such a situation. He wrote in this regard:
When the physician errs in his affairs, he however loses his sense of judgment which is dispersed in his search after his wants. Harm results from this, in his treatment of the healthy and ill. For this reason, it is important that whoever needs his care is aware of his affairs, try to do enough for him such that his soul is at ease and at rest, and then, be devoted to public affairs. For this reason, the physician must not treat a healthy or sick person until he first quiets any irrational opinion and giving his [own] soul and body what they need. With regard to the peace of his [own] soul, this involves its reassurance in regard to frightening matters. As to the body, it must be well preserved together with all its senses; not being hungry or thirsty, and making use of a suitable perfume. Similarly, his senses relax by that; his soul is then cheerful, his reason is clarified, his senses are cleared of all turbidity, his opinion is clarified, and his advice is clear. When this is obvious to you, happy physician, then you are ready for any remuneration. (Levey, Reference Levey1967: 92–93)
Besides, Ruhawi, in his book, refers to physicians who have become unmotivated and are uninterested in studying specialized medical books. He, also, refers to doctors who turn to other businesses and thus lose the opportunity to learn medical knowledge. He described this group of physicians as very dangerous to the health system and patients (Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011). It seems that these groups of doctors had some degree of emotional exhaustion and reduced personal accomplishment. Most importantly, Ruhawi introduced preventive strategies for physicians that are consistent with recent scientific findings on the causes of burnout in doctors and its prevention. They are referred to below.
Physicians’ job characteristics and burnout
Recent studies highlighted the important impact of job conditions on burnout among physicians (Bhutani et al. Reference Bhutani, Bhutani, Balhara and Kalra2012; Bernburg et al. Reference Bernburg, Vitzthum, Groneberg and Mache2016). Job satisfaction is a determining factor in burnout and characteristics like income and economic-well-being of household have a significant effect on job satisfaction (Tarcan et al. Reference Tarcan, Hikmet, Schooley, Top and Tarcan2017). Low income can lead to more burnout among physicians (Azam et al. Reference Azam, Khan and Alam2017; Li et al. Reference Li, Zuo, Gelb, Zhang, Zhao, Yao, Xia and Huang2018). Ruhawi is aware of this fact and has thus paid ample attention to the economics and income of the doctor. He believed that if the doctor’s financial needs are not met, he will tend to other professions and will consequently be deprived of gaining more knowledge and skills. He wrote in this regard:
Since the wealthy and the people profit by the art of the physician, it is necessary that the former strengthen the physician with food, garb, and coins so that his soul and body may benefit. When the wealthy do not carry out justice as we have mentioned, then, it is necessary that the physician ask for assistance in other ways. If he must engage in another vocation to gain his coin, then, he must turn aside from medicine which eventually decreases his understanding and knowledge of the field. (Levey, Reference Levey1967: 94)
An important point in Ruhawi’s view was his critical advice to physicians to observe moderation in making money. This can help physicians reduce the tensions of greed for more money (Larrimore, Reference Larrimore2011). On the other hand, the challenging relationship between doctors and patients can increase the stress and anxiety of doctors and have a negative impact on the physician’s performance and job satisfaction (Hardavella et al. Reference Hardavella, Aamli-Gaagnat, Frille, Saad, Niculescu and Powell2017). In addition, encounters with difficult patients are a known cause of burnout in physicians (An et al. Reference An, Manwell, Williams, Laiteerapong, Brown, Rabatin, Linzer, Schwartz, Lally and Linzer2013). Ruhawi, with a complete understanding of this, taught physicians the principles and skills of relationship with the patients and how to prevent challenging situations. In the 19th chapter of Adab al-Tabib, he described the stressful and challenging situations of a doctor, which resulted from the misunderstanding and pessimism of patient’s family. In order to prevent such stressful situations, ‘Ruhawi’ suggested the physician provide effective education to both the patients and his nurses and ensure the mental well-being of the patients and his fellows before starting a treatment plan. Mutually, he required the patient to follow the physician’s instructions and provided recommendations in this regard in chapter nine of his book (Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011: 236–240).
Nowadays, physically or chemically hazardous factors related to working conditions are considered (Lee et al. Reference Lee, Park, Min, Min, Hwang, Leem, Kim, Jeon, Heo and Moon2014). It is noteworthy that these factors have not been ignored by Ruhawi. He cleverly pointed out the effect of bad smells on health and urges the physician not to expose themselves to the bad smell of patients and their body secretions. He also expected the physician to avoid the inhalation of funky medicines (Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011: 84–86), which were likely to contain harmful chemical ingredients.
Healthy lifestyle and physician burnout
Having a healthy lifestyle for physicians is one of the strategies to prevent burnout (Azam et al. Reference Azam, Khan and Alam2017). Recent studies have suggested positive effects of physical exercise on the prevention of physician burnout (See et al. Reference See, Lim, Kua, Phua, Chua and Ho2016; Shenoi et al. Reference Shenoi, Kalyanaraman, Pillai, Raghava and Day2018); on the other hand, the relationship between some lifestyle-related risks such as sleep deprivation and burnout has been suggested (Suzuki, Reference Suzuki2017; Hannan et al. Reference Hannan, Breslin, Doherty, McGreal, Moneley and Offiah2018). According to a comprehensive survey from seven European countries, health behaviors have a prominent role in preventing burnout in health professionals, and there is a significant relationship between some health-impairing behaviors including higher fast-food consumption, infrequent exercise, higher alcohol consumption, and more frequent painkiller use and burnout (Alexandrova-Karamanova et al. Reference Alexandrova-Karamanova, Todorova, Montgomery, Panagopoulou, Costa, Baban and Mijakoski2016).
From the perspective of Ruhawi, physicians must care more about their health than the general public, because more harm is caused to the society as a result of their diseases. Ruhawi devoted a large part of his book to the medical and health recommendations that physicians, specifically as well as the patients, are required to observe. Ruhawi emphasized some issues to be observed by physicians including: avoiding overeating and consuming unhealthy foods, avoiding getting drunk and extreme drunkenness, avoiding drug abuse, observing personal hygiene, choosing the right place to live, having moderate sleep, and exercising (Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011). On the other hand, a good work-life balance and adequate vacation time are factors that prevent physician burnout (Banerjee et al. Reference Banerjee, Califano, Corral, de Azambuja, De Mattos-Arruda, Guarneri, Hutka, Jordan, Martinelli, Mountzios, Ozturk, Petrova, Postel-Vinay, Preusser, Qvortrup, Volkov, Tabernero, Olmos and Strijbos2017). In this context, Ruhawi believed that a physician must not ignore having enough rest, balanced relaxation, and meeting the basic needs of life. He said:
When a physician has attended to the needs of the people, then he pays attention to bodily matters by bathing, eating, and drinking. These are done in proportion according to what is best for him in quantity and quality, and according to the time and place. (Levey, Reference Levey1967: 55)
Notably, he talked about the work-life balance of a physician: ‘The physician must divide his day and night time according to his needs and practice (Levey, Reference Levey1967: 54).’ In addition, some studies suggested a higher incidence of burnout in single physicians than in married ones (Wang et al. Reference Wang, Xie, Dai, Zhang, Huang and Chen2014; Azam et al. Reference Azam, Khan and Alam2017); and some studies supported the higher incidence of burnout in physicians who do not have a child (Azam et al. Reference Azam, Khan and Alam2017). Interestingly, Ruhawi encouraged physicians to marry and have children (Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011).
Mental health and physician burnout
Mental health, as a great component of doctor well-being, is closely correlated with burnout. Studies show that if a physicians’ mental health improves, then the risk of burnout will be reduced (Wang et al. Reference Wang, Liu, Wang and Wang2012; Győrffy et al. Reference Győrffy, Dweik and Girasek2016; Kleiner & Wallace, Reference Kleiner and Wallace2017; Lacy & Chan, Reference Lacy and Chan2018). The mental health of physicians is one of the most important issues of concern in Ruhawi’s view. In the form of moral advice, he encouraged physicians to be patient, kind, and to practice stress management, munificence, an increasing tolerance to problems, and the reverence of patients.
Studies have shown that physicians are at risk of mental health disorders (Győrffy et al. Reference Győrffy, Dweik and Girasek2016; Kleiner & Wallace, Reference Kleiner and Wallace2017). Despite that, there is no statistical estimation for the mental health status of physicians in Ruhawi’s era. It seems that Ruhawi had a similar understanding of the dangers of the physician concerning mental disorders. Therefore, he suggested the assessment of a physician’s mental health as a part of the physician’s professional competence exam that he designed and recommended (Sadeghi & Ghaffari, Reference Sadeghi and Ghaffari2017). In the 16th chapter, he wrote:
As to his concern with people, this springs from the strength of his character, his removal from the passion of being a head and chief, and from the passion of superiority, from being quarrelsome and obstinate. He must employ justice in his associations; he must treat people as he would like for himself, with much sympathy. It is well known that he must not be proud and to hurt [people] through this but he should like goodness for the sake of goodness alone. (Levey, Reference Levey1967: 85)
From Ruhawi’s point of view, the assessment of mental health in physicians is not limited to the physician’s professional competence exam. He is considered as having a normal status of mental health as one of the main prerequisites for admission to medicine. In this context, Ruhawi considered the children of doctors to be the most suitable individuals for studying medicine. This is because in addition to proper physical characteristics, they have a better level of morality and mental health than those in other occupations (Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011).
Social support and burnout
Social support is one of the concepts that has attracted a lot of attention in recent decades (Williams, Reference Williams2005). This complex concept refers to the emotional and interactive aspects of the individual in relation to others and how much the individual is protected and respected by his social networks (Cobb, Reference Cobb1976; Gottlieb, Reference Gottlieb1978; Williams, Reference Williams2005). Social support has a direct relationship with depressive symptoms in physicians, and it has an inverse relationship with their work ability (Bernburg et al. Reference Bernburg, Vitzthum, Groneberg and Mache2016). Social support is also known as a preventive measure of physician burnout (Voltmer & Spahn, Reference Voltmer and Spahn2009).
Interestingly, Ruhawi suggested that there should be social support of the physician in his book. He considered medicine to be a sacred profession, even higher than the kingdom, and it requires the public, the sick, the kings, and the government system to respect doctors and to observe their rights. The importance of the social support of physicians in Ruhawi’s view was so much that he wrote a chapter of his book on ‘how all people must respect a physician according to his skill. It is necessary he be honored more by royalty and virtuous people’ (Levey, Reference Levey1967: 71). Ruhawi, in this regard, said:
It is necessary that the king and everybody [else] know the value of the physician and the value of his art, honor him, show regard for him, and be intimate with him. He must not fear in his heart nor treat him in a way he doesn’t like; he must not calumniate him, envy him, and not accuse falsely. (Levey, Reference Levey1967: 73)
On the other hand, Ruhawi encouraged physicians to engage in effective social communication with intellectuals, scholars, and wise people, as communication skills are well-known preventive factors of professional burnout as found in new studies (Darban et al. Reference Darban, Balouchi, Narouipour, Safarzaei and Shahdadi2016; Penberthy et al. Reference Penberthy, Chhabra, Ducar, Avitabile, Lynch, Khanna, Xu, Ait-Daoud and Schorling2018).
Spiritual health and physician burnout
Spirituality is one of the most notable issues in Ruhawi’s view. He always encouraged physicians to maintain their religious beliefs and to strengthen their faith in God. He regarded spiritual communication with God and religious practices as one of the major requirements for a physician (Al-Ruhawi, Reference Al-Ruhawi, Anoushiravani, Shariat parsa, Pooti and Alimirzaie2011). Recent studies have indicated that religious commitment can improve mental and physical health (Anandrajah & Hight, Reference Anandrajah and Hight2001) and that there is a relationship between spirituality and the burnout of physicians (Doolittle et al. Reference Doolittle, Windish and Seelig2013). Furthermore, religion/spirituality can also be effective at preventing a physician’s maladaptive behaviors and medical malpractice (Salmoirago-Blotcher et al. Reference Salmoirago-Blotcher, Fitchett, Leung, Volturo, Boudreaux, Crawford, Ockene and Curlin2016).
Discussion
Although Adab al-Tabib is known as an ancient moral and ethical work, it has detailed, precise, and scholarly content on subjects related to the physician’s health, such as burnout. This is justifiable based on the supportive viewpoint of Ruhawi about physicians, in addition to patient support. Paying great attention to the various aspects of physician health and well-being makes Adab al-Tabib a unique book in comparison to other historical works in the field of medical ethics. This is because most of these works focus exclusively on patient rights, and they only refer to medical ethics and the ethical rules of communication with the patient.
There is a lot of content on physicians in ancient manuscripts from the golden age of Islamic medicine such as ‘Firdaws al-hikma’ (Paradise of Wisdom) by Ali ibn Rabban al-Tabari (9th century AD), ‘Al-Teb al-Rouhani’ by Rhazes (865–925 AD), ‘Kamel al-sanae al-tabie’ by Haly Abbas (949–982 AD), ‘Al-Mu’alajat al-Buqratiya’ by Abul-Hasan al-Tabari (10th century AD), and ‘Meftah al-teb’ by Ibn Hindu (10–11th century AD). Most of their focus was on sanctifying the medical status and respect for the physician, medical ethics, the proper etiquette of doctors, medical professionalism, and doctor–patient communications. These ancient resources provided recommendations on the physician’s lifestyle, mental, and spiritual health that could be considered as preventive strategies for physician burnout. There are also recommendations to reduce physician work stress such as paying attention to the living condition and income of the doctors, providing for physician living and housing needs, and socially supporting physicians. However, it seems that there is no work in that era like that of Adab al-Tabib which spoke on the concept of physician burnout accurately in great detail (Ghaffari, Reference Ghaffari2010; Jafari et al. Reference Jafari, Alizadeh and Mortaz2011, Reference Jafari, Alizadeh and Zafarghandi2012). Ruhawi’s attention on the prevention of physician burnout in ancient times is admirable and unique because according to some of the historical evidence, there was not enough attention paid to occupational burnout in ancient times. Moreover, in some cases, there were popular quotes that could lead to burnout. For example, in ‘Post Chu Shi Biao’ (The Later Memorial for the Case to go to War), one of the famous ancient Chinese books in the Three Kingdoms period (220–280 AD), there is a famous statement: ‘I strive to do my best until I die.’ One interpretation of this statement is promoting the belief that the purpose of life is to work. This includes advising humans to work wholeheartedly in any condition without any complaints (Lo et al. Reference Lo, Wu, Chan, Chu and Li2018). In addition, even in some of the new oaths for physicians, there is the statement ‘I swear to put the needs of the patients above all else.’ This can lead to physician burnout due to ignoring the individual needs of the doctor (Blume, Reference Blume1997; Chesanow, Reference Chesanow2017).
Highlighting the concept of physician burnout in Adab al-Tabib comes from Ruhawi’s idealistic view about the figure of the physician. Ruhawi, relying on his knowledge and observation, predicted this occupational phenomenon for doctors and provided an early description of physician burnout that corresponds to recent perspectives. He also proposed some preventive strategies that have potential to prevent burnout in physicians in accordance with recent studies.
After introducing the concept of burnout in 1974, lot of research has been done on the context of physician burnout, its epidemic nature in different societies, the effects of this phenomenon on the health system, and its relation to other psychological disorders. It has become a topic of interest in education, research, and health centers around the world to the extent that at least 142 different definitions of burnout have been provided by researchers (Schwenk & Gold, Reference Schwenk and Gold2018).
Ruhawi’s viewpoint on physician burnout 11 centuries ago is very valuable in terms of the field of medical history but it seems to be simple and primitive compared to recent findings. One important point is that the contents of Adab al-Tabib on physician burnout are mainly sporadic in different parts of the book. No specific heading for burnout is mentioned. Ruhawi also did not provide a precise definition that is comparable to the criteria within the diagnosis of physician burnout.
Conclusion
Physician burnout has a long history and the explanation of this concept dates back to the writings from the medieval Islamic golden ages. Ruhawi is known as a pioneer in the field of occupational medicine, social medicine, and physician self-care by providing detailed, precise, and scientific discussions on the understanding of physician burnout and its prevention. Adab al-Tabib is an outstanding work on physician burnout in the medieval era.
Acknowledgments
This article is based on the Ph.D. thesis of Dr. S. Sadeghi (NO: 206), Department of Traditional Medicine, School of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Financial Support
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Conflict of interest
All authors have no conflict of interest to disclose.
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
