Burnout among Palliative Care Physicians in India: A Multicentric Cross-sectional Study

Study design

This study employed a cross-sectional observational design aimed at assessing the prevalence and severity of burnout among palliative care physicians in India. The cross-sectional approach was chosen to capture a comprehensive snapshot of burnout levels and their associations with various demographic, occupational and lifestyle factors at a single point in time [Figure 1].

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Figure 1:

Flowchart of participant recruitment and study procedure.

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Study setting and population

The research was conducted among licensed palliative care physicians currently practising in India. Physicians from both public and private healthcare institutions, spanning various geographical regions and institutional settings across the country, were invited to participate. The inclusion of a diverse range of participants ensured broader generalisability and representation of the national palliative care workforce.

Sampling method

A non-probabilistic convenience sampling approach was employed for recruitment. Physicians were approached through a range of channels, including institutional contacts, professional palliative care networks, academic departments and digital platforms such as email groups and online forums. Participation in the study was voluntary, and no financial or material incentives were provided, minimising response bias.

Sample size

A total of 68 palliative care physicians who met the inclusion criteria completed the study instruments. This sample size was deemed sufficient for descriptive statistics and preliminary inferential analyses suitable for a pilot-scale cross-sectional investigation. While not intended for national prevalence estimation, it offers valuable initial insights into burnout trends in the Indian context.

Inclusion and exclusion criteria

Physicians were eligible if they (1) were actively practising palliative care in India, (2) could read and understand English, and (3) identified as either gender. Physicians were excluded if they declined to provide informed consent or expressed unwillingness to participate at any stage of data collection.

Study instruments

Data collection involved the administration of two instruments. First, a semi-structured socio-demographic and workplace questionnaire developed by the investigators captured detailed participant data, including age, gender, marital and parental status, professional designation, years of palliative care experience, night duty responsibilities and institutional support availability.

Second, burnout levels were assessed using the Copenhagen Burnout Inventory (CBI), a psychometrically validated tool comprising 19 items that measure burnout across three dimensions: personal burnout, work-related burnout and client-related burnout. Each domain contains 6–7 questions, with cumulative scores indicating burnout severity. The CBI has been extensively validated and used across multiple healthcare settings globally.

However, formal validation of the CBI in the Indian context remains limited, necessitating interpretive caution regarding cultural and contextual relevance.

Data collection procedure

Participants received a participant information sheet detailing the study’s objectives, procedures and ethical rights. On providing written informed consent, they completed the socio-demographic questionnaire followed by the CBI. Surveys were administered either online or in person, depending on logistical feasibility and participant preference.

Data analysis

Normality of data was assessed using the Kolmogorov– Smirnov and Shapiro–Wilk tests, confirming non-normal distribution for all burnout domains. Accordingly, non-parametric tests were employed for analysis. Medians and interquartile ranges (IQRs) were reported for continuous variables. The Mann–Whitney U test was used for two-group comparisons, and the Kruskal–Wallis test for three or more groups. Categorical variables were analysed using the Chi-square test.

No adjustments were made for multiple comparisons or effect sizes, given the exploratory and pilot nature of this study.

Ethical considerations

Ethical approval was obtained from the institutional ethics committee. The study adhered to the ethical principles outlined in the Declaration of Helsinki, ensuring the highest standards of human subject research. Participation was anonymous, voluntary and non-coercive. Participants were informed of their right to withdraw at any time without prejudice, and data confidentiality was strictly maintained throughout the research process.

Distribution and severity of burnout

Burnout data were first tested for normality using the Kolmogorov–Smirnov and Shapiro–Wilk tests, which confirmed a non-normal distribution across all three burnout domains. Consequently, non-parametric statistical methods were used in the analysis. The median burnout scores pointed to moderate stress levels across domains. The median score for personal burnout was 12.0 (IQR: 10.0–15.0), while work-related burnout had a median of 13.0 (IQR: 10.0–17.0), and client-related burnout was at 11.0 (IQR: 6.5–14.0). The total burnout score had a median of 37.5, with an IQR from 29.0 to 45.0 [Table 2]. Burnout severity was categorised based on CBI thresholds: low (0–25), intermediate (26–50), high (51–75) and very high (76–100). Based on these cut-offs, 85.3% of physicians experienced low burnout, 10.3% fell into the intermediate range, and 4.4% were classified as high burnout. One participant (1.5%) fell into the very high burnout category, resulting in a total of 5.9% experiencing high-to-very high burnout. When examining domain-specific burnout, a significant number of participants reported intermediate burnout in personal (66.2%), work-related (58.8%) and client-related (58.8%) domains. Notably, high burnout levels were more frequent in the work-related domain, reported by 19.1% of participants [Table 3]. These patterns are visually represented, as shown in Figure 2.

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Figure 2:

Distribution of median burnout scores across personal, work-related and client-related domains by demographic and occupational subgroups. Stacked bar plots showing the median burnout scores across three core domains-personal burnout, work-related burnout and client-related burnout-stratified by various demographic and occupational subgroups. (a-m) Each subplot, represents a different grouping variable such as age, sex, marital status, professional designation, years of experience and nature of work. Within each bar, the coloured stacks represent individual subgroup contributions to the total median score in that domain. Asterisks above the bars indicate statistically significant differences between subgroups within that domain (P < 0.05).

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Associations between burnout and participant characteristics

Burnout scores were compared across demographic variables to identify potential associations. However, no statistically significant relationships emerged. For instance, age did not appear to influence burnout levels in any domain (all P > 0.7). While female physicians had slightly higher median personal burnout scores than males (14 vs. 12), the difference was not statistically significant (P = 0.188). Likewise, marital and parental status did not significantly affect burnout levels, with P-values across these variables ranging from 0.075 to 0.926. In terms of professional characteristics, burnout scores did not significantly vary by designation, years of experience or presence of institutional support. Nevertheless, a near-significant trend was observed in client-related burnout scores, with higher levels reported by those lacking support staff (P = 0.054). Furthermore, although participants undertaking night duties did not show significantly different total burnout scores (P = 0.960), their personal- and work-related burnout scores trended higher compared to those not assigned night duties [Table 2].

Burnout and nature of work

A significant association was identified between the nature of work and burnout severity (P = 0.040). Physicians working in mixed roles–involving both hospital-based care and home visits–reported the highest burnout levels. In contrast, those engaged exclusively in home-based care reported the lowest burnout scores. Interestingly, all physicians categorised under very high burnout levels were from the mixed work group, suggesting that task variability and the demand of transitioning between clinical environments may increase emotional exhaustion [Table 3 and Figure 3].

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Figure 3:

Burnout severity classification across demographic and professional subgroups. Stacked bar graphs display the distribution of overall burnout levels-categorised as low (0–25), intermediate (26–50), high (51–75) and very high (76–100)-across various demographic and professional subgroups. (a-m) Each subplot, represents a distinct variable including age, sex, marital status, children, designation, experience in palliative care, availability of support staff, night duty status, appreciation at work, optimism regarding continuation in palliative care, nature of work, spirituality and physical workout practices. The height of each bar indicates the number of individuals within that subgroup, while the coloured segments within the bars correspond to the proportion of individuals falling into each burnout category. Asterisks above the bars indicate statistically significant differences between groups (P < 0.05).

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Lifestyle and psychological factors

Lifestyle practices, particularly engagement in physical activity, demonstrated a clear association with reduced burnout. Physicians who reported regular workouts had significantly lower total burnout scores compared to those who did not (median 33.0 vs. 42.0; P = 0.039). This trend held across personal, work-related and client-related domains. In contrast, spirituality did not significantly influence burnout levels (total score P = 0.683), though a majority of individuals in the high burnout group identified as spiritual [Table 3 and Figure 4].

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Figure 4:

Burnout distribution and associated factors in palliative care physicians. Sankey diagram showing the distribution of burnout severity among Indian palliative care physicians and its association with physical activity, work setting and physician seniority. Regular physical activity predominantly aligns with low burnout. In contrast, high burnout is more common among junior physicians and those working in mixed care settings.

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Stratified analysis of burnout severity

Further stratified analysis helped identify specific at-risk groups. All participants with very high burnout were under the age of 30 years and working in mixed care settings. Similarly, high burnout was more prevalent among junior residents and those with fewer than 3 years of experience. Organisational factors such as perceived appreciation of palliative care at the workplace and optimism about the future in the field appeared to influence burnout levels. Although these associations were not statistically significant, those who lacked optimism or felt undervalued were more likely to fall into higher burnout categories [Table 3 and Figure 3].

CONCLUSION

This multicentric cross-sectional study provides valuable insights into the prevalence and determinants of burnout among palliative care physicians in India. Although the majority of participants exhibited low levels of overall burnout, a significant minority–particularly those engaged in mixed-care settings and early in their careers–demonstrated moderate-to-high levels, especially in work-related and client-related domains.

These findings are consistent with international patterns, reinforcing the notion that palliative care professionals face unique occupational challenges due to the emotionally intense nature of their work. Notably, while socio-demographic factors such as age, gender and marital status did not emerge as statistically significant, lifestyle practices– particularly regular physical activity–were clearly associated with reduced burnout, indicating important avenues for nonpharmacologic, behavioural interventions.

Furthermore, the study highlights the influence of work setting, professional seniority and perceived workplace appreciation on burnout risk, suggesting that burnout is shaped not merely by individual traits but by a constellation of environmental, institutional and psychological variables. These observations highlight the need for multi-level interventions that address both structural and individual dimensions of physician well-being.

In light of these findings, the implementation of structured wellness programmes, burnout monitoring systems and organisational policies that affirm professional recognition and offer emotional support should be prioritised. Such interventions not only promote clinician health but are also essential for sustaining the quality and continuity of palliative care delivery in India.

The study serves as a foundational reference for future research in the Indian context. Longitudinal and interventional studies are warranted to further explore causal pathways and to evaluate the effectiveness of targeted strategies in mitigating burnout across varied palliative care settings. In doing so, the Indian healthcare system can move toward a more resilient, compassionate and sustainable palliative care workforce.