To our knowledge, this is the first study to examine the relationship between self-determination, measured by the satisfaction of the three psychological needs, and burnout in medical residents in times of accumulating adversities. Our findings indicate a significant relationship between these variables, such as when the basic psychological needs are met, there is a reduction in EE, the main dimension of burnout that correlates with anxiety and depression symptoms.

SDT posits that the satisfaction of BPNs—autonomy, competence, and relatedness—is essential for psychological wellbeing and optimal functioning. However, the interplay between BPNs and burnout, especially within the context of medical residency where coping mechanisms and the complex nature of work demands can affect this dynamic, remains underexplored. In our study, we found that when the BPNs are met, residents are less likely to experience EE yet more likely to experience DP. In fact, healthcare workers are primarily driven by a mission to help and save and/or rescue others. It is possible that in high-risk situations where their personal safety is compromised, DP may emerge as a protective mechanism. This can lead to extreme dissociation, where healthcare workers do their jobs correctly but disconnect from reality, becoming impersonal or callous to cope with the distress of handling many patients or dealing with multiple stressors simultaneously.

While depersonalization might initially provide some relief from the overwhelming emotional demands of work, it is not a sustainable solution. Depersonalization can lead to a lack of engagement and a decrease in the quality of care or work performance, which can create a cycle of increasing stress and emotional exhaustion (41).

Albeit not surprising given the overall context, our study shows alarming rates of burnout among medical residents in our sample with almost all residents experiencing DP, EE and low PA. A recent study assessing burnout among postgraduate medical trainees in Lebanon similarly found that prevalence rates of high burnout are 37.2% for disengagement and 51.1% for exhaustion using a different scale at the early stages of the pandemic (42). Even prior to the COVID-19 viral spread, a systematic review in the Arab world had also found a wide range of prevalence estimates for the three MBI subscales across studies on medical professionals ranging between (20.0–81.0%) for high EE, (9.2–80.0%) high DP, and (13.3– 85.8%) for low PA (43). Although there are variations in the reported prevalence of burnout among residents across different studies, attributed to the different factors such as country of residence, specialty, ongoing collective stressful events, and measurement tool used, our findings suggest that burnout may be more widespread than previously thought, potentially worsening as crises become chronic and as they accumulate (44–47).

In line with recent findings, our study further shows that frequent interaction with infected patients is a risk factor for burnout, EE dimension in specific. The impact of interacting with COVID-19 patients on levels of burnout and mental health outcomes of residents has been systematically documented in the literature (48). This was indeed one of the highlights of the General Medical Council national survey in 2021 reporting that one third of trainees said they felt burnt out to a high or very high degree because of their work, compared to around a quarter in previous years (49), with 43% of respondents finding their work emotionally exhausting to a high or very high degree(49). A cross-sectional study in Japan additionally found a positive correlation between burnout levels and the actual number of COVID-19 patients the residents handled (50). Keeping in mind that the impact of COVID-19 pandemic on burnout persists for years after the initial interaction, as documented by a national survey involving radiology residents(51) our findings warrant adequate follow-up on the mental health of impacted residents.

Amidst the Lebanese context, trainees faced the dramatic interplay of many crises including the COVID-19 pandemic, the Beirut blast, and an unprecedented economic crisis. Those who felt burdened due to their involvement in educational activities and those who were physically affected by the blast surprisingly had a higher sense of personal achievement. A possible explanation could be that overcoming physical challenges or surviving a traumatic event would foster a sense of resilience and accomplishment. Facing significant adversities and coping with harsh situations might enhance one’s perception of his/her own capabilities and achievements, leading to a stronger sense of PA and subsequently buffer burnout (52). In our study, we found significant demographic factors associated with increased risk for burnout such as being a male, living alone or with a partner, and having a low income. A similar study in Lebanon had recently documented the deleterious impact of ramping economic worries on individuals’ wellbeing amidst the COVID-19 pandemic; worsened by the country’s fragile structural financial status (53). The study further reported that men had increased financial anxiety compared to women as they are traditionally primarily tasked with providing for their families in Lebanon (53). A study on medical staff in Shanghai reached similar results regarding living arrangements (54). Specifically, being single or married without children (equivalent to living with a partner) was associated with higher levels of DP (54). The financial impact on the burnout of healthcare workers is also a consistent finding across several studies (55–58). While having a low income was a risk factor for burnout in our study, rewarding and fair payment was shown to protect against physician’s burnout (59).

Positive screening for anxiety and depression symptoms was also noted in most of the study participants. This is in line with concurrent studies in the general population indicating similar mental distress rates in young adults in Lebanon during the same period (60,61). These high prevalence rates of mental distress in our sample could primarily reflect the mental cost of adjusting to accumulating crises and should be monitored longitudinally, especially in medical residents. We further intriguingly found that elevated symptoms of mental distress correlated with decreased DP but with increased occurrences of EE and low PA. These findings first and foremost highlight the complex relationship between mental distress and aspects of burnout in the medical residents particularly. As such, it could be that residents experiencing symptoms of pervasive anxiety and depression might overly focus on their work to get distracted from their own struggles, increasing connection to their patients and thus decreasing cynical DP while incurring a cost in terms of emotional weariness and depletion and a decreased overall satisfaction with one’s achievements. In this regard, anxiety and depression could be viewed as making individuals more aware of their own emotions and struggles, and would as such reduce the likelihood of becoming distant and impersonal from patients(62–64). Taken altogether, these findings reflect a sizable need to implement institutional collective strategies to alleviate personal struggles.