It is a well-known fact that in the medical field, taking measures to prevent illness is a better approach than treating the illness after it has occurred. This case is also similar to burnout. However, to apply preventive measures, someone has to have a better understanding of the causes and root of the problem. There were limited studies that examined supplemental working hours among residents and their effect on burnout and work productivity. The present study is one of the few studies that evaluated the subject mentioned above. In this study, EE was high among 52.5% of residents, while only 12.2% had a higher risk in DP and 53.1% had low PA (mean score 12.1, 12.6, and 6.13 out of 18 points, respectively). Several studies in Saudi Arabia reported a high prevalence of EE and DP varying from 15.7 to 54% [11,12,13, 16], which was consistent with our study.
Similarly, reports indicated that the prevalence of burnout among medical residents was high, ranging from 62.8 to 93.7% [20,21,22,23,24]. In abroad, one of the recent papers reported that high EE and DP were found among 21.5% and 41.9% of residents, while low PA accounted for 34%  which was in line with our results. The current data of burnout among medical residents in Saudi Arabia is alarming, and there should be a systematic approach to address this issue. Furthermore, it is also important to understand the effect of burnout among medical residents. To attain this, more studies are needed to determine which factors showed a significant effect on burnout.
Our study also found that being a female was more likely to be associated with EE than males. On the contrary, in a study of Alhaffar et al. , they found that males had a higher level of burnout than females; in another paper in Saudi Arabia,  indicated no significant correlation between burnout and gender, which was less substantial than our report. Furthermore, in a study by Al Sareai et al.  they accounted that a higher risk of EE was associated with younger age. This coincided with the paper of Alhaffar et al.  where they documented that age group showed a significant relationship with burnout. However, in our study, although the younger age group showed higher rates of burnout, this did not reach statistical significance, which was similar to the study reported in the USA . Regarding additional responsibilities such as being married and caring for children, some studies showed no correlation between those factors and burnout. Surprisingly, although it is not statically significant, our data showed that married residents with children had a lower level of burnout, which is consistent with Collier et al.’s study  that considers parenting a protective factor against burnout which might increase humanistic feelings that result in less detachment and depersonalization .
The highest EE and DP scores were found in the second level of residency (R2), and that is probably because of the exams that evaluate the residents’ competence for promotion from junior to senior phase in most general residency programs. Several studies reported different findings, such as Aldubai et al.  who find R4 to be the highest in burnout among family medicine residents as it is the last residency level. However, in Martini et al.’s  study, they reported R1 to be the most stressful level, arguing that the transition from a graduate student to a medical practitioner exposes junior residents to greater risk of burnout. The general surgery residents have the highest level of burnout in this study, and this finding is similar to other study conducted in Riyadh . In international studies, obstetrics and gynecology residents were on the top of the list with a burnout rate that reaches 75% . The residents who have on calls “working more than 8 hours per day” have higher EE and DP rate, and this finding was clear in other national study .
The PA score was significantly higher among residents who were satisfied with their choice of specialty. However, those who are not satisfied are significantly higher in EE and DP although the reasons behind their choice of specialty were unclear.
To measure the lost work productivity of medical residents, we used the Stanford Presenteeism Scale (SPS-6) . Apparently, the study suggests that presenteeism posed a serious problem when it comes to the healthcare workplace, arguing that it could reduce the standard quantity or quality of work [8, 9]. In this study, the mean score of SPS-6 was 18.6 (SD 4.49) out of 30 points. About half of the residents (49.1%) scored above the mean score of SPS-6, indicating a concern in lost work productivity. Our result is higher than the study reported in China , where 30.7% of the doctors accounted for presenteeism syndrome. Being a male and having children, in addition to the training in the general surgery program, appear to be the factors most associated with high presenteeism in our study. However, in a study by Jena et al., none of these factors were a risk factor .
Many of the residents worked extended hours or by bringing work at home to reach the desired work productivity. These supplemental working hours affect their life after work that could lead to more stress [11,12,13]. Using the technology-assisted supplemental work scale (TASW), we assessed the residents’ technology used to do work-related tasks after working hours . The total mean score of TASW was 19.7 (SD 3.75), with 53.8% of respondents reported having a score above the mean indicating a higher rate of supplemental working hours. We find that the younger residents tend to use technology and bring their work home, and this might be due to the huge engagement of the young generation in technology.
One of the most recent studies conducted in France reported that self-reported burnout and presenteeism were both associated with a higher risk of EE . This corroborated the study done in China, where it indicated that physicians with a medium and high degree of EE were more likely to practice presenteeism [7, 23]. This had also been validated in our study, as presenteeism showed a significant effect in all MBI subscales, including EE, DP, and PA. Moreover, data in this study revealed that TASW has a positive correlation with burnout, but it was not statically significant. While there were limited papers that examined the effect of TASW in burnout, one of the literature mentioned that the use of technological tools excessively to accomplish pending works increased the level of stress resulting in burnout. However, respondents argued that it was difficult to separate from works, even at home and on weekends .
Our study is limited by the small number of participants in each specialty and the low completion rate, which may affect our results and make it difficult to predict the burnout level in those who did not respond. Furthermore, some factors that might influence burnout, such as medical condition; financial issues; immigration; and daily habits such as diet, exercise, and substance use, are not covered in our study. In addition, to our knowledge, this is the first paper in Saudi Arabia that measures the consumed time of the residents in doing supplemental work right after the duty using technology, so there was a limitation in comparing our data with other local studies. Finally, our study is a cross-sectional study, so we cannot identify the direction of the associations.