Burnout is a serious epidemic affecting medical students, residents, and practicing physicians. This past January, Mohammad Zaher authored an insightful blog discussing the current state of well-being in health care. This current blog will build on these ideas with a focus on medical trainees. In addition, I will discuss practical solutions that can be implemented at your institution to improve trainee well-being.

Burnout is defined as a work related syndrome of depersonalization, emotional exhaustion, and decreased sense of personal accomplishment. Studies have shown that burnout begins in medical school, and intensifies during residency. Furthermore, approximately 50% of practicing physicians meet criteria for burnout. Burnout has grave personal consequences for medical trainees, including decreased quality of life, higher rates of depression, and suicidal ideation. Professionally, burnout affects patient safety, physician turnover, and patient satisfaction. Given these undesirable outcomes, increasing efforts to target burnout and improve physician well-being are an important focus at many training programs. Experts and evidence have suggested a combination of individual and organizational approaches to target burnout. Read on to explore the problem of burnout in medical trainees and get ideas about interventions you can implement at your own institution.

When does burnout begin? Are the high rates of physician burnout a consequence of the medical practice self-selecting individuals with a predisposition or tendency to become burned out? Research has shown that matriculating medical students have lower rates of burnout and depression, and higher quality of life, compared to population-based controls graduating with a four year college degree. However, when surveyed during training, medical students report higher rates of burnout, depression, and fatigue compared to these controls, indicating that burnout emerges in medical school.

Burnout intensifies during residency, with average burnout rates between 50-76% reported in the literature. Burnout during training leads to significant consequences, including suboptimal patient care, increased self-perceived errors, and decreased quality of life. Similar to the phenomenon seen in medical students, residents have significantly higher rates of burnout, depression, and fatigue compared to population-based controls. They also have lower mental, physical, and emotional quality of life. 

Due to the prevalence of burnout in residents, the 2017 Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements introduced a section on resident well-being, mandating that programs educate residents on the symptoms of burnout and provide appropriate resources for those experiencing burnout. Furthermore, the ACGME’s Clinical Learning Environment Review (CLER) Program currently outlines an expectation that institutions measure resident burnout annually. Numerous residency programs are adopting wellness programs, with a focus on integrating well-being topics into the curriculum. Other strategies include stress management workshops, resiliency training, and Balint groups aimed at promoting self-reflection and interconnectedness. These strategies have been shown to reduce burnout among resident physicians.

In addition to encouraging the development of personal resilience and promoting individual wellness, burnout must also be addressed through an organizational approach. The work environment and demanding nature of medical practice are key drivers of burnout. Many studies find loss of autonomy, decreased control over the practice environment, and inefficient use of time due to administrative requirements to be central factors. Other surveys suggest workload, sleep deprivation, lack of work-life balance, medical errors, risk of malpractice suits, and the methods physicians use to deal with patient death and illness as contributing factors.

 What can you do at your home institution to help address burnout in medical trainees? Here are a few ideas to increase awareness of burnout while providing activities that foster wellness, build resilience, and reduce burnout. Keep in mind that it is critical for organizations to also adopt methods to decrease workload, improve efficiency, and modify the practice environment.

  1. Identify champions that are dedicated to wellness. This could include other residents, a chief resident, or faculty.
  1. Implement a well-being curriculum that is part of your core curriculum. Devote an hour or two per month and focus on various well-being topics. Potential ideas include presentations on physical, mental, spiritual, and emotional wellness, faculty or student led panels, resiliency training, mindfulness sessions, narrative medicine, reflective writing, coaching, financial planning, and conflict management.
  1. Promote a culture of wellness. Host a “fitness challenge” and give winning residents an extra day off or first choice of clinical template. Provide healthy food choices on morning rounds and noon conference. Create a culture of no shame. Allow trainees to take a “mental health” day. Provide access to mental health resources and ensure confidentiality. Host a number of social events throughout the year.
  1. Encourage reflection sessions or Balint groups where residents can discuss difficult personal or professional experiences and connect with their peers.
  1. Measure burnout on an ongoing basis using validated survey instruments. The Maslach Burnout Inventory is an excellent resource for measuring burnout. Other outcome measures of interest could include empathy, resilience, grit, quality of life, social isolation, or depression. This is critical to assessing the impact of your interventions.
  1. Partner with your institutional leaders, division or department chair, or program director to brainstorm ideas to modify the practice environment.

In summary, burnout is highly prevalent in medical trainees and leads to adverse personal and professional consequences. Strategies to reduce burnout and improve well-being must address both individual and organizational factors. Click the following link for more information, toolkits, and additional resources. http://www.im.org/page/charm

 

References 

  1. Brazeau CM, Shanafelt T, Durning SJ, et al. Distress among matriculating medical students relative to the general population. Acad Med 2014;89(11):1520-5. doi: 10.1097/ACM.0000000000000482
  2. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA 2006;296(9):1071-8. doi: 10.1001/jama.296.9.1071
  3. Jennings ML, Slavin SJ. Resident Wellness Matters: Optimizing Resident Education and Wellness Through the Learning Environment. Acad Med 2015;90(9):1246-50. doi: 10.1097/ACM.0000000000000842 [published Online First: 2015/07/16]
  4. Ripp JA, Fallar R, Korenstein D. A Randomized Controlled Trial to Decrease Job Burnout in First-Year Internal Medicine Residents Using a Facilitated Discussion Group Intervention. J Grad Med Educ 2016;8(2):256-9. doi: 10.4300/JGME-D-15-00120.1
  5. Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc 2017;92(1):129-46. doi: 10.1016/j.mayocp.2016.10.004

 

Brianna E Vaa Stelling

Brianna Vaa, MD (Educators, ’17) is an Internist at Mayo Clinic in Rochester, Minnesota. She is the Resident Well-Being Director for the Internal Medicine Residency Program and oversees curriculum development for the resident outpatient primary care continuity clinic. She also oversees the pre-clinical doctoring blocks for the medical students. Brianna is passionate about trainee well-being and the relationship between emotions, cognition, learning, and burnout. She loves the outdoors and spending time with her dog, Nala. You can reach her on twitter at @VaaBrianna.