Burnout in Pediatric Residency: A Literature Review

Burnout Research 6 (2017) 9–17
Contents lists available at ScienceDirect
Burnout Research
journal homepage: www.elsevier.com/locate/burn
Review
Burnout and interventions in pediatric residency: A literature review
Tara F. McKinley a , Kimberly A. Boland a , John D. Mahan b,∗
a
b
University of Louisville, 571 S. Floyd Street, Suite 412, Louisville, KY 40202, USA
Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA
a r t i c l e
i n f o
Article history:
Received 15 July 2016
Received in revised form 18 February 2017
Accepted 22 February 2017
Keywords:
Burnout
Residency
Pediatrics
Literature review
Mindfulness
a b s t r a c t
Despite an increase in interest in issues related to burnout in medical education and mandates from
the national residency accrediting body, available literature is sparse in pediatrics, a medical discipline
that requires special empathy and compassion, as well as enhanced communication skills to effectively
care for children and their families. Burnout prevalence ranges from 17 to 67.8% of pediatric residents
in recent studies. There is little that details the pathogenesis of burnout in these residents and little that
compares them with those in other medical disciplines. This comprehensive literature review describes
all that is published on burnout and burnout interventions since 2005 in pediatrics and other primary
care oriented specialty residents, as well as key papers from pre-2005. This review, with its focus on
the available information and evidence-based intervention strategies, identifies four areas for focus for
future interventions and directions. It should serve as a useful resource to program directors, medical
educators and graduate medical education leadership who are committed to preventing and/or treating
burnout in their residents and molding these young physicians to be able to maintain resilience through
their careers. This review should also be useful to investigators exploring burnout in other health care
professionals.
© 2017 The Authors. Published by Elsevier GmbH. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Contents
1.
2.
3.
4.
5.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Measuring burnout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.1.
Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.1.1.
Workload . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.1.2.
Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.1.3.
Reward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.1.4.
Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.1.5.
Fairness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.1.6.
Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.2.
Potential theoretical bases for burnout in residents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.2.1.
Job demands resources model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Literature review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4.1.
Burnout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4.1.1.
Stage of training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4.1.2.
Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4.1.3.
Work hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4.1.4.
Personality traits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
5.1.
Work hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
∗ Corresponding author.
E-mail addresses: tara.mckinley@louisville.edu (T.F. McKinley),
k.boland@louisville.edu (K.A. Boland), john.mahan@nationwidechildrens.org
(J.D. Mahan).
http://dx.doi.org/10.1016/j.burn.2017.02.003
2213-0586/© 2017 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
4.0/).
10
T.F. McKinley et al. / Burnout Research 6 (2017) 9–17
5.2.
Educational and skills-Building workshops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
5.3.
Learner-Driven educational sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
6.
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
7.
Future directions/imperatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
7.1.
Efforts to address work-related stressful factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
7.2.
Building more supportive programs and environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
7.3.
Emphasis on developing self-care and nurturing family and social support for trainees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
7.4.
Developing important personal resilience skills in trainees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1. Introduction
Job burnout can affect any employee in any field. While not
a new phenomenon, job burnout has resurfaced in practitioner
literature as society becomes more complex and more demands
are placed on employees. The first edition of the Maslach Burnout
Inventory, the gold standard for evaluating burnout in the workplace, was published in 1981; the 3rd, and much expanded version,
was released in 1996 and is still widely used today. The seminal definition provided by Maslach and Leiter (2008) states that
burnout is a “psychological syndrome that involves a prolonged
response to chronic interpersonal stressors on the job” (p. 498).
Physical effects of burnout include aches and pains, digestive upset,
and poor sleep quality. In addition, significant emotional effects,
including fatigue, unusual behaviors, mental illness/depression and
poor work performance, have also been noted (Dyrbye et al., 2014;
Eckleberry-Hunt et al., 2009; Landrigan et al., 2008; Maslach &
Leiter, 2008).
The medical field involves unique job factors and responsibilities that put practitioners at risk of significant burnout (Daskivich
et al., 2015; Jennings & Slavin, 2015). While a wide range of literature exists on medical students, residents and career physicians,
specific information on pediatric residents and other primary care
trainees is sparse. Pediatric residents, who complete four years of
medical school and pass national licensing examinations, are significantly engaged in patient care. Pediatric residents work long hours
(typically 50–75 h/week in the U.S) and during three years of training transition from totally supervised work to greater autonomy
and graduate able to practice independently. At the end of training a
high stakes board examination must be passed to gain national certification. Arguably, effective practitioners in pediatrics must have
special skill sets rich in empathy, compassion and enhanced communication to be able to relate to and care for a set of patients at a
special stage of life with unique needs.
In a periodic survey of American Academy of Pediatrics (AAP)
members (n = 1616; response rate 63%), 22% stated that they were
currently experiencing burnout, and 45% stated they had experienced burnout at some time in the past (McClafferty & Brown,
2014; Starmer et al., 2016). Burnout is a real concern for pediatric
trainees (Olson et al., 2015; Landrigan et al., 2008) with prevalence
at 24–46% (typically more emotional exhaustion and depersonalization) during the first year of training with little change thereafter
(Pantaleoni et al., 2014). These levels are similar to that seen in
other primary care oriented specialties (family medicine, internal
medicine) which range from 24 to 84% (Table 1).
While the prevalence of burnout in pediatrics mirrors rates
described in other medical specialties (30%–50%) (McClafferty &
Brown 2014), higher rates are seen in specific pediatric subspecialties such as hematology/oncology, neonatal and pediatric intensive
care, and pediatric surgery. As McClafferty noted, a particular issue
for pediatric trainees and pediatricians is that many of the character traits especially valued in pediatricians, such as compassion,
altruism, and perfectionism, also predispose to burnout when clinicians are pushed to mental or physical extremes. Starmer et al.
(2016) highlighted the increased stress and lower life balance seen
in female compared to male pediatricians and noted the increasing
proportion of females as pediatricians in the US today (from 23.7%
in 1975–56.6% in 2011 − https://www.aap.org)
Four recent reviews of burnout interventions listed only three
studies performed in pediatric residents (Fletcher, Reed, & Arora,
2011; IsHak et al., 2009; Prins et al., 2007; Williams, Tricomi, Gupta,
& Janise, 2015). Calls for increased attention to stress and burnout
in resident physicians (Jennings & Slavin, 2015; Lefebvre, 2012)
have accompanied enhanced requirements by the Accreditation
Council for Graduate Medical Education (ACGME) for programs to
educate trainees and faculty physicians about fatigue and burnout
(Committee, 2013) and the need for evidence-based methods to
address burnout and build resilience in physician trainees (Council,
2015).
Pediatrics has struggled to fashion effective interventions
beyond traditional educational efforts (lectures, workshops, discussions, etc). There lies a veritable chasm between ACGME
recommendations, duty hour regulations, and effective practices
that will be required for residency programs and residents in pediatrics to prevent and/or mitigate the effects of stress and the
demands inherent in caring for and treating children. Program
directors often struggle with practical strategies for implementing
ACGME requirements into residency programs already stuffed with
patient care, educational curricula, and other training mandates.
Beyond specific “burnout” and “wellness” interventions, the workplace culture and realities of complex medical care systems often
form prominent barriers to producing productive and resilient
graduates. There is evidence that one single yet far-reaching cultural change − increasing psychosocial support of residents − may
be the most effective method to minimize burnout (Daskivich et al.,
2015).
The purpose of this literature review is to detail the present
research on pediatric resident burnout and place that in context
with what is being discovered in related disciplines, family and
internal medicine. The following questions will be answered: (a)
How is burnout measured? (b) What theories have been offered
to explain the pathogenesis of burnout in this population? (c)
What interventions have been used to address pediatric resident
burnout? Identifying burnout characteristics and successful interventions in pediatric trainees can help inform future studies and
prompt interventional trials to benefit this unique population and
potentially other primary care oriented specialties.
2. Methods
A systematic search was conducted using GoogleScholar,
OVID and WorldCat. Combinations of the search terms ‘resident,’ ‘burnout,’ ‘pediatric,’ ‘internal medicine,’ ‘family medicine,’
‘medicine pediatric,’ ‘wellness,’ ‘resilient,’ ‘intervention,’ and
T.F. McKinley et al. / Burnout Research 6 (2017) 9–17
11
Table 1
Burnout and influencing factors in general practice residents − 18 reported studies.
Reported Burnout and Influencing Factors in General Practice Residents
Author
Specialty
N (M/F)
Burnout (percent)
Factors associated with more burnout
Study Setting
Billings et al. (2011)
IM
284 (131/153)
45%
2 large Western prgms
Campbell et al. (2010)
IM
86 (44/42)
49%
Doolittle et al. (2013)
IM/MP
108 (54/54)
28%
Dyrbye et al. (2014)
Eckleberry-Hunt et al. (2009)
Fahrenkopf et al. (2008)
Gopal et al. (2015)
Gordon et al. (2012)
Multiple
Multiple
Ped
IM
Ped
1701 (870/824)
168 (77/68)
123 (37/86)
227 (98/127)
1469 (376/988)
60.3%
Not reported
75%
25–36%/cycle
49.4%
Personality traits, female, witness
unprofessionalism
Point in training, personality traits,
male
Personality traits, social support,
spirituality
Point in training/age, female
Personality traits, social support
Personality traits, work hours
Work hours
Work hours
Landrigan et al. (2008)
Lebensohn et al. (2013)
Olson et al. (2015)
Pantaleoni et al. (2014)
Ripp et al. (2011)
Ripp et al. (2010)
Ripp et al. (2015)
Stucky et al. (2009)
Ped
FM
Ped/MP
Ped
IM
IM
IM/MP
Ped/IM
209
167 (67/100)
45 (16/29)
84 (not reported)
184 (84/100)
145
121 (70/51)
144 (60/84)
67.8%
24%
40%
17–46%/cycle
50–84%
34%
68%
Not reported
West et al. (2011)
IM
8396 (4757/3603)
51.5%
Woodside et al. (2008)
FM/psych
155 (77/57)
Not reported
‘United States,’ were used. Articles published between 2005 and
2016 were included in this review.
Original criteria for burnout frequency included use of at least
part of the Maslach Burnout Inventory; one additional study that
measured stress data in real time using other stress scales was
included because the majority of study subjects were pediatric
residents. Reports on interventions and protocols were included
only if they focused on pediatric, family medicine and/or internal
medicine residents as part of the study population.
3. Measuring burnout
3.1. Measures
Across specialties, the Maslach Burnout Inventory (MBI)
remains the gold standard in burnout detection. Maslach and colleagues began their work in burnout in the early 1980s and have
reformatted the MBI twice in the last thirty-five years (Maslach &
Jackson, 1981; Maslach & Leiter, 2008).
Burnout can be divided into three categories (Maslach & Leiter,
2008):
Emotional Exhaustion (EE), Depersonalization (DP) and Personal
Accomplishment (PA). These three components can be evaluated
separately or as a whole with the MBI.
Six risk factors for burnout in a variety of workplaces were identified by Maslach and Leiter (2008); the literature on risk factors for
burnout in pediatric and other primary care oriented residents confirm the existence of these factors in this population of practitioners
in training.
3.1.1. Workload
The key to preventing burnout is recovery time after a particularly stressful event or series of events (Maslach & Leiter,
2008). Jennings and Slavin (2015) argue that residents face additional stressors due to long work hours, responsibility for complex
patients and extensive paperwork requirements. Dyrbye et al.
(2014) identified excessive workload and high fatigue as significant
risk factors for burnout in residents.
Work hours
Personality traits, wellness practices
Personality traits, female
Point in training
Personality traits
Personality traits
Work hours
Point in training, patient load, sleep
quality, male
Point in training, female, less medical
knowledge, US grad, primary care
Age, primary care, male, US grad
1 large Western prgm
2 Northeast prgms
National database
2 Midwest prgms
3 large prms
1 Western prgm
58 prgms, stratified
national sample
3 large prgms
12 prgms
1 large Midwest prgm
1 large Western program
5 Northeast prgms
2 Northeast prgms
2 Northeast prgms
4 large Western prgms
National database
5 Northeast prgms
3.1.2. Control
Spanning the gap between learner, teacher and physician, residents are responsible for patient care with limited “influence
[over] care decisions, their schedules, or their work environment”
(Jennings & Slavin, 2015). IsHak et al. (2009) highlighted multiple
studies that identified lack of control in the work environment as a
major risk factor for burnout in residents from multiple specialties,
including pediatrics and other primary care oriented disciplines.
3.1.3. Reward
West et al. (2014) have demonstrated the effectiveness of multiple layers of reward: salary, small financial ‘perks’ and non-financial
recognition such as teaching, mentorship and awards as methods to
combat what Maslach and Leiter (2008) deem a significant burnout
risk: lack of recognition for work done.
3.1.4. Community
Eckleberry-Hunt et al. (2009) identified insufficient social support as a strong predictor of burnout in residents. IsHak et al. (2009)
described ability of participation in professional organizations and
didactic activities in building work-related social networks that
were associated with less burnout in residents in multiple disciplines.
3.1.5. Fairness
Interestingly, fairness was judged to be the fulcrum for burnout
in employees (Maslach & Leiter, 2008); transparency in programmatic decision making and institutional support for mental health
and stress are strategies that can reinforce fairness and fair treatment in a residency program (Daskivich et al., 2015; IsHak et al.,
2009).
3.1.6. Values
IsHak et al. (2009) described how activities that explored or reinforced personal and organizational values were associated with less
burnout in residents. Jennings and Slavin (2015) suggest listening and responding to resident concerns regarding patient safety
and ethical concerns as methods for institutions to demonstrate
positive values to trainees.
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T.F. McKinley et al. / Burnout Research 6 (2017) 9–17
3.2. Potential theoretical bases for burnout in residents
3.2.1. Job demands resources model
The job demands-resources model or JD-R model is a more
recent construct that describes the stress characteristics of various occupations and workplaces based on the individual worker’s
responses and imbalances between job demands on the individual and the resources available to meet those demands (Demerouti
et al., 2001). The factors that are associated with job stress are
classified into two general categories: job demands (e.g., time
pressures, documentation requirements, work load, etc.) and job
resources (e.g., training initiatives, clear job expectations, supervisor feedback, etc.). The balance and interaction of these factors
results in varying levels of physical and mental stress in individual
workers and also impacts on individual motivation, work engagement, and performance. Burnout can be one result of the resultant
job strain on the individual. Maslach and Leiter (2016) theorize
that people-oriented professionals (nurses, physicians, etc) develop
burnout when individuals experience excessive job demands and
have inadequate resources to address and reduce those demands.
This construct seems to be particularly relevant to understanding
the development of job stress and burnout in residents who experience excessive time and work demands, lack of workplace control,
increasingly complex healthcare organizations, demanding patient
care and learning activities and often have under-developed stress
management skills (IsHak et al., 2009). This construct also suggests that preventive as well as treatment measures will require
efforts directed towards both workplace redesign and individual
professional development 3.2.2 Equity Theory.
According to equity theory, employees are most content when
their input-output ratio equals that of their coworkers. One of the
six main risk factor categories for burnout is fairness, a direct and
measurable component of equity theory. As mentioned above, fairness tends to be a tipping point for burnout in many employees;
those who perceive decisions to be made fairly report less overall
burnout than those who feel unfairly treated in their jobs (Maslach
& Leiter, 2008). While equity theory has not been formally studied
as it relates to burnout in pediatric residents or other primary care
oriented residents, several studies have emphasized that perceptions of special treatment, unfair work requirements or improper
rewards are associated with greater burnout (Daskivich et al., 2015;
IsHak et al., 2009). One hypothesis for the observation of higher
burnout scores in younger trainees and physicians earlier in their
careers (Starmer et al., 2016) may be the greater sensitivity to perceived unfairness and less useful coping strategies (Stucky et al.,
2009; Dyrbye et al., 2014).
4. Literature review
4.1. Burnout
4.1.1. Stage of training
Residents occupy a unique niche in medical training; they take
on increasing responsibility for patient care over time but are still
considered learners and must follow educational mandates from
the ACGME. They are learning to navigate the health care system
as providers and adjusting to their new roles as physicians. These
characteristics have been shown to contribute to burnout.
Several studies found that residency status in itself contributes to burnout (Dyrbye et al., 2014) or burnout peaks earlier
in residency training which subsides, at least on the Emotional Exhaustion dimension, as training progresses (Campbell,
Prochazka, Yamashita, & Gopal, 2010; Pantaleoni et al., 2014;
Stucky et al., 2009; West, Shanafelt, & Kolars, 2011). In some cases,
burnout was found to be associated with younger age groups
(Woodside, Miller, Floyd, Ramsey McGowen, & Pfortmiller, 2008),
but is higher among medical trainees than the general 22–32 year
old demographic (Dyrbye et al., 2014). Evidence points to low sleep
quality and high patient loads (Stucky et al., 2009) or lower medical
knowledge (West et al., 2011) as potential elements of early training years that add to stress and burnout earlier in training. Of note,
burnout tends to be stable in studied resident populations; at least
2/3 of residents who were burned out early in training tended to
stay burned out throughout training, and residents who were not
burned out by the end of their first year of residency generally did
not develop burnout later (Campbell et al., 2010; Pantaleoni et al.,
2014).
4.1.2. Gender
In addition to age and training stage, gender played a role
in stress and burnout in a variety of studies. While high stress
and burnout results were nearly evenly split between males and
females, females trended higher on Emotional Exhaustion scores
(Olson et al., 2015; West et al., 2011) while males trended higher
on Depersonalization (Campbell et al., 2010; Woodside et al., 2008)
(Table 1). One proposed reason for this difference is the protective
effect of parenting, which shows up more strongly in women than
in men (Woodside et al., 2008). Other studies showed men score
higher on real-time stress scales (Stucky et al., 2009), persistent
burnout (Campbell et al., 2010), and cynicism (Billings, Lazarus,
Wenrich, Curtis, & Engelberg, 2011). On the other hand, women’s
greater degree of Emotional Exhaustion is related to higher fatigue
and depression rates (Dyrbye et al., 2014); Billings et al. (2011) also
found that women are more affected by witnessing unprofessional
behavior in others than are their male counterparts. Demographic
characteristics like age and gender cannot be controlled by programs. Specific interventions, as discussed later, could be targeted
toward specific groups based upon different experiences of stress
and burnout within residency training.
4.1.3. Work hours
Work hours and responsibilities are uniformly considered
stressors of residency, but workloads and hours are regulated by
the ACGME and under limited control by residency programs. The
impact of work hours have been extensively studied in general
practice residencies with mixed results. Burned out residents are
generally in favor of shorter work weeks (Gordon et al., 2012), but
actually reducing work hours does not always produce greater job
satisfaction (Gopal, Glasheen, Miyoshi, & Prochazka, 2015; Ripp,
Bellini, Fallar, Bazari, & Katz, 2015).
In 2003, the ACGME mandated resident work hours to be capped
at 80 h per week (averaged over 4 weeks) and 24 h of continuous duty per shift, plus up to 6 h of transitional or didactic time
(slideshare.net, 2010). Two studies (Gopal et al., 2015; Landrigan
et al., 2008) found that emotional exhaustion scores decreased significantly following these duty hour changes even though actual
hours worked did not change (Landrigan et al., 2008); in one case,
residents were less satisfied with the educational aspects of the program, and attendance at didactic conferences dropped considerably
(Gopal et al., 2015). Duty hour requirements were updated again in
2011 to further limit shift length to 24 h (plus up to 4 h transitional
time) for PGY-2 and above and 16 h for PGY-1 residents (slideshare.
net, 2010). Additional requirements for time off between shifts and
moonlighting also took place. Ripp et al. (2015) found no change
in burnout after these more recent work hour changes. Programs
have little control over the hours worked by their trainees or over
demographics of their trainees, as mentioned above. In addition to
program characteristics, personality characteristics of trainees play
a critical role in burnout.
T.F. McKinley et al. / Burnout Research 6 (2017) 9–17
4.1.4. Personality traits
Many studies document correlations between negative personality traits and burnout. Residents who described themselves
as pessimistic (Eckleberry-Hunt et al., 2009), disengaged (Doolittle,
Windish, & Seelig, 2013), anxious/disorganized (Ripp et al., 2010,
2011), or cynical (Billings et al., 2011) showed statistically significantly more burnout on the MBI than residents who did not
self-report these traits. Additionally, residents with high burnout
scores reported receiving little to no feedback (Ripp et al., 2011) and
had difficulty concentrating (Fahrenkopf et al., 2008), personality
features which could create their own negative feedback loop.
Beyond self-reported personality traits, studies found a higher
incidence of depressive symptoms (Campbell et al., 2010; Dyrbye
et al., 2014; Lebensohn et al., 2013; Pantaleoni et al., 2014) as well
as alcohol use and lack of physical activity (Lebensohn et al., 2013)
in burned out residents. An additional cultural trait that correlated
with higher incidence of burnout was belonging to United States
culture rather than coming to the U.S. from abroad (West et al.,
2011; Woodside et al., 2008).
Social and wellness practices also played a role in burnout prevalence. Social support, both within the training program and outside,
was found to reduce burnout in trainees (Doolittle et al., 2013;
Eckleberry-Hunt et al., 2009). Alternatively, witnessing unprofessional behavior in others in the workplace by trainees, faculty,
nursing and other staff contributed to burnout (Billings et al.,
2011). Personal practices, including mindfulness, resilience, and
self-compassion, worked to combat burnout (Olson et al., 2015).
These positive traits, along with wellness practices like sufficient
sleep, exercise, stress coping, and activities to bolster social support
systems could help offset some of the factors of resident trainees
that programs and mentors cannot control.
5. Interventions
The most commonly applied intervention for burnout was some
form of workshop or group session about burnout and/or stress.
However, session content and structure varied tremendously, as
did results. All but one study employed sample sizes under fifty
and included quantitative and qualitative forms of measurement
for the intervention (see Table 2).
5.1. Work hours
Surprisingly, only one study addressed change in work hours as
a possible way to alleviate burnout in trainees, even though mul-
13
tiple studies have cited work hours as a major cause of burnout.
Auger et al. (2012) compared residents with a modified schedule
consisting of shorter shifts and fewer hours per week to a control
group. Results followed those predicted by Gordon et al. (2012)
and Gopal et al. (2015): residents slept more and better, but education suffered; attending physicians rated the amount and quality
of education and resident recall significantly worse in the intervention group. Residents felt worse about patient ownership as
well (Auger et al., 2012). The balance between adequate rest and
effective education is one that certainly is not well defined.
5.2. Educational and skills-Building workshops
Additional studies have explored educational methods to
address burnout in residents. Some of the first to evaluate workshops as an intervention were McCue and Sachs (1991); their study
stands alone as evidence for an early intervention strategy designed
to combat the effects of resident burnout. The authors presented a
half-day workshop that covered personal management, relationship, outlook, and stamina skills. Six weeks after the workshop,
scores on the EE scale of the MBI improved for the intervention
group; scores on the DP and PA scales worsened − but at a slower
rate in the intervention group than in the control group (McCue &
Sachs, 1991).
Workshops and instructional sessions have not fared well in
more recent years. Milstein et al. (2009) and Riesenberg et al.
(2014) presented an instructional session on coping skills and a
workshop on stress recognition, respectively, to trainees without
lasting results. The missing link in both accounts could have been
lack of follow up by appropriate personnel. Both educational sessions taught residents to practice stress management techniques
on their own but did not involve any measures of accountability
for practicing and implementing these techniques.
The ACGME (Committee, 2013) requires programs to educate
personnel so “residents/fellows and faculty members are aware
of general and site-specific strategies for managing fatigue and
burnout” (p. 28). Nevertheless, residents in at least two institutions had trouble recognizing stress in fellow trainees. Riesenberg
et al. (2014) showed video clips of stressful reactions of varying
severity to pediatric residents and attending physicians. Residents
were more likely to view the residents in the clips as good role
models and thought the resident “should be able to resolve these
issues her/himself” (p. 4). After watching the same video clips,
attending physicians reacted quite differently, interpreting significant impairment and a lack of safety, as well as inadequate support
Table 2
Burnout Interventions.
Burnout Interventions
Author
Specialty
N
Intervention
Results
Auger et al. (2012)
Ped
11
Fewer work hours (ACGME
mandate)
Bateman et al. (2012)
Ped
27
Daskivich et al. (2015)
28 spec
28
Debriefing following death in
PICU
Appreciate inquiry session
about ideal work environment
McCue and Sachs (1991)
43
4-h workshop on coping skills
Milstein et al. (2009)
Ped, Med/Ped
Internal Med
Ped
No significant change in burnout;
Lower satisfaction with education,
patient ownership
Burnout not studied;
Improved pt care, teamwork
Need for more
awareness/confidentiality around
depression, formal mentoring,
supportive culture, implementing
wellness program
Lower EE scores
15
Riesenberg et al. (2014)
Multiple specialties
267
45-min instruction on BATHE
psychotherapy
60–90 min workshop on
stressed residents
No significant change
Attending physicians more likely to
recognize stress in residents; Residents
more likely to view stress reaction as
normal
14
T.F. McKinley et al. / Burnout Research 6 (2017) 9–17
from others, in the video clips. This lack of stress recognition, by residents in particular, might point to lack of education, knowledge
acquisition and ongoing reinforcement from residency program
leadership and teaching faculty in this important area.
5.3. Learner-Driven educational sessions
Two additional intervention studies employed interactive,
learner-driven sessions as opposed to educator-driven workshops.
Both achieved some level of result, mainly due to residents feeling
as though they were heard and could contribute to understanding
of the problem and/or solution.
Residents almost unanimously agreed that a debriefing session
after Pediatric Intensive Care Unit deaths helped them connect
with the interdisciplinary care team, was respectful to the child
and family, improved end of life care and gave caregivers the
opportunity to grieve (Bateman, Dixon, & Trozzi, 2012), indicating this method as a viable intervention for stressors identified
with burnout (Eckleberry-Hunt et al., 2009). Pediatric residents
appreciated that the sessions were timely (within 48 h) and multidisciplinary and that it was “safe to share” and directly impacted
their education.
Daskivich et al. (2015) employed appreciative inquiry to generate ideas about an ideal work environment for residents.
Appreciative inquiry asks participants to identify and build on positive aspects of a program (rather than creating a solution from
complaints) (Bushe, 2012). The study authors asked multispecialty
groups of residents to consider these four areas:
“Discovery: Think of a time in residency that was difficult for
you but you emerged from as a more resilient resident. . .
Dream: Describe the characteristics of an ideal learning environment that would help learners manage this transformational
journey.
Design: What must be done to achieve such a learning environment?
Destiny: What can the [ACGME] do to effectuate these changes
in the learning environment?” (p. 144)
Groups constructed five goals for the creation of an ideal work
environment: 1) depression and mental health awareness and
de-stigmatization, 2) identification and handling of stress-related
issues confidentially, 3) formal mentoring by faculty and peers,
4) support from program and trainees, and 5) increased resident
wellness initiatives (Daskivich et al., 2015).
Recent evidence of a positive impact of workshops and educational programs devoted to developing mindfulness and resilience
in a variety of medical disciplines [Mind Body Stress Reduction −
MBSR − and Mindfulness programs] (Fortney et al., 2013; Kemper
& Yun, 2015; Krasner et al., 2009; Lamothe et al., 2016) suggests
that this approach may be very useful to build personal resilience
and capacity in pediatric residents. The results of ‘short course’
mindfulness programs, some which also incorporate online work
to extend the learning experience, are particularly encouraging
since the time commitment for delivering this education is more
reasonable than traditional longer courses. Studies exploring this
promising approach in pediatric residents will be important if the
benefits seen with other groups of trainees and practitioners apply
to them as well.
Another approach is to address work related interactions
through efforts to better understand and augment civil interactions among staff in hospital settings. Leiter, et al. (2011) described
positive results in hospital staff through a detailed 6-month CREW
(Civility, Respect, and Engagement at Work) intervention. Developing better interactions and communication approaches in the local
environment resulted in more civility, respect, cynicism, job satisfaction, and trust and less burnout and absences. This approach to
improving collegiality has been shown to also enhance health care
provider outcomes (Leiter et al., 2012).
6. Discussion
Burnout is a significant problem for pediatric and other primary
care oriented residents, as it is for trainees in all medical disciplines.
The negative effect on important patient outcomes and personal
health and longevity of these future practicing physicians is so
clear, leaders of residency programs and institutions recognize the
need to address these issues with effective interventions (Jennings
& Slavin, 2015; Lefebvre, 2012). The ACGME mandates such training
(Committee, 2013), and general practice residents are among the
most burned out group of learners in graduate medical education.
Perhaps the most striking finding from the literature is the dissonance between causes of burnout in residents and evidence of
few reported specific interventions. Causes of burnout are wideranging, including factors like work hours and workload (Gopal
et al., 2015; Gordon et al., 2012; Landrigan et al., 2008; Ripp et al.,
2015; Stucky et al., 2009), as well as difficulties with mindfulness,
social support and resilience (Doolittle et al., 2013; EckleberryHunt et al., 2009; Olson et al., 2015). Importantly, many of these
factors cannot be easily changed by residency programs within
complex academic medical centers in the context of modern
healthcare in the U.S.
Work hour limitations are mandated by the ACGME; patient
numbers are determined by patient demand, institution and seasonal factors; social support is ostensibly under the influence of
programs but ultimately resides in the trainees who understand
the value and seek the benefit of support. It is likely that personality
and other intrinsic features of residents affect their access and use
of social support systems (Hurst, Kahan, Ruetalo, & Edwards, 2013;
Voltmer, Kieschke, Schwappach, Wirsching, & Spahn, 2008). The
perspectives of the individual trainee are all important in efforts to
build resilience in the face of the stresses inherent in the position,
even under the best of circumstances. Personality and other unique
individual aspects related to tendencies to emotional exhaustion,
depersonalization and loss of personal accomplishment are now
just being explored, but not yet specifically in pediatric residents in
training (Ghorpade, Lackritz, & Singh, 2007; Røvik, 2009; Spickard
Jr., 2002). Notably, when the ACGME work hour mandates did
change, resident burnout scores improved based on the perception of working fewer hours, even though most were not working
fewer hours (Auger et al., 2012; Landrigan et al., 2008).
Addressing work related environmental issues with a detailed
approach that represented a significant investment of personnel
and time demonstrated significant effects on civil behavior and job
satisfaction; importantly burnout was reduced in these nurses and
other health care professionals (Leiter et al., 2011). Resident physicians were not specifically studied in these ‘civility’ interventions
but there is good reason to think the same benefits would accrue
to residents. Based on limited evidence from interventions with
residents, it appears that short limited coping skills programs are
unlikely to be effective and that it will take more detailed skillstraining sessions and formation of truly supportive culture inside
the residency program and the institution to minimize the strong
forces that tend to induce burnout in these residents (McCue, &
Sachs, 1991; Milstein et al., 2009; Leiter et al., 2012).
Techniques like Daskivich’s et al. (2015) appreciative inquiry
session provided a novel approach to burnout. In this study residency programs reported trying educational workshops, group
sessions and formal instruction on coping techniques, whereas
pediatric residents requested more overarching interventions.
T.F. McKinley et al. / Burnout Research 6 (2017) 9–17
These included support for mental illness, mentoring, and wellness programs. These suggestions line up with findings that
self-compassion and mindfulness are inversely related to burnout
(Olson et al., 2015) and that mindful work can have long-reaching
effects and minimize burnout (Krasner et al., 2009; Lamothe et al.,
2016).
Social support could be a key focus for residency programs
committed to preventing and/or mitigating burnout and promoting resilience (Doolittle et al., 2013; Eckleberry-Hunt et al., 2009).
In studies where coping skill-based interventions failed (McCue
& Sachs, 1991; Milstein et al., 2009), no direct follow up or revisiting of these themes and skills after the educational sessions
was noted. In other words, programs presented skills to trainees
and expected them to practice these new skills without ongoing reinforcement from the residency program. Qualitative data
from formal debriefing sessions indicate that follow-up and intentional discussions can be effective burnout interventions (Bateman
et al., 2012). A supportive culture within the residency program
was one of the five recommendations made by a multispecialty
resident panel as well (Daskivich et al., 2015). Thus future directions should stress building supportive environments; developing
important personal resilience skills; developing self-care and nurturing family and other social support; and more effort to address
work-related stressful factors.
7. Future directions/imperatives
Physician health and wellness is an issue of increasing interest because of the well-documented high prevalence of burnout in
medical practitioners and trainees (Dyrbye et al., 2014). Pediatricians, pediatric trainees and other primary care oriented physicians
are as affected by these issues as any other specialty. The negative effects of burnout on physicians and on their patients and
health care systems are well documented (Wallace, Lemaire, &
Ghali, 2009). Resident physicians suffering from burnout often
report suboptimal patient care practices, more perceived medical errors, and a need to distance themselves from their patients
(Fahrenkopf et al., 2008; Prins et al., 2007). Data that now identifies the detrimental effects of chronic stress, including impaired
immune function, inflammation, elevation of cardiovascular risk
factors, and depression (Chrousos, 2009; Danhof-Pont, van Veen, &
Zitman, 2011; Juster et al., 2011) highlight the importance of efforts
to better understand the epidemiology of burnout and its opposite
force, resilience; the natural history of these important markers
of mental health and well-being in pediatricians and trainees; and
the potential benefits of effective interventions in promoting health
and preventing or mitigating burnout in these physicians.
In pediatric residents burnout is clearly multifactorial with different classes of factors. Both external (debt, high expectations,
time pressure, difficult patients, coping with death and bad outcomes, sleep deprivation and unsupportive work environments)
and internal (high personal expectations, need for achievement,
limited free time, sense of loss of former social contacts and support, isolation, poor stress management skills) forces are likely
to be active in pediatric resident burnout, although there is little direct data on these factors in this specific cohort (Shanafelt
et al., 2012). Unfortunately, the much-debated reduction of resident
work hours in 2003 by the ACGME appears to have only increased
burnout and increased job stress in faculty and trainees (Wong &
Imrie, 2013). The additional costs of burnout, including increased
incidences of anxiety, depression and/or suicidal ideation, and the
high relative rate of suicide in physicians (Schernhammer & Colditz,
2004) remains a most compelling call for us to better understand
and ameliorate burnout in our physicians and young trainees who
15
will soon enter the physician pool (Lebensohn et al., 2013). Future
efforts should include:
7.1. Efforts to address work-related stressful factors
More attention to system issues, such as providing physicians
and trainees a greater sense of control, addressing electronic health
record burdens, appropriate social as well as financial rewards, and
attention to the values of the individual in the context of the workplace will be required (Maslach & Leiter, 2008). While programs
and institutions may be addressing some of these issues in piecemeal fashion, an important emphasis should be carefully designed
efforts to address workplace issues with clearly detailed methods
and outcomes, such as MBI, resilience and productivity measures,
that can be further tested by other programs for generalizability.
7.2. Building more supportive programs and environments
The AAP 2014 Report on Physician Health and Wellness
(McClafferty & Brown, 2014) calls upon medical educators and
governing bodies to create programs and policies that promote
pediatric resident wellness and to become leaders and role models
in shaping a healthier culture of pediatric training and environments for practitioners. The report aimed to shift the focus
from burnout treatment to preventive physician health and wellness and identify factors that will increase career satisfaction
and longevity, including promotion of a balanced lifestyle that
includes physical activity, healthy nutrition, restorative sleep, supportive relationships, and effective stress management skills. The
University of Arizona Center for Integrative Medicine Pediatric
Integrative Medicine in Residency Curriculum offers a number of
well-designed educational activities for programs to employ to
address these important issue in trainees (McClafferty et al., 2015).
An important area for developing supportive environments for
residents is attention to improving the local climate related to personal interactions and communication between staff in complex
healthcare settings. Applying such programs as the 6-month CREW
(Civility, Respect, and Engagement at Work) intervention in residency program environments offers the promise of better civility,
communication, respect and mitigation of burnout in residents and
staff (Leiter et al., 2011). Efforts to improve collegiality can provide
better resident and staff well-being and also improve health care
provider outcomes (Leiter et al., 2012).
7.3. Emphasis on developing self-care and nurturing family and
social support for trainees
Studies now demonstrate that issues such as effective work-life
balance, social/family support, adequate rest, and regular physical
activity correlate with career satisfaction, improved sense of wellbeing, increased empathy, and decreased burnout (Bazargan et al.,
2009; Cydulka & Korte, 2008). These salutatory relationships are
being becoming more widely appreciated. Interestingly in the last
periodic AAP survey of members in 2012, pediatricians reported
higher satisfaction with time to spend with spouse/partner, friends,
hobbies, community activities, and spiritual needs than they have
in the past (Cull, Frintner, O’Connor, &, Olson, 2016). We have no
information on how these factors fare in pediatric trainees but programs need to focus on methods to improve these behaviors in
pediatric trainees.
7.4. Developing important personal resilience skills in trainees
In pediatric residency and fellowship training, the Pediatric
Milestone Project further addresses factors related to burnout in
trainees via Personal and Professional Development competencies
16
T.F. McKinley et al. / Burnout Research 6 (2017) 9–17
that involve the development of skills that promote wellness in
trainees and future practitioners (Hicks et al., 2010). In early 2016
the AAP Resilience in the Face of Grief and Loss Resident Curriculum was launched to provide curricular components for developing
cognitive and emotional skills of pediatric trainees to enable them
to provide high quality care while fostering personal wellness and
resilience (Serwint et al., 2016). As residency programs incorporate the AAP Resilience Curriculum into training of their pediatric
residents and fellows outcome studies will be necessary to define
the effectiveness of such educational and skill building approaches.
Mindfulness based stress reduction programs and other efforts to
develop trainee mindfulness and equanimity (Fortney et al., 2013;
Kemper & Yun, 2015; Krasner et al., 2009; Lamothe et al., 2016).
A promising new platform to better define the factors leading
to burnout and promoting resilience in a contemporary cohort of
pediatric trainees has been recently created by a group of medical
educators lead by John D Mahan and Maneesh Batra. The Pediatric Residency Burnout-Resilience Study Consortium consists of
40 pediatric residency programs in the U.S. and is designed to provide a mechanism to test the effectiveness of interventional trials
and programs in pediatric trainees [www.PedsResResilience.com].
In the initial two studies completed in 2016, 1693 pediatric residents had an overall burnout rate of 56% using the standard MBI
measure (Batra et al., 2016). The prevalence of burnout decreased
each year of training with no effects of level of debt, physical
health or family size on the presence of burnout. Residents who
were burned out reported significantly increased stress and poorer
mental health, empathy, mindfulness, resilience, self-compassion,
and confidence in providing compassionate care. Recent educational assignments and schedules and poor patient outcomes did
affect presence of burnout. Lastly, those residents who were burned
out had lower performance assessments by their teaching faculty
(unpublished data). With this baseline data, a variety of educational interventions, such as educational sessions/workshops,
support groups, mind-body skills training, individualized coaching and peer/superior mentorship programs, will be tested by the
40 residency programs that comprise this consortium. It will be
only through well-designed and outcomes-tested interventions
and programs that the community of pediatric medical educators
will be able to reliably and intentionally improve the lives and
effectiveness of their trainees and the pediatric practitioners of the
future.
Conflict of interest statement
The authors declare that there are no conflicts of interest.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial or not-for-profit sectors.
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