494
Managing Burnout
Given the high prevalence of burnout, why don’t more residents actively seek assis-
tance? In one study, 42% of residents reported inability to take time off work to seek
treatment as the most common barrier to treatment, while 24% reported ambiva-
lence, avoidance, and/or denial of the problem. More revealing is only 35% of resi-
dents agreed that they knew how to get help for a burned-out colleague, and 25% of
residents also incorrectly believed burnout is a reportable condition to state medical
board [ 7 ]. Related to the fear of burnout being a reportable condition, stigmatization
also likely plays a role [ 19 , 26 – 28 ] and is also seen in medical students and
physicians.
The biggest challenge facing the graduate medical education community is how
to prevent and mitigate resident burnout. It has been suggested that burnout starts in
medical school with reported rates up to 55.9% [ 29 – 31 ] and may develop or con-
tinue into residency [ 3 , 24 ]. Medical school may therefore be an opportune time to
introduce wellness programs and burnout interventions.
Proposed interventions are often categorized into physician-focused interven-
tions and organizational interventions. Physician- or individual-focused interven-
tions include mindfulness training [ 32 – 35 ], stress management [ 36 , 37 ], meditation
and relaxation training [ 38 ], communication skills training [ 39 ], and exercise [ 40 ].
Examples of organizational or workplace interventions are workload modifications
[ 41 ], mentoring [ 24 ], teamwork and group discussions [ 42 – 45 ], wellness programs
[ 46 ], and duty-hour restrictions. Many of the proposed interventions may reduce
burnout; however most of the studies are small and report inconclusive or conflict-
ing data. In a literature review of 51 studies by Ishak et al., they concluded current
data on interventions is insufficient to recommend any particular intervention [ 24 ].
Another systematic review and meta-analysis published in 2016 reviewed 15 ran-
domized trials and 37 cohort studies and reported overall burnout decreased from
54% to 44% (p < 0.0001), but no specific intervention has shown to be superior to
others [ 47 ]. The most recent review by Panagioti et al. of 19 randomized control
trials and controlled before-after studies similarly concluded, “At present, the low
quality of research evidence does not allow firm practical recommendations” [ 48 ].
However, they did find small significant reductions in burnout with the most signifi-
cant improvements seen in organization-directed interventions compared to
physician- directed interventions, confirming their hypothesis that burnout is an
issue of the entire health-care organization.
Of the proposed interventions, the ACGME duty-hour restrictions during surgi-
cal residency have been studied the most. As discussed earlier in the chapter, the
ACGME currently limits residents to an 80-h workweek (averaged over 4 weeks)
and 16-h shift limit for interns. One of the first to report the effects of the 80-h work-
week restriction, Gelfand et al. found that work hours significantly decreased (100.7
to 82.6, P < 0.05) but there was no significant change in surgical resident burnout
parameters on the MBI [ 49 ]. Antiel et al. studied the first cohort of general surgery
interns to train under the new 16-h shift limit restriction enacted in 2011. They
reported 44% of interns felt the restrictions decreased resident fatigue; however
28% of interns demonstrated weekly symptoms of both emotional exhaustion and
L.M. Douglass and A.C. North