49528% reported depersonalization on the MBI, and one in seven residents considered
giving up a surgical career [ 50 ]. Importantly, interns felt there were decreased coor-
dination of care (53%), decreased ability to achieve patient care continuity (70%),
and decreased operating room time (57%). A systematic review of 135 articles, of
which 57 were considered moderate to high quality, concluded duty-hour restric-
tions did show benefits to resident wellness after the 2003 regulation limiting to an
80-h workweek but no consistent improvement after the 2011 restriction to 16-h
shifts for interns [ 51 ]. They also found negative impacts on patient outcomes and
resident performance on certification exams. More recently, the results of the FIRST
trial were published in 2016 [ 52 ]. The FIRST trial was a national, non-inferiority
trial comparing current, standard ACGME duty-hour policies to flexible policies
that waived rules regarding shift length and time off between shifts. The 80-h work-
week remained in place for both groups. The results showed no significant differ-
ence in overall well-being between the two groups (14.9% vs. 12.0%, p = 0.10).
They also found no significant difference in the effect of fatigue on personal or
patient safety. Everett et al. also found that despite the 80-h workweek limitation,
general surgery residents continue to leave general surgery at an increased rate (0.6–
0.8 residents/lost/program/year, p = 0.0013) [ 22 ]. Overall, a significant proportion
of residents remain burned out despite duty-hour restrictions.
One must consider that wellness is more than the absence of burnout. There has
been recent focus on resident wellness programs (RWP) as a method to not only
reduce burnout but to improve the overall well-being and health of residents. An
article by Lefebvre defined resident wellness programs as a “combination of active
and passive initiatives targeting the various domains of physical, mental, social, and
intellectual wellness” [ 53 ]. The author proposed the key components of an effective
program are a safe place to express grievances; ongoing surveillance that may
include mandatory meetings; educational lectures, workshops, and exercises; and
physical, mental, social, intellectual, and community wellness initiatives and should
include both active and passive strategies. The effectiveness of a RWP likely relies
on the effectiveness of its individual components, although the additive effects of a
comprehensive program are unknown. As an example, a residency program in Texas
developed a Wellness Toolbox with the hope of shifting the focus from burnout to
wellness. The toolbox includes screening for burnout and then providing ongoing
education on achieving wellness. There are lectures to promote wellness, retreats,
support groups, social events, and other activities aimed at promoting wellness.
Objective data is lacking, but the authors report a perceived culture shift within the
department with an increased willingness to openly discuss wellness and participate
in wellness activities [ 54 ].
Conclusion
Resident burnout is a significant issue for patients, residents, and the medical
education community. Despite increased interest in resident burnout, there is a
lack of large, high-quality studies to identify risk factors and protective factors
for burnout. This poses a significant challenge in identifying at-risk residents and
developing preventative strategies. While there are a multitude of proposed
burnout interventions, the current data is not sufficient to recommend a single25 Resident Physician Burnout: Improving the Wellness of Surgical Trainees