Context.—

Physicians face a high rate of burnout, especially during the residency training period when trainees often experience a rapid increase in professional responsibilities and expectations. Effective burnout prevention programs for resident physicians are needed to address this significant issue.

Objective.—

To examine the content, format, and effectiveness of resident burnout interventions published in the last 10 years.

Design.—

The literature search was conducted on the MEDLINE database with the following keywords: internship, residency, health promotion, wellness, occupational stress, burnout, program evaluation, and program. Only studies published in English between 2010 and 2020 were included. Exclusion criteria were studies on interventions related to the COVID-19 pandemic, studies on duty hour restrictions, and studies without assessment of resident well-being postintervention.

Results.—

Thirty studies were included, with 2 randomized controlled trials, 3 case-control studies, 20 pretest and posttest studies, and 5 case reports. Of the 23 studies that used a validated well-being assessment tool, 10 reported improvements postintervention. These effective burnout interventions were longitudinal and included wellness training (7 of 10), physical activities (4 of 10), healthy dietary habits (2 of 10), social activities (1 of 10), formal mentorship programs (1 of 10), and health checkups (1 of 10). Combinations of burnout interventions, low numbers of program participants with high dropout rates, lack of a control group, and lack of standardized well-being assessment are the limitations identified.

Conclusions.—

Longitudinal wellness training and other interventions appear effective in reducing resident burnout. However, the validity and generalizability of the results are limited by the study designs.

Burnout is defined in the latest edition of the World Health Organization's International Classification of Diseases as “… a syndrome… resulting from chronic workplace stress that has not been successfully managed … characterized by 3 dimensions: (1) feelings of energy depletion or exhaustion; (2) increased mental distance from one's job, or feelings of negativism or cynicism related to one's job; and (3) reduced professional efficacy.”1 

Physicians face a higher rate of burnout than the general population. This is especially true during the residency training period, when trainees often experience a rapid increase in professional responsibilities and expectations. Dyrbye et al2  conducted a survey on the well-being of US medical trainees and early career physicians, including 1701 residents from a wide range of subspecialties. They found alarmingly high rates of burnout (60.3%), depression (50.8%), and suicidal ideation (8.1%) within the preceding 12 months among residents. These rates of burnout and depression were significantly higher than the rates of early-career physicians (51.4% for burnout and 40% for depression) and a nonphysician cohort from similar socioeconomic demographics (31.4% for burnout and 41.1% for depression).2  A recent online survey by Han et al3  on the well-being of 79 Canadian laboratory medicine residents during the COVID-19 pandemic identified very high rates of burnout (63%) and depression (47%) among the residents, with 14% of respondents reporting moderate to severe depression that would require immediate treatment. The COVID-19 pandemic likely further aggravated the residents' baseline distress by adversely impacting their learning and career planning, physical and mental health, and personal finance (such as spouse being laid off).3 

Clearly, measures by residency programs and institutions are urgently needed to address this significant issue. Since 2017, the Accreditation Council for Graduate Medical Education formally requires programs to have resident well-being policies and initiatives, which will be monitored through accreditation.4  The most recently published standard of accreditation for anatomical pathology residency programs by the Royal College of Physicians and Surgeons of Canada5  also includes a requirement for programs to specifically address resident well-being issues, in addition to offering academic support to struggling residents. In response, our institution has developed comprehensive wellness guidelines for postgraduate medical trainees that outline the roles and responsibilities of the trainees, training programs, and institutions in trainee well-being, as well as available wellness resources and support.6 

However, in the online survey by Han et al,3  although three-quarters of Canadian laboratory medicine residents surveyed reported having access to burnout prevention activities and resources through either their residency training programs or institutions, these initiatives did not significantly affect the rate of burnout. This survey identified some potential areas for intervention, such as measures to improve career satisfaction, peer support and pathologist mentors, time off for illness and maternity/paternity leave, and measures to decrease financial stressors.3  Several systematic reviews and meta-analyses have been conducted to examine the effectiveness of burnout interventions for resident physicians published prior to 2015.79  The majority of the interventions consisted of duty hour restriction as per Accreditation Council for Graduate Medical Education guidelines or wellness training programs, with both types of interventions found to be effective in reducing resident burnout.8,9  However, few other intervention types were examined in these review studies.

This scoping review examines the content, format, and effectiveness of resident burnout interventions published in the last 10 years.

The literature search was conducted on the MEDLINE database from 1946 to September 18, 2020 with the help of a research librarian. Both subject headings and text word terms were used to search for articles with the following keywords: internship or residency AND health promotion, wellness, occupational stress, or burnout AND program evaluation, program (see supplemental digital content at https://meridian.allenpress.com/aplm in the February 2023 table of contents). Studies written in English published between 2010 and 2020 that described interventions to reduce burnout and provided detail on one or more of the following were included: program content, format, and postintervention well-being assessment. Interventions related to the COVID-19 pandemic were excluded because of their context specificness. Studies on duty hour restriction were also excluded, as this intervention has been extensively studied and may not apply to non-US residents. In total, 30 studies were included in this scoping review. The search results are presented in the form of a flow diagram (Figure 1), as recommended by the Preferred Reporting Items for Systematic Reviews.10 

Figure 1

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

Figure 1

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

Close modal

A summary of the included studies can be found in Tables 1 through 4, classified by burnout program effectiveness. Two studies11,12  were published prior to 2015, and 28 studies1340  were published in 2015 or later. Twenty-eight studies1122,2426,2840  were conducted in the United States and 2 studies23,27  in Canada. The studies included a variety of surgical and nonsurgical residency programs. However, no study involving laboratory medicine residents was identified. The results are synthesized under 3 themes: burnout program content, burnout program format, and burnout program effectiveness.

Table 1

Burnout Intervention Studies With Improved Well-Being Assessment(s) Postintervention

Burnout Intervention Studies With Improved Well-Being Assessment(s) Postintervention
Burnout Intervention Studies With Improved Well-Being Assessment(s) Postintervention

Burnout Program Content

Eighteen studies* reported burnout programs involving a single type of intervention, whereas other programs13,21,26,2831,37,39  involved 2 or more types of interventions. Several types of burnout interventions were identified, targeting mental, physical, social, or occupational well-being (Figure 2). Twenty programs involved wellness training designed to improve mindfulness, resilience, stress coping mechanisms, and sleep quality. The majority of these programs consisted of a series of didactic lectures, with 4 programs specifically mentioning ongoing maintenance wellness activities such as daily or weekly mindfulness exercises13,24,37  and wellness check ins with other residents13,34  after the didactic lectures. One program consisted of individual meditation training using the Headspace (Headspace Inc, Santa Monica, California) mobile application.18  Nine programs§ involved initiatives to promote physical exercises in groups or individually, such as low-cost/free access to the gym, yoga classes, activity trackers, and fitness competitions. Five programs13,21,29,31,37  involved initiatives to promote healthy dietary habits, such as free access to healthy food, nutrition and cooking classes, and healthy diet competitions. Four programs13,21,26,37  involved social and team-building activities among residents other than group physical activities. Four programs15,21,23,30  involved formal mentorship by senior residents or faculty members. Other types of interventions included access to psychological counseling services,16,21  with the study by Salles et al21  going as far as offering weekly one-on-one meetings with a clinical psychologist to all residents; improvements to resident work structure such as streamlined patient admission process21,37 ; incentives for health checkups and access to primary care providers29,37 ; allotted time off for personal health- and wellness-related activities38 ; and a peer recognition program.35 

Figure 2

Burnout program content.

Figure 2

Burnout program content.

Close modal

Burnout Program Format

Twenty-eight programs1113,15,1737,39,40  were longitudinal in nature, consisting of a series of recurring lectures or activities. However, most of these were 1 year or less in duration. Two programs evaluated one-time sessions; one program consisted of a 90-minute session on wellness training,14  and the other program provided one-time psychological counseling.16  The majority of the programs had 50 or fewer participants, with the median number of program participants being 39.

Burnout Program Effectiveness

Pretest and posttest was the most commonly used study design to evaluate burnout program effectiveness, with only 5 studies including a control group,11,20,22,24,32  including 2 randomized controlled trials.11,20  Nineteen studies had more than 70% of program participants involved in program evaluation, with the median number of evaluation participants being 25.5. The majority of the program evaluations were conducted immediately after the end of the programs, with only 2 studies having follow-up evaluations examining the long-term impacts of the burnout programs at 3 months40  and 1 and 2 years32  after the completion of the burnout programs. Twenty-three studies used a validated well-being assessment tool as part of program outcome evaluation (Tables 1 through 3), with most of these studies using more than 1 tool. Full or abbreviated versions of the Maslach Burnout Inventory, which assesses emotional exhaustion, depersonalization/cynicism, and reduced personal accomplishment/professional efficacy, were the most commonly used tools. Other tools used in these studies assessed other aspects of well-being such as depression, anxiety, and quality of life. Of the studies that used a validated well-being assessment tool, 10 studies# reported significant improvements in the assessment scores postintervention (Table 1), 10 studies** reported nonsignificant changes in the assessment scores (Table 2), and 3 studies14,19,28  reported deteriorations in the assessment scores in spite of the positive feedback from program participants (Table 3). However, the programs appeared to affect various aspects of well-being differently. All 10 studies that reported improvements postintervention used more than 1 assessment tool, but only 2 studies reported improvements in the scores of all well-being assessment tools used.23,24  All 7 studies16,26,27,3335,38  that did not use a validated well-being assessment tool reported improvements in some aspects of resident well-being postintervention (Table 4); however, the validity of these results is questionable. Of the studies that used a validated well-being assessment tool, wellness training appeared to be the most effective intervention in reducing resident burnout, with 7 of the 10 effective burnout programs11,22,24,29,32,39,40  having such training. These studies also had some of the most rigorous study designs, with 1 study11  being a randomized control trial, 3 studies22,24,32  having a case-control design, and 5 studies11,22,24,32,40  with wellness training as the only type of intervention investigated. Interestingly, 6 of these wellness training programs11,22,29,32,39,40  had no formal ongoing maintenance wellness activities post–didactic lectures. However, all of these programs were longitudinal in nature, consisting of a series of lectures occurring during 2 months to 3 years. The long-term impacts of these wellness training programs were mixed: whereas 1 study found persistent improvements in well-being assessment scores among program participants at 1 and 2 years postintervention,32  another study found similar well-being assessment scores at baseline and 3 months postintervention among program participants, despite the initially improved scores immediately at the end of the program.40  Regarding other types of burnout interventions, 4 of the 10 effective programs12,29,31,33  included incentives to promote physical exercises, 2 programs29,31  included incentives to promote healthy dietary habits, 1 program29  included social activities among residents, 1 program24  included a formal mentorship program with faculty mentors, and 1 program29  included incentives for annual physical and dental exams.

Table 2

Burnout Intervention Studies With Nonsignificant Changes in Well-Being Assessment(s) Postintervention

Burnout Intervention Studies With Nonsignificant Changes in Well-Being Assessment(s) Postintervention
Burnout Intervention Studies With Nonsignificant Changes in Well-Being Assessment(s) Postintervention
Table 3

Burnout Intervention Studies With Worsened Well-Being Assessment(s) Postintervention

Burnout Intervention Studies With Worsened Well-Being Assessment(s) Postintervention
Burnout Intervention Studies With Worsened Well-Being Assessment(s) Postintervention
Table 4

Burnout Intervention Studies Performed Without Using a Validated Burnout Assessment Tool

Burnout Intervention Studies Performed Without Using a Validated Burnout Assessment Tool
Burnout Intervention Studies Performed Without Using a Validated Burnout Assessment Tool

Interest in burnout interventions for resident physicians and their effectiveness has increased substantially in the last decade, especially in North America. Although many burnout interventions targeting mental, physical, or social well-being at an individual level are described, few programs addressed occupational well-being, and only 2 programs21,37  addressed resident work structure. Burnout is an occupational phenomenon that cannot be mitigated by focusing only on individuals, and effective solutions have to involve occupational wellness initiatives.41  Organizational and systemic changes should also be explored be to prevent burnout. Wellness training programs have been the most extensively and rigorously studied, with the effective interventions all being longitudinal programs occurring as a series of lectures with or without ongoing maintenance wellness activities during 2 months to 3 years. In addition, results on the persistent effects of wellness training were mixed, highlighting the need for ongoing support during the entire residency training period.

Many of these studies had significant flaws in their study designs. The majority of the studies used a combination of various types of burnout interventions. Although in practice resident physician burnout is a complex issue that likely requires multipronged burnout interventions, studies of such programs do not allow for conclusive evaluation of the effectiveness of an individual type of burnout intervention and also have limited generalizability. The majority of the studies also included fewer than 50 program participants and even lower numbers of evaluation participants, and the results can therefore be easily biased and lack statistical power. The lack of a control group in all but 5 studies further increases the likelihood of biases; literature has identified that resident physician burnout is influenced by the training stage,42  making pretest and posttest study design, the most commonly used in this scoping review, potentially unsuitable. These biases may explain why several studies showed worse well-being assessment scores postintervention, despite having positive feedback from program participants. Finally, and perhaps most importantly, only a subset of the studies included the use of a valid well-being assessment tool in program evaluation, with the majority of them using a combination of various assessment tools. Although versions of the Maslach Burnout Inventory were the most commonly used burnout assessment tools in this scoping review, studies have criticized the design and cost of the Maslach Burnout Inventory, as well as the nonequivalence between the full and abbreviated versions of the inventory.43,44  The lack of standardized well-being assessment and the conflicting results among the various assessment tools limit the validity of the study results and the ability to assess the effectiveness of different burnout interventions. Strategies to overcome these design flaws include focusing on one burnout intervention at a time; increasing sample size through the use of multicentered and/or multicohort approaches; minimizing dropout and loss to follow-up through the use of user-friendly burnout interventions, participation incentives, and frequent reminders; ensuring the presence of a well-matched control group; and using well-validated, user-friendly tools specific for burnout assessment.

Although data specific to laboratory medicine and pathology residents are lacking, based on the results from this scoping review, residency program directors and educators looking to implement wellness intervention for laboratory medicine and pathology trainees should consider a longitudinal program that focuses on wellness training, physical well-being, and work support such as mentorship and improved work structure. They should also strive to evaluate program effectiveness, taking into account the design flaws of existing studies and the strategies to overcome these flaws.

Longitudinal wellness training and other burnout interventions appear effective in reducing resident burnout. However, the validity and generalizability of the results are limited by the study designs.

The authors would like to acknowledge Elizabeth Uleryk, MLS, (medical literature search and health science librarian) for her assistance in the literature search.

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*

References 11, 12, 1420, 2225, 27, 3236, 38, 40 .

References 11, 13, 14, 1720, 22, 24, 25, 2730, 3234, 36, 37, 39, 40 .

References 11, 13, 14, 17, 19, 20, 22, 24, 25, 2830, 3234, 36, 39, 40 .

§

References 12, 13, 26, 28, 2931, 37, 39 .

References 1113, 17, 1925, 2832, 3840 .

References 1115, 1725, 2832, 36, 37, 39, 40.

#

References 11, 12, 22, 23, 24, 29, 31, 32, 39, 40 .

**

References 13, 15, 17, 18, 20, 21, 25, 30, 36, 37 .

Author notes

Supplemental digital content is available for this article at https://meridian.allenpress.com/aplm in the February 2023 table of contents.

The authors have no relevant financial interest in the products or companies described in this article.

Supplementary data