We read the review of burnout interventions by Busireddy and colleagues1 with interest and applaud the authors' efforts to synthesize evidence around interventions to reduce burnout among trainees. We published a study that examined the impact of a formal narrative medicine curriculum among obstetrics and gynecology residents at 3 training programs, which demonstrated a significant improvement in emotional exhaustion (measured by the Maslach Burnout Inventory) for residents who attended more of the reflective writing workshops, with a moderate effect size as measured by Cohen's d.2
While the authors1 did not indicate in their methods when they performed their query of the literature, the review includes studies from 1991 to 2015, 1 year before our study was in print. The omission raises 2 important points. The first is that systematic reviews should indicate when they were performed, to avoid the date of publication being interpreted as the date of the most recent articles included, when in fact the review was published almost 2 years after the latest article cited.
The second point relates to the authors' conclusions. The authors conclude that work hour limits are the only intervention that demonstrated improvement in burnout. We believe this intervention stands out not because it is more impactful, but because it is more prevalent and could therefore be studied across a larger sample. Work hour limits are important, and without sufficient sleep and time for self-care, it seems inevitable that residents will suffer from burnout. The findings likely were more robust because this intervention was more common.
The Accreditation Council for Graduate Medical Education recently changed a Clinical Learning Environment Review focus area from work hours to resident and faculty well-being. This signals a recognition that improving burnout requires more than just time outside work. The concept of work-life balance leaves out the important step of integrating a more holistic approach to individual wellness with professional engagement.
Medicine is a calling, not a job. While sleep deprivation can contribute to burnout, there likely are aspects about the way the work is structured that can be influenced at the program level to either ameliorate or worsen burnout.
Narrative medicine uses literature and other forms of art to facilitate a process of reflection. It is often conducted in a shared space that encourages self-awareness, encourages physicians' understanding of vulnerability, and creates enhanced connections within a community to help physicians understand their relationship to self, patients, and society.3 Its role in our obstetrics and gynecology residency programs is to provide a formal opportunity for processing some of the complicated and challenging experiences that residents have as they go through their professional developmental process. We would agree with Busireddy and colleagues' conclusion that adding required activities in the name of improving wellness may miss the mark with residents who are already chronically overburdened.1 For this reason, our curriculum takes place during protected time and does not include any preparatory reading or other homework. It will be challenging to explore whether this and other interventions aimed at improving the learning environment for residents are effective across sites and specialties. Thus, we commend the authors for examining initiatives across specialties and programs.
We feel their conclusion that only work hour limits make a difference has more to do with the interventions that were available for rigorous study than the types of interventions that are promising. Creating a better learning environment will require us to examine the stressors and pleasures in the work, to allow us to work toward mitigating the former and enhancing the latter. Enhancing meaning and fulfillment in work by allowing residents time with patients, providing support by allied health professionals for aspects of the work that do not enhance education, and coaching residents through challenging experiences are promising interventions that should not be overlooked.
