Physician burnout is pervasive within graduate medical education (GME), yet programs designed to reduce it have not been systematically evaluated. Effective approaches to burnout, aimed at addressing the impact of prolonged stress, may differ from those needed to improve wellness.
We systematically reviewed the literature of existing educational programs aimed to reduce burnout in GME.
Following the PRISMA guidelines, we identified peer-reviewed publications on GME burnout reduction programs through October 2019. Titles and abstracts were reviewed for relevance, and full-text studies were acquired for analysis. Article quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI).
A total of 3534 articles met the search criteria, and 24 studies were included in the final analysis. Article quality varied, with MERSQI assessment scores varying between 8.5 and 14. Evaluation was based on participant scores on burnout reduction scales. Eleven produced significant results pertaining to burnout, 10 of which yielded a decrease in burnout. Curricula to reduce burnout among GME trainees varies. Content taught most frequently included stress management (n = 8), burnout reduction (n = 7), resilience (n = 7), and general wellness (n = 7). The most frequent pedagogical methods were discussion groups (n = 14), didactic sessions (n = 13), and small groups (n = 11). Most programs occurred during residents' protected education time.
There is not a consistent pattern of successful or unsuccessful programs. Further randomized controlled trials within GME are necessary to draw conclusions on which components most effectively reduce burnout.
The effect of burnout within health care is well-documented and continues to be a pervasive issue, particularly for physicians.1 Burnout is defined as a syndrome of emotional exhaustion, a sense of detachment from others, and reduced personal accomplishment.2 Moreover, burnout is often experienced by people, such as physicians, who operate in stressful, high-pressure workplaces. One study reported that the various factors influencing burnout levels are particularly challenging for resident physicians due to the demanding nature of residency, along with long work hours, additional nightshifts in later years of residency, pressure of time in the clinical outpatient setting, lack of experienced colleagues, limited resources, and lack of time for family.3
In an attempt to address and reduce resident physician burnout, the Accreditation Council for Graduate Medical Education (ACGME) launched the Physician Well-Being initiative, which provides resources for the graduate medical education (GME) community that are meant to “promote well-being, mitigate the effects of stress, and prevent burnout.”4 Preventative skills such as mindfulness practices, communication skills training, time management, and stress and coping workshops are the most employed programs in influencing burnout, although the ACGME has not adopted a consistent burnout management requirement.5
When developing and implementing GME programs for trainees, it is important to distinguish between wellness and burnout. A framework developed to define the relationship between wellness, burnout, and resiliency during residency identifies wellness as a phenomenon that is “more than a lack of impairment.”6 Wellness is “a dynamic process involving self-awareness that results in healthy choices,” which creates a balance between physical, emotional, and spiritual health, and perpetuates accomplishment and satisfaction, while offering a unique sense of protection from the often-overwhelming demands of medical training.6 Burnout, as mentioned above, is a maladaptive syndrome that occurs due to prolonged occupational stress. Unlike wellness, burnout is associated with lack of control, loss of self-efficacy, increased frustration, detachment, and lower levels of compassion for the field and patients; it is often associated with depression and worsened patient outcomes.6
Authors of this framework clearly discern among unique paths to resident burnout, wellness, and resiliency, showing that wellness and burnout require 2 distinct forms of programming and implementation to affect change in residency. Wellness itself acts as a coping skill not only to preserve residents' mental well-being, but also to help stave off the effects of burnout. In other words, wellness cannot exist if burnout is present.
The Medscape National Physician Burnout and Suicide Report 2021 found that 42% of physicians reported burnout, with specialties including critical care, rheumatology, and infectious diseases seeing an increase in burnout levels compared to previous years.7 Additionally, several recent studies were conducted to determine US resident physician burnout rates across various specialties. Family medicine residents across 12 programs completed burnout assessments each year of the program and found 52% scored in the moderate risk group, 25% scored as high risk, and only 23% scored as low risk.8 Thirty-eight percent of survey respondents in orthopedic surgery residency programs reported symptoms of burnout,9 and a cohort study of psychiatry residents reported 78% of its residents met criteria for burnout.10 Despite this clear evidence of the prevalence of burnout, a lack of understanding on how to reduce it persists. There is no consensus on what education programs are currently used and best reduce burnout within residency programs. This review aims to compile current skills-based programs employed to reduce burnout within GME programs.
We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.11 We published a review protocol with PROSPERO (protocol number: CRD42020159482).
Eligible studies included those that had participants who were exclusively GME trainees. Eligible studies were peer-reviewed empirical publications that evaluated a program intended to reduce burnout with a skills-based outcome. Any type of experimental study design (eg, pre/post, controlled trial) was eligible for inclusion. Studies were also not limited by curriculum design, teaching methods, program length, or when the program was completed. To be included in this systematic review, studies required a measurement of burnout as a dependent or outcome variable. Studies were included through the identification of program content, including explicit burnout reduction, reducing stress behaviors, and addressing well-being. Studies were excluded from the review that did not report a skills-based program, did not measure residents' burnout as an outcome, and/or included participant samples outside of GME programs.
A comprehensive electronic literature search of articles published through October 2019 was conducted in the following databases: PubMed, ERIC, Communication & Mass Media Complete, and Academic Search Premier. Controlled vocabulary (MeSH) and keywords were used. Four broad concept categories were searched, and the results were combined using the appropriate Boolean operators. The broad categories included skills-based programs, training programs, burnout, and GME or residency. Studies focused on medical residents from all postgraduate years, and all specialties were included in the literature search.
Study Selection, Data Extraction, and Quality Assessment
All selected studies were uploaded into Covidence, a web-based software project management system for systematic reviews. One author independently extracted data from the 24 studies using a standard data collection form that extracted: sample characteristics (sample size, mean age and gender distribution, country of study origin, postgraduate year, and specialty); type of study design; how the skills-based programs were structured, length of the program, main teaching method, and the specific content taught; whether the program occurred within residents' protected education time; how GME trainees' burnout levels were measured; the level of change pre- and post-program in burnout (if applicable); when the data was collected in relation to the study; and the key findings of the study.
The Medical Education Research Study Quality Instrument (MERSQI) was used to establish the quality of each individual study included in this systematic review.12 The highest possible score a study could receive was a 15.
A total of 3534 abstracts were independently screened by 4 coders after duplicates were removed. Contradictory abstract exclusions were reconciled by the coders. Two authors retrieved 106 full-text studies that were assessed for eligibility, 24 of which were determined as eligible for inclusion. See Figure 1 for the PRISMA flow chart of the study selection process.
Content and Teaching Methods
Aggregate curriculum characteristics from the included studies are found in Table 1. The content and teaching methods varied widely across the range of studies and often employed multiple combinations of instruction. The most common content taught within these resident training programs were stress management (n = 8), burnout reduction (n = 7), resilience (n = 7), and general wellness (n = 7). The teaching methods used most frequently included discussion groups (n = 14), didactic sessions (n = 13), small groups (n = 11), and mentors or coaches (n = 8). Serial programs, programs with a predetermined schedule spanning over the course of weeks or months, were the most common program length (n = 12), with 9 studies spanning the course of a full academic year and 3 isolated workshop-style programs. Most programs were taught to exclusively resident populations, with one study including both residents and fellows.13 There was a wide range of postgraduate years among the studies.
An important distinction among the selected articles is that most programs (n = 16) were offered during the residents' protected didactic education time that was already incorporated into their weekly and monthly schedules, including specific ambulatory rotations or academic half-days. In one study, researchers gathered informal feedback at the conclusion of the program, and most residents reported that since the sessions did not effectively free them from their clinical responsibilities, the burnout reduction program unintentionally created an added burden.14 Another study that utilized both in-person, mindfulness-based stress reduction classes and a daily practice outside of work found increases in burnout levels reported at 2 different time periods after the program's completion.15 Detailed curriculum characteristics for each study can be found in Table 2.
Burnout Scale Differences
Of the 11 studies that produced significant results related to burnout, 5 used the Maslach Burnout Inventory (MBI),16–20 2 used the abbreviated MBI,13,21 1 used the MBI General Survey,22 2 used the Copenhagen Burnout Inventory (CBI),23,24 and 1 used the Professional Fulfillment Index (PFI).25 The abbreviated MBI adds job satisfaction as a measure of burnout, and the MBI General Survey measures emotional exhaustion on a 5-point scale which is shortened to “exhaustion” as well as cynicism and professional efficacy. The CBI examines personal, work-related, and client-related burnout, while the PFI examines work exhaustion and interpersonal disengagement. The differences in burnout measures and burnout conceptualization among studies should be noted when reviewing Table 3.
A visual analysis of the aggregate burnout reduction results from programs that utilized the MBI scales is provided as online supplementary data. This table breaks down the number of times each MBI subscale was used among the studies and shows which study produced significant burnout reduction, no change, and increased significant burnout.
Program outcomes are described in Table 3. Of the 15 single group (pre/post) trials, 7 reported significant results from the instituted program.13,16,17,21–23,25 Five of these studies utilized the MBI,13,16,17,21,22 one used the CBI,23 and one used the PFI.25 Six single group studies produced decreased burnout while one produced a significant increase in burnout.
One study reported statistically significant increases in depersonalization and emotional exhaustion pre- to post-program completion, with no significant change in personal accomplishment.16 Additionally, over the course of the intervention period spanning the first 6 months of residents' first year, depression symptoms and fatigue increased significantly.
Of the 24 included studies, 2 were nonrandomized controlled trials.18,26 One trial did not yield any significant reductions in burnout between MBI measures, although they did report a reduction in emotional exhaustion for the intervention groups compared to worsening exhaustion levels in the nonintervention group.26 The other's use of the Respiratory One Method, an intentional breathing practice, decreased emotional exhaustion scores within the intervention group, but there was no significant difference between the intervention and control group.18 There was a statistically significant increase in emotional exhaustion among the control group compared between baseline and immediately post-program completion.
Three of 7 randomized control trials (RCTs) produced significant burnout reduction results.19,20,24 Two RCTs using the MBI had statistically significant decreases in emotional exhaustion of the intervention groups across varying time periods, and both had significant increases in emotional exhaustion in the control group across varying time periods.19,20 Another RCT that used the CBI saw an increase in burnout in the control group and a significant decrease in the intervention group.24 Using information gathered from programs that successfully reduced burnout, a best practices chart for burnout reduction interventions was developed and are outlined in Figure 2.
More than half (n = 13) of the studies found that there was no effect of the training program on residents' burnout scores. These studies included all study designs (single study, control trials), various teaching methods and program structure, lengths of the program, and curriculum content. Seven programs occurred during protected education time,15,26,31 3 programs occurred outside of the residents' protected education time,14,32,33 and 1 program required residents to participate in modules outside of the workday in addition to program participation during protected time.34 Two programs did not report when the training took place.35,36 Program length varied from an isolated 4-hour workshop to 9 program sessions over the course of 1 academic year. Programs showcased a broad spectrum of specialties with all programs taught exclusively to residents and one study that included residents and fellows. Instructors of the programs varied, spanning from a self-led program by the residents themselves to clinical psychologists, although most programs were either led or co-led by faculty (n = 8).
This systematic review synthesized data of 24 existing educational programs aimed to reduce burnout in GME. Most programs that were successful in reducing burnout incorporated multiple teaching methods and were most often serial programs that occurred during a predetermined amount of time during trainees' protected education time as part of their residency. Programs used a wide variety of training facilitators, including residents, program directors, certified yoga instructors, clinical psychologists, and professional coaches who were educated in each program's curriculum. We did not discover a consistent pattern of successful or unsuccessful programs pertaining to burnout reduction based on content. While studies received varying scores on the MERSQI assessment between 8.5 and 14, there were no clear outliers, and no studies were removed based on this.
Of the 24 studies included in this review, 8 produced significant positive results pertaining to burnout reduction using the MBI and 3 produced significant results using other burnout measurement scales. Nine studies occurred solely within residents' protected education time,13,16,18,20–25 one had training elements occur both inside and outside of protected time,17 and one occurred completely outside of residents' protected time.19 It is possible that incorporating training programs within residents' protected time, such as part of academic half-day lectures or scheduled wellness days, could effectively reduce burnout. Incorporating an additional responsibility for residents to participate in outside of protected education time could act as a barrier to prolonged change in physician burnout levels when some of the well-known contributing factors to burnout are excessive administrative tasks and long work hours.3
It is important to highlight the commonalities of successful burnout reduction programs to ensure increased implementation of such interventions in the future. Of the 10 programs that successfully reduced burnout, 4 were led by GME faculty, 4 were led by certified instructors or program facilitators, one was led by both faculty and program facilitators, while one was led by residents. Nine of the 10 programs included first-year residents, which could signify the need for early adoption of burnout reduction programs to lower residents' burnout scores throughout the course of the training program and showcase the value in residents incorporating these skills early in their careers. Additionally, the most common length for successful programs was a serial program structure, such as weekly meetings over the course of several weeks or months. The most common content types included stress management, resilience, general wellness, and mindfulness-based stress reduction; the teaching methods most often employed were small groups, discussion groups, and didactic learning sessions. Using these findings as a baseline for burnout reduction in conjunction with the conceptual logic model proposed by Eskander and colleagues37 could greatly assist those who want to develop a burnout reduction intervention for their GME program. Instituting burnout reduction programs for residents will help provide necessary interpersonal and professional skills to aid in the development of wellness, mindfulness, resilience, and ultimately lower burnout scores during the residents' time in the training program.
While all 11 studies that produced significant burnout results used burnout scales as a measurement tool, only one of these programs was designed with burnout reduction as a main topic of training.26 This calls into question how educators and researchers conceptualize burnout, how they define it, and how people perceive burnout. There were studies excluded from this systematic review that measured burnout as a secondary or tertiary outcome, including communication skills training, mental health support, altering the learning environment, and team learning behavior programs. Future research could extend this systematic review by including all study types that had burnout as an outcome measure even if burnout was not the main topic of study to determine if there are overarching skills or training programs that could better influence burnout reduction and maintain this reduction over a long period of time.
Of the programs that did not produce significant burnout reduction, it was more common to see 2 or fewer teaching methods used as compared to programs that produced significant burnout reduction, which used 3 different teaching methods on average. This might suggest a need for multiple teaching methods used throughout the program to reduce burnout most effectively, potentially through using Kolb's experiential learning theory as a foundation for program development.38 This education model can be useful when training residents due to the wide range of interactions and varying patients physicians interact with daily. Specifically, when teaching burnout reduction this can also prove useful in applying the skills and strategies taught in various programs to different scenarios throughout residents' training, not only immediately after program completion. Through a 4-stage learning cycle and the identification of 4 separate learning styles, Kolb developed an integrated process of learning where it is possible to enter the cycle at any stage and follow it through its natural sequence.38 This systematic review adds to the body of research pertaining to burnout and burnout reduction and showcases what is currently implemented within GME. Residency program directors and administrative staff could use this information to incorporate a burnout reduction protocol within their training programs by identifying which teaching methods, curricula, and program length have an influence on specific measures of burnout. This review could also be used by ACGME to discern which teaching methods, content, and program structure could enhance their currently instituted Physician Well-Being initiative that aims to address, reduce, and ultimately prevent physician burnout.4 Additionally, the ACGME requires residents and fellows to complete a well-being survey throughout the course of their program, with its questions addressing measures commonly found in burnout scales, such as emotional exhaustion, stress, and resilience scores.39 This review could help tailor this questionnaire to better encompass the needs and deficiencies in GME.
This systematic review adds to the current knowledge regarding best practices in addressing and reducing burnout among GME trainees. Previously published reviews in this area identify prevalence of burnout and interventions to prevent burnout such as the wellness intervention systematic review published in the Journal of Graduate Medical Education,37 and our review serves as a complement to this important piece of literature. Interventions addressing wellness may be perceived as a variant of burnout reduction programs, but there are distinct differences between wellness and burnout, as evidenced by having just 4 studies in common with Eskander and colleagues' review37 and ours. The relationship between wellness and burnout is much more complex than a simple dichotomous relationship that sits at either end of a continuum. Through examining burnout reduction programs that address residents who already suffer from moderate to high degrees of burnout compared to interventions meant to prevent burnout, this review creates a deeper, more holistic picture of the current issues with burnout in resident populations and can begin to develop longitudinal programs that create lasting change.
In addition to program directors and administrative staff, this review provides a strong foundation for medical educators who are looking to teach a skills-based program to reduce burnout. Additional programs to develop discrete skills outside of a strictly medical lens are often incorporated into residency training, such as breaking bad news, traditional communication skills, or shared decision-making, and this review provides a baseline of past programs that both did and did not have a significant outcome on burnout for educators to develop a new curriculum. This research also shows what has not proven effective so future program directors can work toward developing and instituting a validated program. More randomized controlled trials and multiple trials using similar methods would not only help to expand the knowledge of this topic but also assist in establishing a reliable program that is proven effective in reducing resident physician burnout.
While educational programs such as those included in this review are necessary to improve burnout, they have not proven sufficient for the long-term well-being of physicians. A multifaceted approach is needed, one that shifts the sole burden of burnout reduction from physicians' individual behaviors to health care systems more broadly. Several studies included in this review support the importance of organization-directed interventions to better ascertain the more systems-based components of residents' daily experiences that contribute to higher degrees of burnout.16,19,20,22,36 Organizational elements including high workloads, long work hours, and prohibitively time-consuming administrative tasks are cited as some of the most common organizational requirements that lead to higher resident burnout scores. Institutional factors such as these and the necessary medical curriculum residents must complete as part of their training program may contribute substantially to residents' experience of burnout, in which case educational approaches such as those implemented within the studies in this review may have little impact on their burnout scores. Until systemic changes are made to the treatment and training of residents, prolonged meaningful change will remain out of reach.
Due to this insufficiency, an integrated approach is necessary to ensure a shared obligation and accountability to improve the well-being of all who work in the hospital setting. This shift is discussed by Bohman and colleagues as well, who stated, “Health care organizations must embrace their responsibility to build an efficient practice environment and to foster a culture of wellness while also supporting physicians' effort to improve their own resilience.”40
An important limitation of this review is that it is based only on educational programs that have been evaluated and published. There were several feasibility studies that were excluded from the data, as they tested whether a burnout reduction program could be successful within a residency program and did not provide any empirical data to determine if there was a significant difference in burnout. Brief reports, editorials, and commentary were excluded for the same reason.
Among the included studies, wide variance in sample size and attrition rates was found, which has the potential to skew data toward or away from statistical significance. A consistent level of participation among each of the training programs was not found to accurately determine effects, with sample size ranging from 7 to 256 participants and response rates for burnout measures pre-/post-program completion ranging anywhere from not reported to 100%.
Included studies also had varying ranges of quality when evaluated using the MERSQI, which is another limitation of this systematic review. Longitudinal effects that the burnout reduction programs may have on participants are not accounted for as well, given the cross-sectional nature of the MERSQI. This review was also limited to a maximum score of 15 when the MERSQI is typically evaluated on an 18-point scale due to the type of training programs that were instituted and evaluation methods used. This adjustment in scoring can distort quality results and was not double coded to establish intercoder reliability.
This systematic review synthesizes the current programs instituted in GME that aim to reduce resident physician burnout. Certain program structures and content provide more significant burnout reduction than others, including program participation during protected education time and utilizing multiple teaching methods (ie, didactic, role-play, and group discussion). Additional randomized control trials can help produce a consistently successful burnout reduction protocol for residents.
The authors would like to thank Hayley Markovich, MA, and Aantaki Raisa, MA, for their assistance in screening the studies for this review, and Chelsea Hampton, MA, MSW, for her editorial assistance.
Editor's Note: The online version of this article contains a table of the aggregate burnout reduction results from programs that utilized the Maslach Burnout Inventory scales.
Funding: The authors report no external funding source for this study.
Conflict of interest: The authors declare they have no competing interests.
This study was presented as a poster at the Kentucky Conference on Health Communication, April 3, 2020.