Physicians across multiple specialties report high levels of burnout and occupational stress.1 Trainee physicians experience similar, if not higher, levels of burnout compared with practicing physicians.2 This higher level is likely not just a generational phenomenon, as burnout among trainee physicians is also higher than among their age-adjusted, nonphysician peers.2 Understanding burnout is important because it impairs clinicians’ effectiveness at work and is detrimental to their mental and physical health.3
Previous studies have focused on trainee burnout, although many of these investigations have been limited by small sample sizes, generalizability, and varying methods, including the use of different survey instruments to measure burnout and occupational stress.4 The study by Zhou et al4 is important because of its design as a systematic review and meta-analysis. By pooling 48 studies that included more than 36 000 trainees, the authors aimed to identify occupational and nonoccupational factors that were most strongly associated with burnout and stress in trainee physicians.
What Zhou et al4 found was that workplace-related factors, such as excessive work demands, concerns about patient care, a dysfunctional work environment, poor work-life balance, and poor career development, demonstrated stronger associations with burnout and stress compared with non–work-related factors, such as sex and financial worries. However, the results also showed that the non–work-related factor of poor mental or physical health had the second highest odds ratio for trainee burnout and stress. Nonetheless, this study generally supported what narrative literature reviews have described,5 and the authors concluded by emphasizing the importance of focusing interventions on modifiable aspects of the workplace environment to address trainee burnout and stress.
The distinction made by Zhou et al4 between workplace- and non–workplace-related factors appears to be related, in part, to whether a factor can be modified. It is easy to identify ways that workplace factors could be improved to address trainee burnout. For example, excessive work demands and a dysfunctional work environment could be mitigated by changes in duty hours, improved workflow efficiency, delegation of administrative tasks to support staff, and efforts to promote professionalism and workplace civility. Similarly, trainees’ concerns about patient care could be moderated by education on tolerance for uncertainty and taking steps to enhance team performance.
The differentiation between modifiable workplace factors and presumably less modifiable non-workplace factors, however, seems ultimately semantic. While poor mental (eg, depression and anxiety) and physical (eg, nutrition and fatigue) health can be viewed as individual (ie, non–workplace-related) factors, it is apparent that the structure and culture of graduate medical training play a large role in how health manifests or is experienced by trainees. For instance, the design and layout of health care workplaces do not always leverage human factors and systems engineering principles to promote clinicians’ abilities to rest, access healthy foods, or gather and build camaraderie. Work demands during training may also make using time to obtain personal medical care challenging. Similarly, while financial worries may be categorized as a non–work-related factor in this analysis, it is not hard to imagine how educational debt, trainees’ perceptions of inadequate financial literacy, and limited financial compensation during training are inextricably related to the workplace. The workplace environment can even influence how inherent personal characteristics, such as sex, are experienced, as the authors mention in their discussion.4 Many studies have reported higher levels of burnout and occupational stress among women clinicians, which may be due to harassment and discrimination from supervisors, coworkers, and patients, as well as workplace policies regarding family and maternity leave.6
Concerns surrounding burnout among trainees are particularly important because their future personal and professional habits may be shaped by what they learn and experience during training. Career choices, such as the pursuit of additional training in fellowship or of an academic vs community practice, may also be influenced by the burnout and stress they experience during the transient but intense period of postgraduate training. Decisions made by the tens of thousands of trainee physicians graduating each year will have significant implications for the medical profession and the sustainability of the health care workforce.
Graduate medical education leaders, training programs, medical schools, health care organizations, and accrediting bodies should address all the factors—both workplace and non-workplace—that contribute to trainee burnout and stress. These efforts need to be comprehensive and creative. Prior systematic reviews and meta-analyses of controlled interventions aimed at reducing clinician burnout have revealed relatively low-quality evidence, with the few intervention programs that have been developed and evaluated demonstrating small treatment effects.7 In addition, most work on alleviating clinician burnout and occupational stress has focused on individual-based interventions, such as building personal resiliency and practicing mindfulness-based stress reduction.7 While there is a role for individual interventions, without concurrent systems- and organization-based actions, such interventions are not sufficient. There remains a dearth of large-scale and rigorous studies of burnout interventions for trainees and other clinicians. As the landscape of medicine changes in the face of political, economic, and social challenges, issues surrounding burnout and occupational stress are not going away. Robust, evidence-based recommendations to promote the professional well-being of trainees and other health care professionals are essential.
Published: August 18, 2020. doi:10.1001/jamanetworkopen.2020.14345
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Lu DW. JAMA Network Open.
Corresponding Author: Dave W. Lu, MD, MS, Department of Emergency Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Box 356123, Seattle, WA 98195 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
Lu DW. Factors Associated With Trainee Physician Burnout—Where Should the Focus Be? JAMA Netw Open. 2020;3(8):e2014345. doi:10.1001/jamanetworkopen.2020.14345
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