13. Physician burnout and the impact on resident well-being

Introduction

The issues of physician wellness and physician burnout have become increasingly important and recognized over the past decade. Although physicians of any age and at any stage of their career are vulnerable to burnout, the literature demonstrates that resident physicians are at a higher risk of having their well-being compromised. The most recent Canadian figures, from the Canadian Medical Association’s 2017 National Physician Health Survey,¹ indicate that while 29% of practising physicians who responded to the survey were experiencing burnout, 38% of the residents who responded were frequently feeling burned out. In addition, 48% of those residents screened positive for depression and a frightening 15% indicated that they had had suicidal ideation within the past year. Further, more recent data gathered from the Resident Doctors of Canada National Resident Survey in 2020 demonstrated that 51.6% of residents report symptoms of burnout with 20.2% having thoughts of suicide. Bullying also contributes to resident burnout, and the 2020 Resident Doctors of Canada Survey notes that 64.1% of residents experienced bullying in the prior year, with the most frequent basis of bullying was due to age/seniority, followed by sex. Residents who come from diverse identities, including BIPOC, LGBTQ2S+, or those who are parenting, may have preventable experiences that contribute to overall burnout.  Burnout is a serious problem, which leads in turn to serious consequences for many people, including physicians and their patients. It is abundantly clear why program directors must take resident well-being very seriously.

It is imperative that you as a program director, and all those engaged in residency education, be informed about this issue and that wherever possible, you take steps to mitigate the risks including through explicit curricular initiatives. This chapter presents you with information on what is currently known about the factors that contribute to poor resident health. It also provides you with some ideas on how you can address this situation in your program.

Burnout and its impact on resident well-being

Defining physician burnout

You’ve probably heard about physician burnout many times, but how easily could you define and describe it? As the program director of a residency program, it’s important that you have a solid understanding of burnout so that you are prepared to support your residents and their well-being throughout their training. To start, take a step back and consider how burnout is defined. In 1997 Maslach and Leiter defined burnout as “a psychological syndrome emerging as a prolonged response to interpersonal stressors on the job.” Ruzycki and Lemaire defined it as “a work-related syndrome that occurs in occupations where others’ needs come first, and where there are high demands, few resources and a disconnect between workers’ expectations and experiences.”² When you consider these definitions, it is easy to understand why resident physicians are considered to be such a high-risk group.

Three elements of burnout

Burnout is a syndrome that is characterized by three elements. As a PD, it will be helpful for you to be aware of these elements and how they typically manifest. The first is emotional exhaustion. Residents who have burned out feel fatigued and physically and emotionally drained, and they have lost their enthusiasm for their work. The second element is depersonalization. Depersonalization manifests as cynicism or uncaring behaviour toward others, particularly toward those who are being served. The third element is a low sense of personal accomplishment, associated with a perceived loss of meaning in the work and feelings of ineffectiveness.

All three of these elements are captured in Leiter and Maslach’s description of burnout: lost energy, lost enthusiasm and lost confidence.³ Burnout is problematic for the affected resident physicians, the patients for whom they provide care, their peers and their colleagues across the health care system. On the ground, burnout might look like excessive presenteeism or absenteeism, increased turnover and decreased job performance. In the more extreme cases, some of these signs may be visible to you as the program director, but often the problem may be very difficult to detect. The reason for this is that there continues to be stigma attached to burnout and many residents go out of their way to hide their problems for fear that they may negatively affect their training and future career prospects. It’s therefore a good idea to ensure that the residents and faculty in your program are aware of these three elements, so that they can take steps to ensure their own self-care and can pick up on early warning signs in others.

Impact of burnout on resident well-being

Although burnout will look different from person to person, the bottom line is that no matter how it presents itself, burnout negatively affects a resident’s well-being. Burnout has personal costs, which may include feelings of hopelessness; irritability; impatience; decreased empathy; poor interpersonal relationships with family, coworkers and patients; depression; drug abuse; or physical illness.⁴ Research shows that all of these personal consequences have a direct negative effect on patient safety, job satisfaction and quality of care. There is considerable evidence that physicians who are burned out have increased needle stick injuries and decreased efficiency and their patients experience more complications; these all result in increased costs and resource use for the organization. For these reasons, it’s important for your program to both mitigate the risk of burnout and ensure that there are supports available to your residents when they are suffering.⁴

Recognizing and addressing factors that contribute to burnout

There has been a substantial amount of research on physician burnout and the factors that contribute to it. As you may expect, the factors are numerous, complex and context dependent. There is some good news, though. Research suggests that recognizing these factors and taking appropriate action will make a positive difference. Table 11.1 provides a framework to help you organize and consider these factors.

As a program director, your ability to influence these factors may depend on the current state of your program, as well as external factors. A practical approach may be to concentrate your early efforts on those factors for which your sphere of influence is highest. Once you’ve created some momentum and have a good understanding of the needs in your program, you can expand your efforts, engaging the resources available to you. Further, you could engage your fellow program directors and your postgraduate dean in the creation of a wellness committee for your institution. In this way, you could have a positive impact on the clinical and learning environment for residents across your organization.

Table 12.1

Category	Example factors that may contribute to burnout	Example actions you may take to support your residents
Health care system	• There are pressures to contain costs • Medical professionals are expected to increase efficiencies	• Monitor and check in with your residents to explore impacts and engage learners in practical plans to mitigate the issues
Workload	• Residents are assigned a heavy burden of work and are given a limited amount of time to complete it • The available technology may be inadequate to support the work or may be challenging to use • On-call requirements can lead to sleep deprivation	• Monitor and take responsibility for addressing workload issues when they arise • Advocate for technology and appropriate training to improve efficiencies • Ensure call requirements meet the contractual standards • Ensure on-call workflow is designed with efficiency and wellness in mind • Exploring alternative models of call • Exploring fatigue risk management strategies (e.g. reducing non-urgent overnight pages)
Medical culture	• There are high expectations of medical professionals and a low degree of empathy for their challenges • There are generational differences in workplace expectations • Workplace bullying and discrimination	• Create wellness champion positions in your program • Develop services or programs that are accessible to residents and faculty • Encourage open conversations about generational differences in medical education • Connect residents with EDI leaders, listen deeply to acts of bullying/discrimination, and support actionable changes in these domains
The nature of individual residents	• Medicine attracts high achievers who may find it challenging to step back from work	• Ensure your selection processes reflect the mission and vision of the program • Provide access to confidential wellness counsellors • Provide a mindfulness-based stress reduction program

The factors identified in Table 11.1, along with many others not mentioned, contribute to a high prevalence of burnout among resident physicians. Multiple studies over the past decade have reported high rates of depersonalization, emotional exhaustion and overall burnout among residents. The implications for the learners are significant. Burnout will have a negative impact on the resident’s professional development, as it can affect their motivation, their ability to concentrate and learn, their decision-making ability, their acquisition of knowledge and skills and ultimately the patient care they provide. Consequences outside of their work life may also include things such as alcohol or illicit drug use, suicidal ideation, depression and career regret. Quite clearly, efforts to reduce and prevent burnout are necessary, along with simultaneous efforts to enhance the work and learning environment for residents.

Burnout and the role of the learning environment

As a program director, part of your responsibility is to ensure that residency education occurs in a positive learning environment that promotes resident wellness.⁵ As you know, the learning environment comprises the diverse physical locations, contexts and cultures in which residents learn. Over the course of their training, residents learn and work in settings that include classrooms, simulation laboratories, anatomy laboratories, ambulatory clinics, acute care hospitals, long-term care homes and more. These settings, taken in aggregate, constitute a resident’s complex and rich learning environment.

You and the team of people who help provide education and care in the learning environment share a common goal — better health for all.⁶ Ironically, however, burnout in residents stems primarily from their experiences in the learning environment.⁷ In addition to the factors listed in Table 11.1, learner-specific factors such as “inadequate preparation and support, supervisor behaviors, peer behaviors and a lack of autonomy” also contribute to burnout.⁷

Given the multiple settings and the complexity of the factors that contribute to burnout, it is challenging to know where to begin to address the learning environment issues that influence resident well-being. The good news is that you’re not alone: others are considering this very question. A report produced by the Josiah Macy Jr Foundation in 2018, Improving Environments for Learning in Health Professions Education, provides many ideas and recommendations to guide you.⁶ Their work suggests conceptualizing the learning environment as four overlapping, interactive components: the personal component, the social component, the organizational component, and the physical and virtual component. Each of these aspects can be a focus of attention when you implement changes to improve your resident’s learning environment.

• Personal component: This refers to the interaction between the learner and their environment. The environment in which we learn and work influences our thinking, emotions and behaviours. Also, the temperament and attitude of the learner reciprocally influences the environment. Suggestion: Consider how your program already supports individual residents. Is this working well? What could be tweaked? What could be added?
• Social component: Learning happens when we engage with others. The multiple relationships your residents have — supervisor–resident, patient–resident, peer–peer — influence their learning. Suggestion: Consider how your program supports socialization and connection. Perhaps you have established peer-to-peer mentorship programs, engagement activities, etc. Ask your residents to tell you what is working well, what could be tweaked and what could be added.
• Organizational component: The organizational culture, values, policies and supports provided to your residents are markers of the learning environment. Suggestion: Consider whether the organizational components of your program are enhancing or detracting from your learners’ experience. What are you doing to nurture the culture of your program and support its values? Is this working well? What could be tweaked? What could be added?
• Physical and virtual component: Resident learning takes place largely in physical workspaces that exist primarily to deliver care. What kind of facilities exist to also support learners and facilitate learning? Learning also occurs in virtual settings. What informational and technological resources are available to support this process? Suggestion: Take some time to ask your residents how the physical and virtual set-up supports their learning. For example, do they have enough space and technology to do their work? What is working well? What could be tweaked? What could be added?

As health professionals, we wish to provide a learning environment that is stimulating, collaborative and respectful while also recognizing that the work can be challenging and stressful. We know that a positive learning environment facilitates learning and caring within a program. If your program’s learning environment is already positive then your job may be easier; you can nurture and enhance the great foundation that you’ve inherited. On the other hand, if there are signs that the learning environment needs improvement, then you can enhance it by working with others to deliberately choose strategies that address each of these four components.

Strategies to enhance resident wellness

Your approach to resident wellness will be most successful if it is multi-pronged. This is because there is no clear evidence that any one single approach to resident wellness is effective on its own. On the other hand, there are multiple interventions that have been implemented that show promise. Therefore, each program should consider the nature of their unique learning environment and approach it considering the need to support individual residents, the social aspect of wellness, the organization and the culture in which the residents are learning and working, as well as the physical and virtual facilities. Suggested strategies to approach the implementation of wellness programming are provided below. These lists are not exhaustive, but they do provide you as the program director with a menu of possible strategies to prevent or mitigate resident burnout.

Addressing the needs of individual residents

• Conduct a wellness survey, including an exploration on workplace bullying and discrimination
• Establish or referral to a mentorship program or peer support program, specifically for diverse residents are connected to physicians with similar backgrounds (e.g., Black or LBGTQ2S+ resident connected with a staff physician)
• Provide access to confidential wellness counsellors and culturally appropriate leaders (e.g., Elders)
• Support access to a family physician, recognizing that a resident may have specific needs for safety (e.g., Trans residents wanting a Trans-inclusive provider)
• Provide access to an employee assistance program
• Provide access to occupational health services
• Provide a mindfulness-based stress reduction program
• Adopt the Road to Mental Readiness program
• Adopt the Resident Doctors of Canada’s Resiliency Curriculum
• Teach self-assessment and self-reflection skills
• Teach time management
• Provide financial management instruction
• Provide time to attend health care appointments

Addressing the need for social connection

• Organize regular resident retreats
• Establish a resident social committee
• Arrange financially supported resident social events
• Engage in athletic activities as a program (e.g., soccer team, cycling team, running team)
• Engage resident partners and family members in social events
• Ensuring that some events are accessible for residents who are parents (e.g. events take place in late afternoon) or residents who do not drink alcohol (e.g., hosting events at alcohol-free locations)
• Establish a book club
• Establish a movie/film club
• Establish a dinner club
• Establish a COMPASS (Colleagues Meeting to Promote and Sustain Satisfaction) group

Addressing the organizational component of wellness

• Engage senior leadership in this work
• Ensure alignment between the values of the organization and your program
• Establish a lead wellness position for your organization
• Establish a wellness committee for your program
• Create wellness champion positions in your program
• Establish policies to support flexibility in training, including leaves
• Ensure that part-time training is available
• Provide accommodation when required
• Establish a Balint group
• Establish a quality improvement process to streamline workflow
• Provide training on the appreciative inquiry model and organizational AI processes

Addressing the physical and virtual facilities

• Offer access to nutritious food 24 hours per day
• Provide access to clean and comfortable on-call rooms
• Offer access to a quiet room for prayer, sleep, fatigue management
• Easy access to room for breastfeeding and fridge for safe storage of breastmilk
• Offer access to childcare facilities
• Easy access to gender-neutral bathroom facilities, recognizing that having only one area in a large hospital may not actually be accessible
• Provide effective training on how to use your institution’s electronic health record
• Ensure access to online library resources and point-of-care tools
• Provide transportation between clinical sites
• Provide instruction regarding professional use of social media

Putting it all together for your program

As you can see, enhancing resident well-being and understanding burnout and the contributing factors are critical roles for you as a program director. Whether you have inherited a program with robust processes in place or a program that is just beginning to design a curriculum around wellness, it may be useful for you to have a framework to which you can map your activities.

In 2015, when the Royal College of Physicians and Surgeons of Canada refreshed the CanMEDS Physician Competency Framework,⁵ it was apparent that increased emphasis had to be placed on competency within the domain of physician wellness. It was clearly recognized that, to provide optimal patient care, physicians needed to take responsibility for their own health and well-being and that of their colleagues. Physician wellness is considered to be an aspect of competence that resides within the Professional Role.⁵

In addition to updating the Professional Role and establishing the competencies of physician wellness, the Royal College engaged a task force to further articulate the principles of physician wellness. These are presented below; they provide a framework that you may want to use in your program for conceptualizing physician wellness.

1. Physician wellness is an essential and evidence-based aspect of medical education, practice and quality patient care.
2. Physician wellness is important in all phases of the physician career and life cycle from medical school through to retirement.
3. Physician wellness is a shared responsibility between our profession, the individual, and our learning and practice environments.
4. Physician wellness requires commitment and engagement from stakeholders across the entire health care system to optimize physician health and well-being.
5. Physician wellness acknowledges our collective responsibility to communicate when we are experiencing difficulties and to listen with support and without judgement when our colleagues reveal they are struggling.

The Royal College recognizes the importance of physician wellness — this starts in training and extends through to the end of practice. CanMEDS and Competence by Design provide the frameworks to help you make resident wellness a priority. There are now accreditation standards for programs to ensure that the program director is supported in their effort to create a safe and healthy work and learning environment.⁸

Conclusion

Even excellent residency programs will present challenges to residents on occasion. The nature of the work is inherently stressful. However, residents should be provided a program in which they feel supported and respected, and they should feel that their well-being is of paramount importance to the program. It should be made clear to them that the part they play in the provision of health care is valued and that their success as a physician is the program’s ultimate goal; their contributions should be acknowledged and celebrated regularly. Therefore, efforts to prevent and mitigate burnout and promote resident well-being are an essential aspect of your portfolio as a program director.

References

1. Canadian Medical Association. CMA national physician health survey: a national snapshot. Ottawa: Canadian Medical Association; 2018. Available from: cma.ca/sites/default/files/2018-11/nph-survey-e.pdf
2. Ruzycki SM, Lemaire JB. Physician burnout. CMAJ 2018;190(2): https://doi.org/10.1503/cmaj.170827
3. Leiter MP, Maslach C. Banishing burnout: six strategies for improving your relationship with work. San Francisco (CA): Jossey-Bass; 2005.
4. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017:92(1):129–146. https://doi.org/10.1016/j.mayocp.2016.10.004
5. Frank JR, Snell L, Sherbino J, editors. CanMEDS 2015 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015.
6. Irby DM. Improving environments for learning in the health professions. Proceedings of a conference sponsored by the Josiah Macy Jr. Foundation. New York (NY): Josiah Macy Jr. Foundation; 2018.
7. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking action against clinician burnout: a systems approach to professional well-being. Washington (DC): National Academies Press; 2019.
8. Royal College of Physicians and Surgeons of Canada. General standards of accreditation for residency programs. Version 2.0. Ottawa: Royal College of Physicians and Surgeons of Canada; 2020.