The evidence is growing that burnout in trainees, as well as in practicing physicians, comes at a cost to the physicians, those they interact with at home and work, and their patients.1 In their article in this issue entitled “Pediatric Resident Burnout and Attitudes Toward Patients,” Baer et al2 surveyed pediatric residents at 11 programs in New England to better understand the pathogenesis of burnout in these trainees; the goal was to assist in efforts to develop effective measures to prevent and/or address these maladaptive responses.
It is unsurprising to those who work with trainees that 101 of 258 pediatric residents reported being “burned-out.”3–5 In fact, many studies show higher rates of burnout in pediatric trainees (40%–75%) depending on site and year of training.6,7 In the study by Baer et al,2 there were no significant differences in burnout rates according to sex, race/ethnicity, and relationship or parental status; younger residents (<30 years of age) were slightly less likely to report burnout than older residents. Residency factors (year of training, program size and location, current rotation schedule, and hours worked in past week) were not associated with burnout. Sleep deprivation did correlate with burnout. Both perceived sleep deprivation and burnout were independent risk factors that predicted poorer self-reported quality of patient care (eg, discharging patients to make the service more manageable, making treatment or medication errors, feeling guilty about how a patient was treated).
The Consequences of Burnout
Burnout is all too common in trainees and practitioners, as well as in all members of the health care team. Burnout in physicians is associated with the following: (1) higher levels of job dissatisfaction and shorter job tenure; (2) more reported medical errors, negative attitudes toward patients, and patient dissatisfaction; and (3) on a personal level, more failed relationships, depression, alcohol abuse, and suicidal ideation.2 For the physician in training, the personal effects are sobering, including greater rates of neglect of family commitments, dysfunctional relationships, mental health disorders, and self-harm behaviors.8 Moreover, burnout in physicians is associated with more disruptive behaviors, as well as poorer staff relationships and performance in the workplace.
A particular issue for pediatric trainees and pediatricians is that many especially valued traits, such as compassion, altruism, and perfectionism, also predispose to burnout when clinicians are pushed to mental or physical extremes.2 Burnout can also be regarded as a byproduct of the culture of medicine, exemplified by an educational system and profession that reward self-denial, persistence, and expert performance under trying conditions, driving learners to perfect clinical abilities with far less attention to the personal-social, leadership, and teamwork skills necessary to achieve success in our complex systems.9
The Call for Better Systems, Personal-Social Skills Development, and Perspectives
These consequences of burnout are not unique to medicine and have been described in many contemporary workplaces related to the increasingly complex tasks and “production facility” mindset that characterize much of modern work. Burnout and its downstream effects must be seen as both a systems issue and an individual issue. Systems issues, such as diminished physician and trainee sense of control, electronic health record burdens, misaligned social and financial rewards, and disengagement of trainees and physicians from workplace governance, are certainly problematic. Thoughtful efforts to address organizational issues with detailed methods that focus on the mismatch between the individual and the work must be part of the solution.10
Ideally, these systems approaches are complemented by person-centered, developmental methods to prevent and/or reduce burnout by building effective self-care skills, social support, and individual resilience in trainees and physicians. We are particularly encouraged with the attention now given to educational programs designed to develop resilience, empathy, self-compassion, and mindfulness. These efforts include: mindfulness training, presented through workshops11 and/or online modules12; CREW (Civility, Respect, and Engagement at Work) training to develop better civility and communication and to mitigate burnout in the workplace13; and comprehensive wellness curricula such as the University of Arizona’s Pediatric Integrative Medicine in Residency Curriculum14 and the American Academy of Pediatrics’ Resilience in the Face of Grief and Loss Resident Curriculum that focus on developing important cognitive and emotional skills of pediatric trainees to help them provide high-quality care while fostering their personal wellness and resilience.15 The Pediatric Residency Burnout–Resilience Study Consortium (www.pedsresresilience.com) was recently formed to provide an innovative research platform to address burnout and promote resilience in a contemporary cohort of pediatric trainees in 41 programs in the United States committed to this work.
Burnout is a serious problem with significant effects on pediatric trainees, colleagues, and patients. The problem is clear; the “Call to Action” is for our community to do the hard work to address systems factors and facilitate residents to develop the personal-social skills necessary for resilience in the face of the myriad stresses and difficult outcomes they will inevitably face. Lastly, these efforts will be most effective for trainees and physicians who retain the joy, passion, and purpose of the calling that is pediatrics.16 Modeling and encouraging this appreciation of our work should remain a high priority for all of us who care for our patients and our profession.
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