Is the Institutionalization of Wellness the Answer to Trainee Burnout?

The frequency at which medical trainees experience depression and burnout and die by suicide demands a response. A cohort study found that the incidence of depression in a nationwide population of physician interns increased nine-fold to 27.1% of the study population in the first 3 months of training, and thoughts of death increased nearly four-fold over the same period (3). Physicians die by suicide at 1.4–2.3 times the rate of the general population, leading to 300–400 physician deaths by suicide annually (3).

Despite the stated desire to improve these outcomes, there is limited evidence to support specific interventions to improve resident wellness and reduce burnout. Interventions found to be effective in small studies include structural changes to the clinical environment to promote increased direct patient contact, decreased working hours, and formal physician training in self-care (4). Although statistical significance was achieved in a meta-analysis of antiburnout interventions, the absolute overall reduction in the percentage of "burned out" physicians—from 54% to 44% of the study population—begs the question of pragmatic significance and whether these wellness initiatives provide a sufficient return on the time and cost required for their implementation (4). For example, participation in wellness initiatives necessarily requires the expenditure of time previously dedicated to clinical and nonclinical tasks, increasing the risk of work compression. Importantly, these interventions are not without risk and may worsen patient outcomes, infringe on resident education, and reduce perceived satisfaction of the training experience, largely due to reduced time in the clinical environment (4). The rush to implement minimally tested interventions may result in the opposite of their intended effect and compete with the vocational, educational, and nonwork experiences shown to be rejuvenating in the face of physician burnout (5).

Recent history provides an example of a large-scale, institution-led initiative with a secondary aim of improving trainee wellness: duty hour restrictions. Designed to reduce trainee fatigue and improve patient safety, duty hour restrictions have been found to, by and large, succeed in neither, as demonstrated in large longitudinal studies (6). Other studies have associated increased trainee burnout with duty hour restrictions (7), although this finding is not universal (6). These findings provide a valuable lesson in the potential for unintended consequences of well-meaning initiatives.

Similarly, institutions and organizations risk the same outcome with resident wellness by satisfying requirements without substantively changing outcomes. Limited evidence exists to support the broad deployment of any particular wellness initiatives. The impact of these interventions, even if positive, may be minimal. Absent careful implementation, wellness initiatives may worsen trainee wellness by shifting time away from direct patient care and education, increasing working hours overall, and reducing satisfaction with training. Training programs and sponsoring institutions should intimately involve trainees in the creation of wellness programs to maximize the probability of meaningful cultural change while monitoring for inadvertent adverse effects from wellness initiatives that may worsen, rather than alleviate, burnout. Further scientific work to better understand factors that mitigate and exacerbate the risk of burnout in conjunction with longitudinal monitoring of the efficacy of wellness initiatives over time may also allow for the implementation of efficient, targeted interventions that achieve their stated purpose.