Is the Institutionalization of Wellness the Answer to Trainee Burnout?

Physician burnout is a variably defined syndrome that includes cynicism, physical and emotional exhaustion, and a low sense of personal accomplishment related to the physician’s occupational responsibilities and performance (1). The recently heightened focus on physician burnout has led to a flurry of organizational and institutional initiatives aimed at understanding and reducing the prevalence of this phenomenon. In 2017, the Accreditation Council for Graduate Medical Education (ACGME) revised its Common Program Requirements to promulgate specific responsibilities of residency training programs and sponsoring institutions to directly address resident well-being (2). A number of professional organizations and academies, including the American Psychiatric Association, have created similar wellness initiatives.

Despite these efforts, the prevalence of depressive symptoms and incidence of deaths by suicide among medical trainees remain markedly higher than that found in the general population (3). The relative novelty of these initiatives and the ambitious goal of reshaping the culture of medical training perhaps make the lack of immediate improvement unsurprising. The creation of standardized requirements for training programs related to trainee wellness has the potential to humanize the clinical learning environment. However, the undeveloped literature surrounding effective interventions to address burnout and the enthusiastic desire to implement changes immediately may, instead, provide all stakeholders with a false sense of assurance due to a "something is better than nothing" approach to institutional wellness programs. Trainees and their institutions may exert significant effort implementing antiburnout interventions, in accordance with ACGME requirements, with little to show in the way of improved outcomes. Worse, wellness initiatives may paradoxically worsen trainee wellness and satisfaction with the training experience. Although the broad goal of improving the residency training experience is welcome, specific wellness interventions require a risk-benefit analysis to ensure that the stated goals are achieved.

The Institutionalization of Wellness: Positive Culture Change or Simply More 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).

Proceed With Caution

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.