Abstract
BACKGROUND:
Residents in all fields of medicine experience high levels of burnout and less job-related satisfaction due to the stress experienced during training. Reduced complement residency classes often experience increased workloads due to the need to compensate for the fewer number of classmates.
OBJECTIVE:
The goal of this study was to examine whether residency classes of reduced size experience higher levels of burnout.
METHODS:
The Maslach Burnout Inventory Survey was distributed to all orthopaedic residents at our institution for four consecutive years. Emotional exhaustion≥27 and depersonalization≥10 correlate with high levels of burnout. At our institution, two residents were lost during their second year of training. Group 1 (n = 56) consisted of residents with reduced-size classes, while group 2 (n = 60) consisted of residents with full complement classes.
RESULTS:
Mean emotional exhaustion (29 vs. 30) and depersonalization (17 vs. 17) scores were comparable between reduced and full complement classes. The Maslach data from our study showed no statistical difference in burnout levels between classes of full complement and reduced complement.
CONCLUSIONS:
When compared to a previous study on burnout conducted in large orthopaedic residency programs, our entire residency program did demonstrate similar levels of emotional exhaustion and depersonalization.
Introduction
The initiation of residency training marks a challenging period of transition from medical student to skilled physician. While rewarding, residency is characterized by long working hours, lack of sleep, and intensely stressful encounters – all factors which have been shown to contribute greatly to high levels of burnout and reduced job-related satisfaction [1]. Stress experienced by resident physicians has a profound impact on their quality of life and the quality of care for their patients. Residents that cannot cope with stress may have reduced job satisfaction, suffer from depression, develop substance abuse, undergo divorce, and subject patients to poorer outcomes [2, 3]. Physician burnout can be described by increased emotional exhaustion and depersonalization, with decreased sense of personal accomplishment, and may be particularly prevalent in the healthcare field [4–11]. Studies of orthopaedic residents have found burnout rates to be as high as 56% [12].
While uncommon, loss of residents in a residency program may occur due to disciplinary, personal, or health-related reasons, leading to smaller residency classes. Classes that are diminished in size must compensate for their missing co-residents, leading to increased stresses and potentially increased risk of burnout. The purpose of this study is to analyze physician burnout in residency classes with a reduced complement compared to classes with a full complement and to report on data which may guide residency program directors on decision making following the loss of a resident.
Materials and methods
This study received Institutional Review Board (IRB) exempt approval. Inclusion criteria were orthopaedic residents who fully completed the questionnaire. All residents at a single institution participated in this survey; no respondents were excluded. All survey information was kept anonymous without any means of personal identification.
Participants
One survey was distributed to all orthopaedic residents at our institute (New Jersey Medical School, Newark, NJ, USA) from the years of 2011– 2014, ranging from post-graduate year (PGY)-1 to PGY-5. The survey was administered once a year, from 2011 to 2014, to all residents enrolled in the program. Year-1 is identified as the first year the survey was administered. The full complement of a PGY class at our institution is defined as a class with six residents. When this survey began, there were seven residents in the PGY-3 class due to the inclusion of one additional resident completing his trial extended residency program for a research year. Two residents were lost from the PGY-4 and PGY-5 classes each, resulting in a reduced number of residents for these classes. Residents were then separated into two groups. Group 1 (n = 56) consisted of all residents in the program with reduced size PGY classes in 2011 and 2012, while Group 2 (n = 60) consisted of residents with full complement PGY classes in 2013 and 2014.
Questionnaire
The Maslach Burnout Inventory (MBI)-Human Services Survey (HSS) subscales and categorization scores were obtained from The MBI Manual [13]. Along with the questionnaire, each participant was prompted to provide his or her current post-graduate year. The MBI uses three different subscales to evaluate three viable components of burnout syndrome. The components were emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). Though the critical values in each standardized subscale vary, each subscale has a low range, an average range and a high range. As stated by the MBI, the low, average and high ranges of the subscale for emotional exhaustion in occupational health care are≤18, 19– 26 and≥27, respectively. For depersonalization, the low, average and high ranges are≤5, 6– 9 and≥10, respectively. Lastly, for personal accomplishment, the low, average and high ranges are≥40, 39– 34 and≤33, respectively. Values found in the high ranges of these subscales (higher values of EE and DP and lower values of PA) correlate with burnout [13].
Statistical analysis
Graph demonstrating Maslach Burnout Inventory scores in emotional exhaustion, depersonalization and personal accomplishment over four years.
All completed surveys were input into a database and analyzed by a blind third party. Independent t-test was used to assess statistical difference in the nominal data of the two groups. GraphPad Prism (GraphPad Software, La Jolla, CA) was used for any statistical analysis.
No external funding was received for this study.
Results
A total of 45 orthopaedic residents (39 males, 6 females) participated in the completion of the MBI, and all questionnaires were fully completed. Mean scores for EE were 33, 27, 33 and 28 for year-1, year-2, year-3 and year-4, respectively. In addition, average scores for DP were 17, 16, 17, 16 for year-1, year-2, year-3 and year-4, respectively (Fig. 1). The standardized MBI subscales and categorization scores used in this study were specifically derived for individuals of occupational medicine. Based on these scales, the residents, as a group, demonstrated high emotional exhaustion and depersonalization each year. Personal accomplishment was shown to be moderate in all years, except in year-3, when personal accomplishment was found to be high.
Mean emotional exhaustion score was 29 (range, 3– 51) for Group 1, while mean emotional exhaustion score for Group 2 was 30 (range, 9– 54) (Table 1). In addition, mean depersonalization scores were 17 (range, 3– 30) and 17 (range, 0– 30) for Group 1 and Group 2, respectively. There was no statistical difference seen for emotional exhaustion and depersonalization between the two groups.
Compares Reduced Complement and Full Complement classes for average Maslach Burnout Inventory scores in emotional exhaustion, depersonalization and personal accomplishment
Compares Reduced Complement and Full Complement classes for average Maslach Burnout Inventory scores in emotional exhaustion, depersonalization and personal accomplishment
Burnout in orthopaedic residency continues to be a concerning topic in residency training programs. Sargent [12] studied 384 orthopedic residents and found a 56% burnout rate and levels of emotional exhaustion and depersonalization in 32% and 56%, respectively. In addition, the study found that residents from programs with six residents or more to be at increased risk for burnout compared to their smaller program counterparts [12]. Larger residency programs may be associated with high volume hospitals managing larger and more critically ill patient populations, which may contribute to increased levels of burnout. Our study showed similar concerning results, with high levels of emotional exhaustion and depersonalization seen in 75% and 83%, respectively. As the residents in our study are from a program with six residents per year, our results support Sargent’s [12] findings. This highlights the importance of programs with a large group of residents to pay particularly close attention towards efforts to reduce burnout. Studies have shown physician burnout to increase the frequency of medical errors and negatively affect scores in patient safety and quality of care [14, 15].
Residents at different levels of training may experience unique challenges following the loss of one of their classmates. At the time of our study, the classes missing residents were considered “seniors” (PGY-4, PGY-5), with a full complement of “juniors” and an additional PGY-3 resident. Junior residents typically share a greater proportion of the workload, particularly with more shifts on-call, which plays a direct role in increasing stress levels and risk of burnout [12, 16]. Further, Tendulkar [16] studied stress levels utilizing laboratory and vital measures of residents while on call, finding that senior surgical residents were better able to cope with stress than junior residents and interns. It is possible that if the creation of a reduced complement class occurred earlier in their training, the remaining residents would have suffered increased burnout scores.
Although the years with a reduced complement did not see an increase in burnout compared to the full complement program, it is still important to find ways to combat the high levels of burnout in larger programs, especially when there are reduced complement classes. One of the first steps that a program should take is to fill vacated spots with suitable residency candidates. The new resident may not be as experienced as the other residents, but he or she will provide the support needed by the reduced complement classes. Institutes may tailor additional educational support for the new resident in order to bring him or her up to class standards. Furthermore, residents from these programs may find it difficult to finish their duties within work-hour regulations due to the increased workload. For this reason, it becomes increasingly important for these programs to provide support in several ways, including engagement of additional medical staff such as physician assistants or nurse practitioners, as well as increased mentorship from the attending faculty.
In addition to taking action to compensate for the loss of a resident, preventative measures to reduce resident burnout should be pursued. Currently, little data exists with regards to a reproducible strategy to educate residents to better cope with work-related stressors. However, the impact of stress in other high-stakes professions has led to development and implementation of successful stress management techniques in fields including military, aviation, and competitive athletes [17–21]. In 2006, Moorthy [22] first described the use of surgical crisis simulation to assess operating room performance and stress management in residents. Maher [23] studied surgical residents placed in a high-stress surgical simulation with and without a 9-hour training program on identification of stress triggers, stress management strategy, and application of stress management techniques. Performance on an objective structured assessment of technical skill checklist in residents who had completed stress training prior to simulation was 5% higher than in residents who had not completed stress training. While there are a multitude of factors that lead to increased stress and burnout during residency training, education on stress management may provide a broad benefit to residents.
There are a few limitations to our study. First, our sample groups are small and may demonstrate beta error. Resident attrition in orthopedic surgery is an uncommon event and rarely discussed, which makes it difficult to find large enough sample sizes. Also, our study was performed at a single institution with larger residency classes. This may not be applicable to residency programs with smaller classes or institutions with different demographics.
In conclusion, classes with reduced complements in orthopaedic residency programs do not appear to experience increased burnout when compared with full complement classes in the same residency. However, programs with resident attrition may sustain increased emotional exhaustion and depersonalization due to an increased burden shared by remaining residents as demonstrated in previous studies in general surgery [24]. Residency programs must find effective interventions to battle resident burnout either causing or resulting from a loss of residents.
Conflict of interest
None to report.