Burnout and Self-Reported Patient Care in an Internal Medicine Residency Program

Context Burnout, a syndrome of emotional exhaustion, depersonalization, and perceived low personal accomplishment, is common among practicing physicians. The frequency and consequences of burnout among physician trainees (residents) are largely unknown. Contribution This survey from a single university-based training program showed that 76% of medical residents met criteria for burnout. Of these residents with burnout, 50% had depressive symptoms and 9% had at-risk alcohol use. Burned-out residents more often reported career dissatisfaction (41% vs. 11%) and suboptimal patient care practices (53% vs. 21%) than residents without burnout. Editor's Note Useful information on burnout and renewal can be found at www.acponline. org by searching under physician burnout. The Editors Burnout is a syndrome of depersonalization, emotional exhaustion, and a sense of low personal accomplishment that leads to decreased effectiveness at work (1). Burnout differs from depression in that burnout only involves a person's relationship to his or her work, whereas depression globally affects a person's life (1). A broad range of professions that share an intense involvement with peopleincluding physicians (2, 3), nurses (4, 5), and educators (6)experience burnout. Burnout is associated with decreased job performance (7) and reduced job commitment (5) and predicts stress-related health problems (8) and low career satisfaction (9, 10). Burnout appears common among practicing physicians, with rates ranging from 25% to 60% (3, 10-14). However, only two small studies have described burnout in physicians during postgraduate residency training (15, 16). Moreover, no research has evaluated the potential relationship between physician burnout and patient care. We evaluated the prevalence of burnout among internal medicine residents in a single university-based program and evaluated the relationship of burnout to self-reported patient care practices. Methods Participants All residents in the University of Washington Affiliated Hospitals Internal Medicine Residency program (except the first author, who was a 3rd-year resident) were eligible for this study. Residents in the program graduated from 45 U.S. medical schools and 4 international medical schools; the cohort comprised residents in primary care and residents in categorical and preliminary internal medicine. The residents rotate through a university medical center, a Veterans Affairs hospital, and county and community hospitals. Fifty percent of their rotations include in-hospital on-call shifts. The University of Washington Human Subjects Institutional Review Board approved the study. Data Collection We mailed a 92-item, self-administered survey to residents' homes in February 2001. The survey addressed topics in the following order: demographic characteristics; residency experience of work stresses; Maslach Burnout Inventory (MBI) (1); depression, at-risk alcohol use, and other substance abuse; patient care practices and attitudes; personal coping strategies to manage stress; the value of program features aimed at resident well-being; and career satisfaction. The accompanying cover letter stated that the purpose of the survey was to better understand residents' feelings and identify what aspects of the residency are most stressful; the letter also explained that participation was elective and that responses would be anonymous. Residents were blinded to any specific hypothesis of the study, and burnout was not mentioned in the cover letter. As an incentive to participate, residents who returned a separate postcard indicating that they had completed a survey were eligible for a drawing for a $100 gift certificate. After the survey was mailed once to all residents, two reminders were sent by e-mail. Survey Measures Burnout The MBI is a 22-item questionnaire that has been shown to be reproducible and valid (1, 17-19) and is generally considered the gold standard measure for burnout (8). The inventory asks respondents to indicate on a 7-point Likert scale [which does not include the word burnout] the frequency with which they experience certain feelings related to their work. The MBI evaluates three domains of burnout: 1) emotional exhaustion, which is measured with a subscale of 9 items [for example, I feel emotionally drained from my work]; 2) depersonalization, which is measured with a subscale of 5 items [for example, I've become more callous toward people since I took this job]; and 3) personal accomplishment, which is measured with 8 items (for example, I feel I'm positively influencing people's lives through my work) (1). On the basis of the MBI responses, independent subscale scores are calculated for each of the three domains of burnout. Low, average, and high scores for each domain are based on the low, medium, and high terciles of scores from a previously published study of 1104 medical professionals (1). For our study, we defined burnout as a high score on the depersonalization or emotional exhaustion subscales. We did not include the subscale scores for personal accomplishment in the criteria for burnout because previous research has suggested that this subscale measures a somewhat distinct dimension (1). Self-Reported Patient Care Practices and Attitudes For this study, we specifically developed eight statements describing self-reported practices (5 items) and attitudes (3 items) of patient care (Table 1). These statements were developed on the basis of hypothesized effects of burnout on patient care. In this report, we describe these items collectively as suboptimal patient care practices and attitudes; however, the questionnaire did not use this wording or explicitly indicate that these aspects of patient care were considered undesirable. The survey instructions asked residents to rate how frequently you found yourself exhibiting the following attitudes or behaviors for any reason (time constraints, feeling rushed, need to leave hospital, etc.). The response options were never, once, several times per year, monthly, and weekly. Table 1. Self-Reported Characteristics of Participants We constructed two summary measures for self-reported patient care practices. The first, more inclusive, summary measure was self-report of one or more sub-optimal patient care practices reported monthly or weekly; this measure is hereafter called suboptimal patient care practices at least monthly. A second summary measure identified residents who self-reported one or more suboptimal patient care practices weekly. Residents identified by the second summary measure, which is hereafter called suboptimal patient care practices weekly, are a subset of those identified by the first. We did not include the items for suboptimal patient care attitudes (Table 1) in these summary outcome measures because the suboptimal patient care attitude items were similar to items on the depersonalization subscale of the MBI and were therefore expected to be correlated with that subscale. Neither the individual questions about suboptimal patient care practices nor the summary measures have been validated. Depression and Substance Abuse We hypothesized that depression and substance abuse would be related to burnout and to self-reported suboptimal patient care attitudes and practices. The survey included a two-item screening questionnaire for depression that was developed as part of PRIME-MD (Primary Care Evaluation of Mental Disorders) (20) and that performs as well as longer screening questionnaires (21). Screening positive for depression was defined as answering yes to at least one of the two questions. This screening instrument has a positive likelihood ratio of 2.23 (95% CI, 1.98 to 2.50) for the diagnosis of current major depression and a negative likelihood ratio of 0.07 (CI, 0.04 to 0.15) (21). In addition, residents were asked whether they had had major depression at any time in residency. The survey included the three questions on consumption from the Alcohol Use Disorders Identification Test (AUDIT) (questions 1 to 3) to screen for at-risk alcohol use [22]. To assess symptoms of alcohol dependence, we also included three additional AUDIT questions that pertained to 1) not fulfilling responsibilities because of drinking, 2) being unable to stop drinking, and 3) drinking in the morning [23]. At-risk alcohol use was defined as self-report of 1) consuming 6 or more alcoholic drinks on at least one occasion per month (AUDIT question 3) or 2) having one or more symptoms of alcohol dependence in the past year. Question 3 on the AUDIT has a positive likelihood ratio of 11.00 (CI, 5.24 to 23.23) and a negative likelihood ratio of 0.48 (CI, 0.39 to 0.60) for heavy drinking or active alcohol abuse or dependence according to Diagnostic and Statistical Manual of Mental Disorders, third edition revised (DSM-IIIR) (22). By using the same comparison standard and data from the same validation study (unpublished findings), the screening test in our surveywhich used questions about any symptoms of alcohol dependence in the past year combined with AUDIT question 3has a positive likelihood ratio of 7.77 (CI, 4.29 to 14.06) and a negative likelihood ratio of 0.46 (0.29 to 0.62). To measure recreational use of other substances, such as 3,4-methylenedioxymethamphetamine (MDMA, also known as XTC or Ecstasy), we developed the following question: How often do you use other recreational substances (marijuana, sedatives, stimulants, XTC, other)? The response options were never, less than monthly, monthly, weekly, and daily or almost daily. This question has not been validated. Demographic and Other Participant Characteristics We collected limited demographic information to ensure the anonymity of the respondents and to encourage participation and honest reporting (Table 1). The survey did not ask residents their age; however, as a proxy measure to identify older residents, one question asked whether the respondent had taken a break more