Medical training is a demanding endeavor—physically, intellectually, and emotionally. Although medicine can be an extremely rewarding career, there are adverse effects from the training process. One of the most widely recognized and rigorously studied of these consequences is burnout. Burnout is comprised of three domains: (1) emotional exhaustion, (2) depersonalization, and (3) decreased feelings of personal accomplishment.1 Recent estimates indicate 1 in 3 to nearly one-half of practicing physicians meet criteria for burnout at any one time.2 This creates significant risk for the affected physician, and translates into downstream effects for patients and the larger health care system. Burnout appears to originate early in training. Empathy begins to decline in medical school, and that trend continues during internship and residency.3 Thus, interventions aimed at medical trainees are urgently needed.
The impact of burnout in both the personal and professional spheres of medicine is well documented. In a large study of medical students in the United States, those with higher scores of burnout were more likely to engage in unprofessional behaviors, such as cheating on a test or lying about physical examination findings.3 Students with increased burnout were also less likely to prioritize altruistic aims of medicine, such as caring for underserved populations.3
The Effects of Physician Burnout
Burnout also appears to affect the professional ability of physicians. A study of 16,000 internal medicine residents showed those trainees with higher scores of emotional exhaustion and lower self-reported quality of life had significantly lower scores on standardized tests.4 Practicing physicians with higher levels of burnout have decreased levels of workplace efficiency, lower patient satisfaction, and are more likely to provide self-reported suboptimal care,5,6 leading a 2009 article to call physician wellness a “missing quality indicator.”5
Medical errors have been shown to precipitate physician distress, but a study also shows the reverse may be true.7 Physicians with elevated scores with respect to depersonalization and emotional exhaustion had a statistically significant increased risk of reporting a medical error in the subsequent 3 months. In fact, each 1-point increase in depersonalization and emotional exhaustion score was associated with a 10% and 7% increase, respectively, in the odds of reporting a medical error.7
Burnout appears to affect the personal lives of physicians as well. A large body of evidence suggests physicians have higher rates of mental health issues compared to the rest of the population.8,9 Dyrbye et al.3 studied almost 5,000 medical students, and found that more than 11% had considered suicide in the past year, a number that is substantially higher than the national average. After controlling for depression, aspects of burnout appear to be independent risk factors for adverse personal outcomes. Higher levels of physician burnout scores have been linked to increased levels of depression, alcohol abuse, and suicidal ideation.10 Thus, addressing burnout is, in our view, of the utmost importance for protecting the health and safety of physicians, in addition to the patients for whom they care.
A number of interventions have been proposed to mitigate the effects of burnout,11,12 and mindfulness-based techniques are among the most promising. Mindfulness can be defined as the intentional act of paying attention, in the present moment, without judgment. Mindfulness-based stress reduction, created by Jon Kabat-Zinn, PhD,13 at the University of Massachusetts, uses an 8-week course to teach skills in mindfulness. Although mindfulness interventions have been shown to be effective,11 the 30-hour time commitment is often a limiting factor for busy physicians. The pilot study14 discussed here aimed to examine the feasibility and potential impact of a brief mindfulness intervention using a free smartphone application on a resident population.
Design and Methods
Thirty-three residents were recruited from the pediatric residency program at the University of Chicago on a volunteer basis.14 Prior to the intervention, participants filled out surveys regarding demographic information, perceptions of mindfulness and its application, as well as two validated questionnaires—the abbreviated Maslach Burnout Inventory (aMBI)1 and the Mindful Attention Awareness Scale.15 Participants then used the free smartphone application Headspace16 to complete a 10-day program in mindfulness meditation. Each session was comprised of a 10-minute recording, which was a combination of educational material and a short guided meditation. Some of the sessions were completed in a group setting as parts of scheduled resident education conferences, but residents completed most on their own. After the completion of the 10 sessions, participants were asked to repeat the same surveys. At the conclusion of the exercise, residents who completed both surveys were eligible to be entered in a drawing for a small monetary prize. Statistical analysis was performed using paired t-test, and a value of P < .05 was considered statistically significant.
Of the 33 enrolled participants, 31 completed the initial survey and 11 completed the follow-up survey.14 A total of 71% of residents had either tried some form of meditation or already had a personal practice. Prior to beginning the 10-day mindfulness intervention for this study, a majority of residents agreed that some form of mindfulness practice could be useful for patients and providers. Lack of time and knowledge were the top two barriers to regular meditation practice, with 84% of residents citing time as the major limitation (Figure 1). After the intervention, an increased percentage of residents perceived mindfulness as a useful intervention for patients (Figure 2), and there was a statistically significant increase in the number of residents who planned to discuss mindfulness as a therapeutic option for their patients (61% from 48%, t = 2.7078, 95% CI 2.3–23.9) (Figure 3). The aMBI was analyzed based on four subcategories: (1) personal accomplishment, (2) depersonalization, (3) emotional exhaustion, and (4) job satisfaction. Overall, residents expressed a high level of personal accomplishment. High levels of emotional exhaustion were also present, with postgraduate year 2 residents accounting for the highest average score of 15.4 of 18.8. There was no statistically significant change in aMBI scores from pre- to poststudy groups.
Perceived barriers to a regular mindfulness meditation practice. Data from Taylor et al.14
Results of question as to whether mindfulness meditation can be used as an effective adjunct clinical tool for my patients. Data from Taylor et al.14
Residents' opinions on mindfulness. Data from Taylor et al.14
Conclusions and Limitations
In our view, the use of a brief, convenient mindfulness smartphone application shows promise as an educational tool for pediatric residents. Integrating a program of this nature into a residency curriculum teaches a useful skill to busy residents, and it has the potential to positively affect a number of challenges facing medical professionals today. After the intervention, an increased percentage of residents perceived mindfulness as useful, and a greater number planned to discuss it as a therapeutic option for their patients. More research in this area using a larger population is needed to further characterize the effects of mindfulness on medical trainees.
This study was limited by a small sample size, as well as possible selection bias because participants were volunteers. Additionally, all participation information was self-reported and not objectively confirmed by the researchers.
Some of the mindfulness sessions were incorporated into scheduled resident education sessions, but the majority had to be completed by residents on their own time. Most residents cited lack of time (84%) as a barrier to regular practice.14 Thus, in the future, integrating a mindfulness program into an established educational curriculum could help to relieve some of the burden of time limitations in a busy resident schedule.
There is clear evidence that burnout is a significant problem facing many physicians today.2,17,18 The negative effects are far-reaching, affecting the individual providers, the patients for whom they care, and ultimately the entire health care system. Interventions to mitigate these effects are urgently needed, and mindfulness-based strategies show promising results.2,19 Using convenient technology may be a successful alternative to traditional in-person classes and retreats for a busy physician's schedule.
- Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.
- Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among us physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377–1385. doi:10.1001/archinternmed.2012.3199 [CrossRef]
- Dyrbye LN, Massie FS, Eacker A, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA. 2010;304(11):1173–1180. doi:10.1001/jama.2010.1318 [CrossRef]
- West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. 2011;306(9):952–960. doi:10.1001/jama.2011.1247 [CrossRef]
- Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374(9702):1714–1721. doi:10.1016/S0140-6736(09)61424-0 [CrossRef]
- Shanafelt TD, Bradley KA, Wipf JW, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358–367. doi:10.7326/0003-4819-136-5-200203050-00008 [CrossRef]
- West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy. JAMA. 2006;296(9):1071–1078. doi:10.1001/jama.296.9.1071 [CrossRef]
- Goldman ML, Shah RN, Bernstein CA. Depression and suicide among physician trainees: recommendations for a national response. JAMA Psychiatry. 2015;72(5):411–412. doi:10.1001/jamapsychiatry.2014.3050 [CrossRef]
- Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians. JAMA. 2003;289(23):3161–3166. doi:10.1001/jama.289.23.3161 [CrossRef]
- Rath K, Huffman L, Phillips GS, Carpenter K, Fowler J. Burnout is associated with decreased career satisfaction and psychosocial distress among members of the Society of Gynecologic Oncology. Am J Obstet Gynecol. 2015;213(6):824.e1–9. doi:10.1016/j.ajog.2015.07.036 [CrossRef]
- Regehr C, Glancy D, Pitts A, Leblanc VR. Interventions to reduce the consequences of stress in physicians. J Nerv Ment Dis. 2014;202(5):353–359. doi:10.1097/NMD.0000000000000130 [CrossRef]
- Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284–1293. doi:10.1001/jama.2009.1384 [CrossRef]
- Center for Mindfulness in Medicine, Health Care, and Society. History of MBSR. http://www.umassmed.edu/cfm/stress-reduction/history-of-mbsr/. Accessed September 28, 2016.
- Taylor M, Hageman J, Brown M. Mindfulness for pediatric residents. Poster presented at: Pediatric Academic Societies Annual Meeting. ; April 25–28, 2015. ; San Diego, CA. .
- Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003;84(4):822–848. doi:10.1037/0022-35220.127.116.112 [CrossRef]
- Headspace. https://www.headspace.com/. Accessed September 15, 2016.
- Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ. 2016;50(1):132–149. doi:10.1111/medu.12927 [CrossRef]
- Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89(3):443–451. doi:10.1097/ACM.0000000000000134 [CrossRef]
- Shanafelt T, Dyrbye L. Oncologist burnout: causes, consequences, and responses. J Clin Oncol. 2012;30(11):1235–1241. doi:10.1200/JCO.2011.39.7380 [CrossRef]