Abstract
Background:
Burnout is harmful and frequently experienced by medical residents. Causes of burnout are numerous. To date, there have been no qualitative studies incorporating semistructured interviews and resident-taken photographs on their perspectives of burnout. This method is advantageous for its ability to explore the lived experience of burnout, in depth.
Objective:
The purpose of this study is to discover, through photographs and semistructured interviews, medical residents’ perspectives on what burnout means in their lives and how they manage burnout experiences.
Methods:
In 2017, 8 residents from Internal Medicine and Family Medicine Residency Programs at a large, Midwestern academic medical center participated in this study. The Transcendental Phenomenological Method was used to analyze the data collected through semistructured interviews, which used resident photographs as a guide.
Results:
Residency training was often described as a challenging experience, particularly because it took away residents’ ability to focus on their personal lives due to long work hours. This often resulted in exhaustion, self-doubt, and damaged or neglected relationships. Despite this, residents took active steps to mitigate burnout through a variety of coping strategies. In addition, residents found camaraderie, joy, and personal growth during their residency experience.
Conclusion:
Burnout continues to be an important topic in medical education and specifically for medical residents. Learning more about how burnout is perceived and the effects of burnout on residents day-to-day lives can guide the future development of strategies to promote wellness and minimize the impact of burnout.
Keywords
Introduction
Burnout has been characterized as emotional exhaustion, depersonalization, and feelings of decreased personal accomplishment. 1 It is a common experience for residents, though prevalence variability exists between specialties. 2 Burnout can lead to unwanted outcomes, including psychological distress, poor work performance, patient safety concerns, 2 decreased academic performance, 3 and suicidality. 4 Contributing factors to resident burnout include working long, high-stress hours, little control over daily events, and high levels of responsibility.5,6 Recognition of the dire effects of burnout on medicine and medical training has led to increased attention to wellness on a health system level as in the recent Common Program Requirements by the Accreditation Council for Graduate Medical Education. 7 However, medical educators and the medical community at large have not yet developed best practices for addressing burnout.
Previous studies have documented factors associated with resident burnout and interventions used to mitigate its affects.8–10 Most of these studies have been methodologically limited to self-report surveys as a means of data collection.8–10 Although quantitative methods can allow for breadth of understanding and generalizability of results, qualitative methods are advantageous because 1 topic is covered in great detail. 11 There have been few qualitative studies analyzing resident burnout experiences and coping strategies. 12
Photographs have long been used in qualitative research as a tool to understand the meaning of actions and events from an individual’s perspective. 13 Visual images allow for valuable descriptive information and reflection. In addition, researchers can use photographs to assist with guiding a qualitative interview process. This method is useful for discovering interviewee perspectives while minimizing researcher bias. 11 These characteristics make qualitative inquiry and the use of photographs applicable for exploring what burnout means to residents, during training.
The purpose of this study was to discover, from residents’ perspectives, what burnout means in their lives and the methods they employ to cope with burnout. Having an in-depth understanding of the ways in which residents experience burnout and how they cope with this experience can allow not only for greater understanding but can provide information that can lead to appropriate wellbeing-promoting interventions and practices.
Method
Based on the tenets of the biopsychosocial (BPS) model, 14 we designed a qualitative phenomenological study to discover, from residents’ perspectives, what burnout means in their lives and their methods of coping with burnout. Using the BPS model allowed the authors to organize, assess, and recognize ways in which burnout is influenced by multiple, complex factors in residents’ lives. This model is a logical means of understanding burnout because burnout is a multisymptom, complex phenomenon. Institutional review board (IRB) approval was granted through the University of Nebraska Medical Center.
Recruitment
Recruitment was initiated by sending an email to Family Medicine (FM) and Internal Medicine (IM) residents at our institution. The e-mail was sent to 120 residents, described the study, and asked residents to reply if they were interested in participating. Information about the study and recruitment was also included in the announcements made during each clinic half day for 1 month at a resident-run IM primary care clinic.
Participants
Any resident in the IM or FM Residency Program at a large, Midwestern academic medicine center was eligible to participate in this study.
Data collection
At study initiation, in 2017, residents completed informed consent and a demographic questionnaire through Qualtrics, an online data collection program. Participants then took photographs of their experience of burnout with their smartphones and e-mailed the photographs to the principal investigator 2 weeks after study initiation. Within 6 weeks, residents participated in semistructured interviews with the principal investigator, during which they discussed captured images and experiences with burnout. During interviews, residents were asked 6 open-ended questions (see Table 1) that were developed using extant literature on burnout experiences during residency. Interviews were audio-recorded and transcribed verbatim by another member of the research team who was blinded to resident demographic and/or program data.
Interview questions.
Data analysis
The Transcendental Phenomenological Method (TPM) 15 of qualitative analysis was chosen to guide study design, data collection, and analysis. Saturation was achieved after 8 interviews. Two researchers coded data from the transcribed interviews independently and subsequently developed themes and subthemes based on these codes. Disagreements were resolved through discussion between the coders until a consensus was reached.
Results
A total of 8 residents participated in this study. Demographic data can be found in Table 2.
Sociodemographic information.
Through the data analysis process, 4 core themes emerged: (a) burnout-related challenges, (b) facilitators of burnout, (c) facilitators of wellbeing, and (d) coping strategies. Within each of these core themes were multiple subthemes further describing the categories and these are outlined below. See Table 3 for an overview of themes and subthemes.
Themes and subthemes.
Burnout-related challenges
During interviews, each resident described their challenging encounters with burnout. Below is a narrative of their experiences.
Subtheme 1: burnout is invasive
Per resident reports, burnout was an ever-present, toxic phenomenon, which required constant awareness and action to stave off. Burnout was described as a “never ending thing that I battle,” despite engaging in numerous coping skills. Because of the consuming nature of residency, there was consistently some portion of life that was neglected, leading to an inability to escape guilt. Residents noted burnout “wasn’t safe for patient care,” because they experience themselves as less effective physicians when experiencing burnout.
Subtheme 2: self-doubt
Burnout was strongly tied to feelings of self-doubt. Some participants felt a sense of “inadequacy” and “chronic feelings of inferiority.” They experienced burnout as having felt “incompetent and lost.” For some, residency took its toll and led to feeling “overwhelmed, maybe apathetic in some sense.”
Subtheme 3: disengagement
When experiencing burnout, residents often felt disengaged from work. A participant remarked that burnout felt like being “over my job” or “over whatever is causing burnout, done with it” and that they “can’t physically [work] for one more day or it would drive [me] nuts.” One resident stated that they were “done with thinking, with being on all the time.” Loss of “motivation,” “interest,” and “enjoyment” were also mentioned.
Subtheme 4: depression
Residents described sadness coming from their inescapable duties. During low points, 1 resident mentioned having felt “depressed, like I am never going to feel normal again” and “I felt like my brain was in a fog” and that there were even gaps in memory. Residency was described as devoid of joy in patient care and work relationships. These emotional difficulties were discussed as invasive in professional and personal life.
Subtheme 5: relationship deterioration
Burnout impaired the way residents related to others in their lives. Regarding friends, family, and coworkers, it felt like a “loss of empathy and compassion” for loved ones and “[pushing] away from others,” which makes it “easy to feel isolated.” Burnout was associated with neglecting relationships both in the outside world and at work. On particularly challenging days, 1 resident stated they became irate at colleagues, stating, “I would just like go off on them, swearing at them, swearing at co-workers, swearing at superiors . . . I was not okay, not okay.”
Facilitators of burnout
Residents reported numerous aspects of residency that contributed to burnout. Variance was present, yet common themes emerged.
Subtheme 1: meaninglessness
Residents reported that the meaninglessness of parts of their job exacerbated or led to their sense of burnout. Residents often entered the field to care for patients, yet described how patient interactions might be “less than 11%” of the job. Often, the medical record was noted as taking precedence over direct patient care. One resident explicitly stated, “I think a lot of what we do, and what takes up a good chunk of our day, does not feel particularly meaningful.” Specifically, completing notes was described as tedious and residents felt note writing detracted from their sense of purpose.
Subtheme 2: patient care
Patient care was also a cause of burnout for residents. While feeling connected to patients makes it easier “to be in the moment and enjoy [work],” doing so made it “easier . . . to be overwhelmed and just burned out.” Residents also stated managing difficult patient encounters was challenging. One commented, they have “terrible thoughts, like oh my gosh that patient is coming in again. Um, I really don’t want to see them . . . and kind of forgetting to remember that they [patients] have their problems.” Residents also felt alone and as though they had sole responsibility for patient’s care.
Subtheme 3: lack of positive reinforcement
There was also a perceived lack of reward for doing difficult work. Residents reported that the “big reward” for a patient improving was typing a discharge summary. If it was a particularly “good day,” they would have the opportunity to tell a patient, in person, that their condition improved and they were consequently being discharged. Residents perceived an inability to get away from “bureaucracy and coding.”
Subtheme 4: feeling like a cog in the machine
Residents described a very impersonal side to medicine. The medical system has made them feel like we are cogs . . . in the bigger machine. We are all very replaceable, and rightfully so within the hospital system . . . But I think the more burned out you get, you just are like an emotionless, faceless person doing a job.
Subtheme 5: the resident-attending relationship
The resident-attending relationship can, at times, have a negative impact on residents. Residents felt as though the resident-attending relationship became particularly strained when residents felt a “lack of support” because “some attendings do not respect residents’ [personal] time.” In addition, residents felt like the “attending-resident relationship [was] not reciprocal,” with residents recognizing they have to work for the attendings, but feeling attendings did not have to consider residents’ needs.
Subtheme 6: long work hours
Work was described as “never ending.” Residents mentioned that because their training is so time-consuming, other areas of life are naturally neglected. Being a resident meant “not having time for family.” This left residents feeling as if they were missing out on life with loved ones. A resident mentioned, “Burnout did not affect me until having a child.” Another resident mentioned they never felt like they had done enough at their job because “even when [I am] not on call there are still notes to do at 11:00 pm.”
Facilitators of wellbeing
Despite the often-challenging nature of residency, residents mentioned positive aspects of residency life. Some experienced parts of residency as “manageable” and positive, overall.
Subtheme 1: personal growth
The challenging nature of residency allowed for extensive personal growth. As 1 resident noted, “three years is not much time but there is so much personal and professional growth within that, like far beyond what three years seems.” A resident mentioned that residency “gets easier as it progresses,” whereas another remarked, “I enjoy residency despite it being overwhelming.” One interviewee remarked that residency really “isn’t all bad.”
Subtheme 2: strong colleague relationships
Colleague relationships were often discussed as “bright spots” during a difficult program. Residents described how easy it is to be friends with those in medicine because of professional commonality. One resident noted that “loving the people I work with” had detracted from the stress of the job. After all, “If you work around people you like, it helps and makes going to work a lot better.” For 1 resident, there was never a sense that they felt, as a physician and a person, wholly alone because of the support of their coworkers. Some residents felt they could talk about burnout and challenges with both residents and attendings. They believed strong working relationships led to an ability to ask for and receive support.
Coping strategies
Managing the deleterious effects of burnout was often learned through “trial and error.” Residents were generally aware of resources and coping strategies to combat burnout. However, they believed that engaging in these strategies required time and energy which, to an already depleted resident, could lead to more exhaustion or detract from work responsibilities.
Subtheme 1: unproductive coping strategies
Residents reported frequently eating less-than-healthy foods as a means of coping with distress. One added that comfort food is something I kind of go to when I’m tired and I don’t want to be at work and I just feel overworked. So going to things like taters tots after being on call [is] a poor choice but at that time it’s the best thing for me.
Another resident noted that they cope by neglecting household responsibilities which, while not ideal, allowed them time to disengage from life responsibilities.
Subtheme 2: enjoyable activities
There was a common sentiment that burnout could be soothed by stepping away from work and finding joy in non–medicine-related activities. Residents found fulfillment in a variety of activities including “journaling,” “time in the outdoors,” “listening to music,” and “just having fun.” At times, they coped with feeling overwhelmed by remembering to “breathe, [close] my eyes, think about what the next step is.” One resident believed it necessary to dress comfortably. They noted, “I look for every excuse not to dress up. I’d . . . rather be in scrubs and it is one less thing to have to worry about.” Some residents mentioned that they “exercise whenever able,” whereas others felt slowing down by taking “lunch breaks” was useful.
Subtheme 3: change of perspective
Because residents were unable to physically escape from work, they often mentioned it was helpful to change their perspective regarding work and work relationships. A method of shifting perspective was savoring the little victories. One participant explained, “I remind myself I am here to do a service for someone” and “I mentally tell myself I’m going to try and do the best thing I can for someone today.” After all, “it doesn’t need to be a heart transplant every day” to be helpful while on the job. Accepting the parts of residency that can’t be changed was also helpful. A resident commented that “it helps not to get quite as hung up with the notes.” They also found it helpful to remind themselves not to take strained work relationships personally because it was “not only me that is under a lot of stress in hospitals.
Subtheme 4: finding a work-life balance
Finding new ways to view work-life balance was mentioned as a coping strategy. Succinctly stated, it was necessary to “prioritize personal happiness.” One resident candidly admitted, “There’s no longevity in this job if you cannot step away.” Residents reported that they understood that taking care of oneself is important because not taking care of oneself not only leads to burnout but detracts from patient care. “Going to counseling” had been helpful for some and others wished they would have seen a “mental health professional” before burnout became severe for them.
Subtheme 5: leaning on social supports
Social support with friends, family, or coworkers was frequently cited as a way to manage burnout. Residents enjoyed quality time with a partner, called family daily, and found it helpful being surrounded by others who are “doing well and are happy.” Residents found being “open about what’s going on” promotes wellbeing.
Community involvement was also useful. One resident noted they are “active in church” when they can and they have found volunteer work to be rewarding. Helping other residents who are struggling was also effective. A resident concisely concluded that it is useful to “know you are not alone; there is always a team” with you.
Subtheme 6: identifying personal burnout
One resident mentioned they want to improve personal burnout prevention by “being more conscientious of . . . how I am feeling and preemptively doing something about it.” However, another noted it is “difficult to identify when we are burned out because your head is to the grindstone.” Therefore, some residents preferred if others monitored their wellbeing and/or that they regularly take a burnout questionnaire to assist them with recognizing their own wellbeing and burnout symptoms. Peer/colleague support was also noted as being possibly very helpful, with 1 resident stating, “I feel like there could be something gained from hearing peers experiences [of burnout] and doing something different than medicine together as a group.”
Conclusions
Results from the current study suggest that burnout experienced by residents from 2 training programs is multifactorial. Despite the wide range of individual differences, common themes were uncovered in the categories: burnout-related challenges, facilitators of burnout, facilitators of wellbeing, and coping strategies. Recognizing burnout is an important first step that may lead to broader understanding and help build interventions to support the individual and address institutional barriers to resiliency and resident wellbeing. Taking photographs of what burnout means to residents provides a unique opportunity for perspective-taking and for better understanding the impacts of burnout.
Medicine must continue to include rigorous training with high expectations for those who choose its practice. However, we must also prepare physicians to recognize, understand, and lead the promotion of self-care. Medical educators have been experiencing the tension between appropriately preparing residents for a challenging and high-stakes career and recognizing the importance of wellness in trainees—and medicine at large—for some time. The recent revisions to the Common Program Requirements, specifically those in Section VI, by the ACGME reflect these shifting paradigms. 7 Institutions, educators, and residents must work together to find creative and sustainable solutions. As burnout continues to affect physicians at all levels of training and practice, the themes uncovered here can help to guide our understanding and problem-solving strategies.
Future research should continue to address physician burnout using the BPS model to develop practical multifaceted solutions that target the whole person. Asking residents to take photographs of what wellness means to them may yield additional insights and ideas to continue the enhancement of personal growth and development of resiliency. Understanding the drivers of burnout and resilience is imperative for sustainable solutions to influence the future of medicine. One recent study described resilience as a developmental phenomenon that changes through engagement with uncertainty and adversity. Thus, it would suggest that to maximize success in decreasing burnout we must adapt and grow in our professional and personal lives. Program development should be innovative and timely. The literature supports both individual and institutional program development to combat burnout. It is our hope that introducing photographs as a means for capturing the landscape of burnout will broaden the understanding of burnout specifics and spark continued discussion regarding programmatic and institutional developments.
Limitations
Although the results of this study provide an in-depth understanding of the ways in which residents experience burnout and how they cope with this experience, generalizability of results is not possible with the methodology used in this study. Also, as saturation was reached after interviewing 8 participants, it is likely that varying experiences of resident burnout exist that have not been captured in this study. Results from this study may not be generalizable to the experiences of burnout for residents who are not white or for female residents. However, due to the small sample sizes inherent in qualitative research, it is not necessarily feasible that diversity be reflected in each sample. 16 Rather, diversity through variety in sample characteristics for each study is desired. Finally, residency faculty were actively involved in the interview processes of participants and this could have affected the openness of residents to express their feelings regarding this important topic.
Footnotes
Acknowledgements
Each participant provided permission to have photographs published. This paper has been presented at the Society for Teachers of Family Medicine Annual Conference in San Diego in 2017. This paper has not been presented elsewhere nor has it been published previously.
Author Contributions
Conceived and designed the experiments: JH, RB
Analyzed the data: TL, JH, JK, RB
Wrote the first draft of the manuscript: TL, JH, JK, RB
Contributed to the writing of the manuscript: TL, JH, JK, RB
Agree with manuscript results and conclusions: TL, JH, JK, RB
Jointly developed the structure and arguments for the paper: TL, JH, JK, RB
Made critical revisions and approved final version: TL, JH, JK, RB
All authors reviewed and approved of the final manuscript.
Funding:
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests:
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.