maintaining well-being

A narrative review on burnout experienced by medical

students and residents
Liselotte Dyrbye & Tait Shanafelt

OBJECTIVE To summarise articles reporting development, place patients at risk, and con-
on burnout among medical students and resi- tribute to a variety of personal consequences,
dents (trainees) in a narrative review. including suicidal ideation. Factors within the
learning and work environment, rather than
METHODS MEDLINE was searched for peer- individual attributes, are the major drivers of
reviewed, English language articles published burnout. Limited data are available regarding
between 1990 and 2015 reporting on burnout how to best address trainee burnout, but mul-
among trainees. The search used combina- ti-pronged efforts, with attention to culture,
tions of Medical Subject Heading terms medi- the learning and work environment and indi-
cal student, resident, internship and residency, and vidual behaviours, are needed to promote trai-
burnout, professional. Reference lists of articles nees’ wellness and to help those in distress.
were reviewed to identify additional studies. A
subset of high-quality studies was selected. CONCLUSION Medical training is a stressful
time. Large, prospective studies are needed to
RESULTS Studies suggest a high prevalence identify cause‒effect relationships and the best
of burnout among trainees, with levels higher approaches for improving the trainee experi-
than in the general population. Burnout ence.
can undermine trainees’ professional

Medical Education 2016: 50: 132–149

doi: 10.1111/medu.12927

Discuss ideas arising from the article at

http:// www.mededuc.com discuss.

Department of Medicine, Mayo Clinic College of Medicine, Correspondence: Liselotte Dyrbye, Department of Medicine, Mayo
Rochester, Minnesota, USA Clinic College of Medicine, 200 First Street SW, Rochester,
Minnesota 55905, USA. Tel: 507 252 4716;
E-mail: dyrbye.liselotte@mayo.edu

132 ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2016; 50: 132–149
 Burnout across the continuum of doctors’ training

INTRODUCTION WHAT IS THE EXTENT OF TRAINEE BURNOUT AND

HOW DOES IT VARY ACROSS DIFFERENT STAGES OF
Medical schools and residency programmes are TRAINING?
responsible for ensuring that future doctors are
well prepared to deliver high-quality patient-cen- Studies consistently find that a high proportion of
tred care, uphold ideals of the profession and be medical students and residents across all residency
leaders within evolving health care systems. Ideally, specialties and throughout the world experience sev-
trainees should also enter the workforce optimistic ere work-related stress and burnout.1,2,8–15 In our
about the future of medicine and satisfied with national or multi-institutional studies we found that
their career choice. Medical educators design and 35–45% of medical students had high emotional
implement curricula to move trainees toward these exhaustion, 26–38% had high depersonalisation and
goals. Some components of training and accultura- 45–56% had symptoms suggestive of burnout
tion, however, have an unintended and detrimen- (Table 1).1,4,5,16–19 Limited cross-sectional data sug-
tal impact on trainees’ mental health. A high gest the prevalence of burnout is higher for stu-
proportion of medical students, residents and fel- dents in more advanced years of training.12,17,19,20
lows (trainees) experience severe work-related Most of this increase appears to stem from an
stress and burnout.1,2 Burnout is a multifaceted increase in the experience of depersonalisation.17,20
construct characterised by various degrees of emo- This is particularly concerning because depersonal-
tional exhaustion, depersonalisation (i.e. feeling isation, an aspect of burnout primarily manifested
detached from or callous toward patients) and a as being callous or detached toward patients, is most
low sense of personal accomplishment.3 Burnout strongly associated with negative effects on profes-
can undermine trainees’ professional development, sionalism.4,8
place patients at risk and contribute to a variety
of personal consequences, including suicidal idea- Residency programme directors are likely to inherit
tion and substance abuse.4–8 Given its prevalence medical school graduates with a substantial burden
and the serious nature of the consequences, of burnout symptoms.21 In a pooled analysis of
action is needed to prevent burnout among doc- responses to the 22-item Maslach Burnout Inventory
tors in training and help those who are struggling (MBI) completed by 1428 fourth-year medical stu-
get the necessary care. In this narrative review, we dents attending five to seven US medical schools just
present an overview regarding the extent of trai- prior to graduation, the mean emotional exhaustion
nee burnout, professional and personal conse- score was 23.8, the mean depersonalisation score was
quences of burnout, why trainees commonly 9.3 and the overall prevalence of burnout of 49%.21
experience burnout, and how to best address trai- These findings suggest that the burden of burnout
nee burnout. We also discuss and identify critical symptoms continues during the transitional period
areas that need further research to better inform from medical school into residency. One longitudi-
intervention strategies. nal study that followed medical students as they tran-
sitioned from the Karolinska Institute Medical
Search strategy and selection criteria School into residency found that a high degree of
worry about the future during the final year of medi-
We searched MEDLINE for peer-reviewed, English cal school predicted postgraduate exhaustion (as
language articles published between 1990 and measured by the Oldenburg Burnout Inventory,
2015 with use of the search terms medical student [OLBI])22 6–10 months after graduation.23 This
OR resident OR ‘internship and residency’ AND burn- study suggests that students who are anxious about
out, professional. We identified additional studies workload, long hours, volume of information to
from the reference lists of these articles. Each arti- learn and ability to meet future responsibilities may
cle was critically reviewed and included as appro- be more vulnerable to a spike in their burnout level
priate based on reporting primary data, validity of as they start residency.
the methods used, clarity of the results and reli-
ance on an established tool to measure burnout. Once in residency the prevalence of high emotional
We included a subset of high-quality studies that exhaustion continues at about the same level found
we thought most pertinent and insightful. This during medical school (44–50%).1,8,15 The preva-
paper is informed by our narrative review and lence of high depersonalisation (32–38%) and over-
experience. all burnout (60%), however, increases.1,10 Some

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L Dyrbye & T Shanafelt

Table 1 Select large, multicentre or national studies using 22-item Maslach Burnout Inventory

No. Overall
Year of No. Response schools/ EE* High DP† High burnout‡
Citation study trainees rate (%) institutions (mean) EE* (%) (mean) DP† (%) (%)

Medical students
Dyrbye et al.17 2004 545 50 3 US 21.8 35 6.4 26 45
Dyrbye et al.16 2006 1701 55 5 US 23.3 37 6.8 28 47
Dyrbye5 2007 2248 52 7 US 24.0 40 7.3 32 50
Dyrbye41 2009 2682 61 7 US 24.4 42 8.0 36 53
19
Paro 2011–12 1350 82 22 Brazil 25.7 (men); 9.2 (men);
27.7 (women) 8.0 (women)
Dyrbye1 2012 4402 35 US national 25.0 45 7.0 38 56
study
Dyrbye18 2012 873 36 6 US 24.8 42 7.8 34 53
(second–
fourth year)
Residents
Golub26 2005 684 50 US national 22.4 33 10.7 53
study of
otolaryngology
residents
Blanchard11 2009 204 60 French national 23 35 44
study
of oncology
residents
Takayesu 2011 218 75 8 US emergency 33 59
(2014) medicine
programmes
Dyrbye1 2012 1701 23 US national 24.0 44 10.0 51 60
study, all
specialties

* EE, emotional exhaustion; high EE defined as a score of 27 or higher.

†
DP, depersonalisation; high DP defined as a score of 10 or higher.
‡
Burnout, defined as having high EE (≥27) or DP (≥10)15.

multicentre cross-sectional studies10 and small with the highest rate among those working in disci-
longitudinal studies suggest the prevalence of burn- plines at the front line of access to medical care
out increases with each year of residency,24,25 with (emergency medicine, general internal medicine,
others finding an equivalent prevalence across years neurology and family medicine).28 The extent to
of residency26 or a lower risk of developing burnout which this can be extrapolated to the residency
after the intern year.13,27 training environment is uncertain.

It is unknown whether the prevalence of burnout In addition to potential differences by specialty, the
varies by specialty during residency training; a prevalence of burnout may also vary by country of
recent national study of US doctors, however, sug- training and the trainee’s country of origin.
gests rather large variations in the prevalence of Although some of the stressors are likely to be
burnout among practising US doctors by specialty, different there are also bound to be similarities

134 ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2016; 50: 132–149
 Burnout across the continuum of doctors’ training

(e.g. suffering, death and dying, medical error, through the rigorous academic preparation
workload, etc.). Direct comparisons between studies required for acceptance, medical students begin
from around the world are problematic due to the medical school with mental health profiles similar
wide variations in medical training and methodolog- to or better than peers who pursue other
ical differences. Two recent large studies reported careers.33,34 A 2012 study of medical students at six
that burnout was less common among international US medical schools found that matriculates had a
medical graduates than among US medical gradu- lower prevalence of burnout (27.3% versus 37.3%)
ates training in the US.6,29 Whether this finding is and depression and higher reported quality of life
due to the extreme process of selection that interna- relative to age-matched college graduates pursuing
tional medical graduates must go through before other careers.34 Once medical school begins, how-
arriving in the US or is due to other factors merits ever, data suggest many medical students’ mental
further exploration. Regardless, studies indicate that health follows a downward trajectory and becomes
burnout among trainees is a global phe- worse than that of peers outside medicine.1,33,35 In
nomenon2,9,11 and often persists into practice.28,30 national samples of 4402 medical students and 1701
residents high emotional exhaustion, high deperso-
nalisation and overall burnout was substantially
IS THE PREVALENCE OF BURNOUT INCREASING? more prevalent among medical students and resi-
dents than age-matched college graduates not study-
Unfortunately, a lack of large, multi-institutional or ing medicine.1
national studies using similar methodologies makes
it difficult to draw conclusions about historical It is not known if burnout is more prevalent among
trends. Prior to May 2005 there was one publication medical trainees than trainees preparing for other
on burnout among medical students.31 A decade highly demanding fields (e.g. the airline industry,
later such publications are common, raising the police or military). However, a national study of
possibility that either the prevalence is increasing burnout in a sample of more than 7000 US doctors
or at least interest in the topic is increasing. When and a probability-based sample of the general US
reviewing results from large cross-sectional, multi-in- population conducted in 2011 found that relative to
stitutional or national studies conducted over the individuals with a high school diploma, doctors were
last decade using similar methodologies, the mean at increased risk of burnout (odds ratio [OR],
emotional exhaustion and depersonalisation scores, 1.36), whereas those with a bachelor’s degree (OR,
as well as the prevalence of high emotional exhaus- 0.80), master’s degree (OR, 0.71) or professional or
tion, high depersonalisation and overall burnout, doctoral degree other than MD or DO (OR, 0.64;
among responding medical students appear to have e.g. JD or PhD) were at lower risk of burnout, after
an upward trajectory overall (Table 1). adjusting for age, sex, relationship status and hours
worked per week. Although useful for providing
Whether the likelihood of burnout is higher among context, the importance of such comparisons is
residents today compared with in the past is simi- debatable, as distress among any of the groups
larly difficult to determine. Three of seven US stud- should not be disregarded, no matter how the
ies using historical controls suggest the prevalence groups’ relative distress levels compare.
of burnout has declined since 2003.32 However, a
recent national study of over 16 000 US internal
medicine residents who started training after 2003 WHY SHOULD WE BE CONCERNED ABOUT
found a prevalence of burnout similar to earlier TRAINEES WITH BURNOUT?
studies.6 To really get a sense of changes in the
experience of burnout large, longitudinal studies Burnout has potentially serious professional as well
using consistent methodology are needed. as personal consequences (Table 2). Data suggest
that burnout may erode medical students’ profes-
sional development and diminish a number of pro-
HOW BIG A PROBLEM IS IT, REALLY, WHEN fessional qualities (e.g. honesty, integrity, altruism
COMPARED WITH OTHER HIGHLY DEMANDING and self-regulation). In a multi-institutional study of
FIELDS? US medical students, those with burnout were sub-
stantially more likely to engage in unprofessional
The high prevalence of burnout among trainees behaviours, with the potential to undermine compe-
begs the question of whether burnout just affects tency (e.g. cheating and plagiarism) as well as
everyone. Data suggest that despite having gone impair the delivery of timely and accurate patient

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 Burnout across the continuum of doctors’ training

40 Durning SJ, Costanzo M, Artino AR Jr et al. one medical school results in improved psychological
Functional neuroimaging correlates of burnout well-being. Acad Med 2009;84:655–62.
among internal medicine residents and faculty 56 Howe A, Smajdor A, Stöckl A. Towards an
members. Front Psychiatry 2013;4:131. understanding of resilience and its relevance to
41 Dyrbye LN, Thomas MR, Power DV et al. Burnout medical training. Med Educ 2012;46(4):349–56.
and serious thoughts of dropping out of medical 57 van Vendeloo SN, Brand PLP, Verheyen CCPM.
school: a multi-institutional study. Acad Med Burnout and quality of life among orthopaedic
2010;85:94–102. trainees in a modern educational programme:
42 Enoch L, Chibnall JT, Schindler DL, Slavin SJ. importance of the learning climate. Bone Joint
Association of medical student burnout with J 2014;96-B:1133–8.
residency specialty choice. Med Educ 2013;47 58 Dyrbye LN, Thomas MR, Harper W et al. The
(2):173–81. learning environment and medical student
43 Oreskovich MR, Kaups KA, Balch C et al. The burnout: a multicentre study. Med Educ 2009;43
prevalence of alcohol use disorders among american (3):274–82.
surgeons. Arch Surg 2011;147:168–74. 59 Dahlin M, Fjell J, Runeson B. Factors at medical
44 Oreskovich MR, Shanafelt T, Dyrbye LN et al. The school and work related to exhaustion among
prevalence of substance use disorders in American physicians in their first postgraduate year. Nord
physicians. Am J Addict 2015;24(1):30–8. J Psychiatry 2010;64:402–8.
45 Larkin C, Di Blasi Z, Arensman E. Risk factors for 60 Ripp J, Babyatsky M, Fallar R et al. The incidence
repetition of self-harm: a systematic review of and predictors of job burnout in first-year internal
prospective hospital-based studies. PLoS One 2014;9: medicine residents: a five-institution study. Acad Med
e84282. 2011;86:1304–10.
46 Ohberg A, Vuori E, Ojanpera I, Lonngvist J. 61 Campbell J, Prochazka AV, Yamashita T, Gopal R.
Alcohol and drugs in suicides. Br J Psychiatry Predictors of persistent burnout in internal medicine
1996;169:75–80. residents: a prospective cohort study. Acad Med
47 Yaldizli O, Kuhl HC, Graf M, Wiesbeck GA, Wurst 2010;85:1630–4.
FM. Risk factors for suicide attempts in patients 62 Reed DA, Fletcher KE, Arora VM. Systematic review:
with alcohol dependence or abuse and a history association of shift length, protected sleep time, and
of depressive symptoms: a subgroup analysis from night float with patient care, residents’ health, and
the WHO/ISBRA study. Drug Alcohol Rev 2010;29: education. Ann Intern Med 2010;153:829–42.
64–74. 63 Ripp JA, Bellini L, Fallar R, Bazari H, Katz JT,
48 Van der Heijden F, Dillingh G, Bakker A, Prins JT. Korenstein D. The impact of duty hours restrictions
Suicidal thoughts among medical residents with on job burnout in internal medicine residents: a
burnout. Arch Suicide Res 2008;12:344–6. three-institution comparison study. Acad Med
49 Center C, Davis M, Detre T et al. Confronting 2015;90:494–9.
depression and suicide in physicians: a consensus 64 Ludmerer KM. Redesigning residency eduction –
statement. JAMA 2003;289:3161–6. moving beyond work hours. N Eng J Med
50 West CP, Tan AD, Shanafelt TD. Association of 2010;362:1337–8.
resident fatigue and distress with occupational blood 65 Cook AF, Arora VM, Rasinski KA, Curlin FA, Yoon
and body fluid exposures and motor vehicle JD. The prevalence of medical student mistreatment
incidents. Mayo Clinic Proc 2012;87:1138–44. and its association with burnout. Acad Med
51 Williams ES, Konrad TR, Linzer M et al. Physician, 2014;89:749–54.
practice, and patient characteristics related to 66 Prins JT, Gazendam-Donofrio SM, Dillingh GS, van
primary care physician physical and mental health: de Wiel HBM, van der Heijden FMMA, Hoekstra-
results from the physician worklife study. Health Serv Weebers JEHM. The relationship between reciprocity
Res 2002;37:119–41. and burnout in Dutch medical residents. Med Educ
52 Maslach C, Leiter MP. The Truth about Burnout. San 2008;42(7):721–8.
Francisco: Jossey-Bass 1997. 67 Haglund ME, ann het Rot M, Cooper NS et al.
53 Reed DA, Shanafelt TD, Satele DW et al. Resilience in the third year of medical school: a
Relationship of pass/fail grading and curriculum prospective study of the associations between
structure with well-being among preclinical medical stressful events occurring during clinical rotations
students: a multi-institutional study. Acad Med and student well-being. Acad Med 2009;84:258–68.
2011;86:1367–73. 68 McManus IC, Keeling A, Paice E. Stress, burnout and
54 Rohe DE, Barrier PA, Clark MM, Cook DA, Vickers doctors’ attitudes to work are determined by
KS, Decker PA. The benefits of pass-fail grading on personality and learning style: a twelve year
stress, mood, and group cohesion in medical longitudinal study of UK medical graduates. BMC
students. Mayo Clin Proc 2006;81:1443–8. Med 2004;2:29.
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A change to pass-fail grading in the first two years at W, Thomas MR, Szydlo DW, Sloan JA, Shanafelt TD.

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 Burnout across the continuum of doctors’ training

common among residents with burnout.48 Although collaboration has also been shown to relate to resi-
data regarding the frequency of medical student dent burnout.57 In a national study of orthopaedic
and resident suicide are limited, the prevalence of residents in the Netherlands poor peer collabora-
suicide among US doctors is substantially higher tion was the strongest learning climate factor stud-
than that among the US population, despite a simi- ied associated with increased symptoms of
lar prevalence of depression.49 Other personal rami- burnout.57
fications of burnout include higher relationship
stress26 and risk of motor vehicle incidents.50 In the above-mentioned multi-institutional study of
year 1 and year 2 students, there was no significant
Together these studies suggest that burnout has association between hours spent in lectures and
potentially wide ramifications for the profession and small groups, hours of clinical experiences, hours
the public it serves, with its effects on professional and number of exams, weeks of vacation, and any
behaviour, attitudes and competency, safety and measure of student well-being.53 Similarly, a sepa-
quality of care, career or specialty decision making, rate study of third and fourth-year students found
and individual risk behaviours and decisions. no independent relationship between clinical rota-
tion characteristics and workload (e.g. outpatients,
inpatients, intensive care unit, overnight call fre-
WHAT IS DRIVING BURNOUT? quency, and number of patients seen per day or
admitted per week) and burnout.58 These studies
The finding that matriculating medical students suggest that curricular and clinical hours may not
have a similar or even better mental health profile drive the burnout experienced by medical students.
than age-matched college graduates pursuing other
careers and that medical students’ mental health Among residents burnout is commonly attributed to
deteriorates once in medical school to become excessive workload, with higher patient volumes,
worse than that of age-matched college gradu- more frequent overnight calls, greater work-hours
ates,1,34 suggests that the origins of burnout are and lower autonomy associated with an increased
rooted in the learning and work environment. This risk of burnout, although studies are inconsis-
framework resonates with studies demonstrating tent.2,11,26,30,32,59 Two longitudinal studies on the
that workplace conditions, more than individual post-2003 Accreditation Council for Graduate Medi-
characteristics, are the major determinants of doc- cal Education (ACGME)-mandated work-hour limi-
tors’ well-being51 and drivers of burnout.52 tations, reported no relationship between self-
reported workload (e.g. average number of patients
What is the role of the curriculum and training admitted per on-call day), work-hours, overnight call
experiences? frequency and incidence of burnout.60,61 Other
studies examining the prevalence of burnout among
Although some sources of stress persist throughout residents before and after the 2003 ACGME-man-
training and into practice, other sources of stress dated work-hour reform have mixed results, with
vary at the different career stages (Table 3). In a only three of seven studies showing statistically sig-
large multi-institutional study designed to identify nificant reduction in burnout.32 A national study of
modifiable curricular factors related to first- and over 16 000 US internal medicine residents who
second-year student burnout, grading schemes were started training after 2003 found a prevalence of
independently associated with an increased risk of burnout similar to earlier studies.6 Although studies
burnout.53 Students in a grading system with three examining the impact of the 2011 ACGME duty
or more hierarchies (e.g. A‒F letter grade; hon- hour standards (shift length and night float limits,
ours/high pass/pass/marginal pass/fail; honours/ protected sleep time) on overall well-being and
pass/fail) rather than a strict pass or fail curricu- mood and depression scores have had mixed
lum had 1.97 times increased odds of experiencing results,62 a recent study of first-year internal medi-
burnout. Other studies have demonstrated that pass cine residents at three institutions found similar
or fail grading schemes during the first 2 years of year-end prevalence and incidence of burnout
medical school promote group cohesion,53–55 sug- between the 2011–2012 and 2008–2009 cohorts.63 It
gesting that grading scheme may influence the is possible that some of the benefits of limiting total
degree to which the learning environment is sup- work hours have been offset by work compression,64
portive, help ease the initial adjustment to medical where the same workload and educational require-
school and facilitate development of social support ments must be completed in fewer hours, such that
networks that are important to resilience.56 Peer

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L Dyrbye & T Shanafelt

Table 3 Potential stressors and contributors to burnout among medical trainees

Medical students Residents

Stage-specific stressors Human dissection Added responsibility for patient care

First death experience Research productivity
Medical licensure requirements
Job search
Lack of control
Excessive administrative tasks
Stressors for both medical Adjustment
students and residents Competition
(at all stages of training) Patient and family suffering
Specialty/sub-specialty decision making
High stake assessments
Lack of personal time
Financial concerns related to student debt
Negative personal life events

Learning and work Poor learning environment Work compression

environment factors Inadequate support from faculty Excessive workload
associated with burnout staff, medical school staff and peers
Education of medical students is Overnight call frequency
not a priority for faculty staff
Disorganised clinical rotations Work-hours
Poor supervision Limited autonomy
Cynical residents Lack of timely feedback
Little variety of medical problems encountered Stressful relationships with supervisors
Mistreatment Uncertainty about the future
Grading schema Medical error
Perception that personal needs are
inconsequential to training programme

the net effect of work-hour limitations on residents’ from an ethnic minority who perceived their race
mental health is neutral. had adversely impacted their medical school experi-
ence were substantially more likely than ethnic
Does supervisor behaviour relate to trainee minority students who reported no such experiences
experience of burnout? to have high emotional exhaustion, high deperson-
alisation and burnout.16 More recently, a national
In a multi-institutional study involving over 3000 study of 564 third-year medical students found that
students, dissatisfaction with the overall learning perceptions of recurrent mistreatment by faculty
environment and amount of support from faculty staff or residents were associated with an increased
staff most strongly related to burnout among year 1 risk of burnout.65
and year 2 students, whereas dissatisfaction with the
overall learning environment, poor clerkship organi- Similarly, stressful relationships with supervisors,2
sation and working with cynical residents most attending physician demands,26 insufficient auton-
strongly related to burnout among year 3 and year 4 omy,26 a perception that personal needs are incon-
students.58 Studies have also found that students sequential8 and lack of timely feedback60 are
who perceive they have been mistreated or belittled associated with resident burnout. By contrast, per-
are more likely to have burnout.16,58,65 For example, ceptions that supervisors within the work environ-
in a 2006 multi-institution study, medical students ment accept residents’ need for education, feedback

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 Burnout across the continuum of doctors’ training

and support may buffer the development of exhaus- mechanisms are likely to have some degree of
tion, as measured by the OLBI, during postgraduate moderation of the stress that effects vulnerability to
training.59 Furthermore, a Dutch study found that burnout.2
residents who describe their relationship with super-
vising doctors as mutually supportive and beneficial Life stressors outside of medicine also drain trainees’
had lower emotional exhaustion and depersonalisa- personal resources. Personal experiences, such as
tion scores than residents who felt under-appreci- personal illness, illness in a family member, going
ated by their supervising doctor.66 Although there through a divorce, family-related stress and financial
are substantial data supporting a relationship concerns increase the risk of burnout among medical
between supervisor behaviour and trainee burnout, students and residents.2,9,17,60,61 Medical students70
there is no direct evidence of causality. It is possible and residents6 with a high educational debt are also
that trainees with symptoms of burnout view the more likely to experience burnout. Accordingly, the
learning environment differently, leading to lower experience of burnout is a complex phenomenon
ratings of factors within the learning environment, due to the multifaceted interplay of personal, profes-
or that a poor learning environment leads to trai- sional and environmental characteristics.
nees experiencing burnout. In a single-centre longi-
tudinal study of third-year medical students, What might be some new drivers of burnout among
perceptions of mistreatment by superiors or poor trainees?
role modelling were associated with higher end-
point depression scores,67 suggesting the direction- A number of new stressors are on the horizon for
ality is one of suboptimal behaviour by faculty staff the next generation of doctors. For one, competi-
adversely impacting trainees’ well-being. Additional tion for residency slots is increasing as a result of
studies designed to understand modifiable factors new medical schools opening, existing medical
within the training and work environment that drive schools expanding and relatively stagnant growth of
burnout are needed to broaden our understanding residency and fellowship programmes. This will
of burnout and identify targets for intervention increase competition and stress as trainees strive
studies. harder to achieve the highest test scores and grades,
potentially fuelling a culture of competition that
Are there individual factors that increase could undermine social support. Second, a mile-
vulnerability to burnout? stone-based flexible progression to shortened paths
to completion of training could accelerate assess-
Although the learning or work environment rather ments and amplify stress, increasing the risk of
than individual characteristics (e.g. demographics burnout, or lead to reduced educational burden
and personality) is thought to be the primary con- and lower risk of burnout. Third, seemingly expo-
tributor to burnout,2,3 individual characteristics and nential growth in the medical knowledge to be
experiences influence how workload and level of learned, coupled with new competencies to be
support are perceived.9,68 With respect to demo- reached within fields such as interprofessional team-
graphics, studies have found non-minority students work, quality and safety, population health and data
to be more likely to have burnout than ethnic analytics, increases the challenges that accompany
minority students, after controlling for age, sex, par- curriculomegaly. Fourth, trainees today are entering
enting and marital status.16,58,69 Similar findings a rapidly evolving and changing health care system
have been reported among residents2 and outside experiencing dramatic environmental and cultural
of medicine.3 Why minority students have a lower shifts. In addition, they will work in an era of work-
prevalence of burnout is not known. It may be dif- force shortages. Hence, trainees face an enormous
ferences in life experiences that have culminated in amount of uncertainty coupled with new con-
them being more resilient to the stressors of train- straints.71 This is concerning because studies suggest
ing. Some studies suggest female medical students that residents who feel uncertain about the future
and residents may also be at greater risk of burn- are more likely to experience burnout.8
out58 or emotional exhaustion,2 whereas male resi-
dents may more often experience
depersonalisation2 but these relationships are not WHAT SOLUTIONS OR STRATEGIES MIGHT BE
strong.2 In terms of personality, a study found weak EFFECTIVE?
but statistically significant associations between
degree of neuroticism and emotional exhaustion.68 Trainee well-being is a shared responsibility of indi-
Personal disposition, social support and coping vidual trainees, training programmes (i.e. medical

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L Dyrbye & T Shanafelt

school or residency), academic medical centres, a skill that can be learned and strengthened.56 In
accreditation organisations and organised medicine. fact, the psychological literature confirms that
Given the myriad of stressors and individual prefer- social support and constructive coping skills are
ences, a one-sized solution is unlikely. Rather, strate- pivotal to resiliency, and as such should be part of
gies should systematically engage trainees in an individual’s approach to cultivating personal
addressing burnout, use available resources, be resiliency.56
grounded in best available data, be customised to
the local environment and include a variety of Trainees may also find mindfulness training useful
approaches. We should aspire to eliminate or for combating stress and promoting engagement in
reduce the root causes of burnout and promote self-care activities. Mindfulness training can include
resilience and well-being. After all, being mentally self-awareness and positive self-reinforcement, strate-
healthy is more than the absence of mental illness, gies to lower physical and emotional reactions to
and is critical to personal well-being and to stressors, communication skills training, meditation
society.72 and yoga exercises.75,76 Although rigorous ran-
domised trials with a comparative control group are
What should trainees be encouraged to do to lacking,76 data from a 1-year longitudinal study
reduce their risk for burnout? found that primary care doctors who voluntarily par-
ticipated in a 52-hour mindfulness training pro-
Despite the rigours of training, not all medical trai- gramme delivered after hours and on weekends
nees experience burnout.60,69 Notably, among those experienced markedly reduced burnout and
who do burnout, 15–25% recover over the course of improved empathy and mindfulness, with results
the next 1–2 years without any specific program- sustained 3 months post-intervention.77
matic intervention.61,69 Although many factors con-
tributing to burnout are beyond individual control, Additional strategies include seeking support and
personal choices have some influence on how stres- frank discussions with supervising faculty staff when
sors impact well-being. For example, being a trainee suspects he or she may have had a role in
employed in order to have an income while a medi- a medical error. Such conversations can help pre-
cal student increases the risk of developing burnout, vent future errors and reduce inappropriate self-
and if already burned out, employment is strongly blame and distress.15,78 Trainees also have a per-
associated with not recovering from burnout.69 Med- sonal responsibility to seek additional instruction
ical students and residents who report higher levels for specific work-related tasks they find particularly
of social support are less likely to have burnout stressful (e.g., relaying bad news, procedural tasks),
symptoms,29,69 whereas individuals with higher levels set reasonable personal expectations for the amount
of fatigue are at increased risk of burnout.69 of work-related tasks that can be completed within
allowed work hours, and handover all patient care
Relying on a personal strategy to find meaning in needs at the end of a shift to avoid extending work
work or training, engaging regularly in recreation, once officially relieved of duty. Doing so, however,
hobbies or exercise, maintaining a positive outlook can be extremely difficult and may amplify stress if
and avoiding a mentality of delayed gratification the trainee feels their own inadequacy prevented
(i.e. ‘survival attitude’) lowers the risk of burn- them from getting needed work done before the
out.8,73 Personal choices that ensure adequate end of their shift or if they hear conflicting mes-
sleep during time off, build relationships and sages about their personal responsibility for
social support, maintain personal health, reduce patients’ welfare and need to leave the hospital with
debt burden and manage stress reduce the risk of patient-care work yet to be completed. Trainees will
burnout (Table 4).6,9,58,66,69 In taking ownership of also need to embrace a culture of change and con-
their own mental well-being, it is important that tinuous improvement as new health care systems are
trainees are attentive to integrating their personal designed and implemented consistent with key
and professional lives, with appropriate allocation strategies79 and national quality priorities80 to
of time for independent study, personal pursuits improve patient outcomes and reduce costs.
and rest. Other constructive coping strategies, such
as positive reframing and problem solving, have To promote well-being trainees should also take
also been shown to decrease the risk of other men- steps to calibrate personal distress and well-being,
tal health problems67 and promote resilience.56 determine if their mental health is adversely impact-
Resiliency is the ability to remain positive despite ing their learning or care of patients, and seek help
adversity.74 It is important to note that resilience is when appropriate. How well trainees perform these

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 Burnout across the continuum of doctors’ training

Table 4 Personal strategies to promote well-being

Medical students Residents

Stage-specific Do not work for income (e.g. employed while in medical school) Seek extra training for stressful job-related
strategies tasks specific to your specialty discipline
(e.g. delivering bad news, dealing with
angry patients, procedures)
Improve organisation skills
Handover all patient care needs at end of
shift to avoid extending work once
officially relieved of duty
Set reasonable personal expectations
for work tasks to be completed
within allowed work hours
Strategies for Use available tools to assess personal level of well-being
all stages Obtain treatment for mental or emotional concerns
Manage time away from work to ensure adequate sleep
Build relationships with peers, mentors and faculty staff
Seek support from supervisors when worried about possible medical error
Find meaning in work
Engage regularly in recreation and hobbies to reduce stress
Maintain a positive outlook
Seek advice about debt reduction
Avoid an attitude of delayed gratification
Focus on what is most important in life
Obtain mindfulness training to become more self-aware and lower physical and emotional reactions to stressors
Allocate time for independent study and personal pursuits
Find ways to contribute to society (e.g. donate blood or volunteer)
Exercise in accordance with CDC guidelines
Obtain age and sex-appropriate health screening

tasks is unknown; however, data suggest that doctors Curriculum

in practice are poor at calibrating their own level of
distress81 and both trainees and doctors in practice One reasonable step is to introduce the concept of
are reluctant to seek help for mental health con- self-care, well-being and resilience into the training
cerns.30,82 Unfortunately, few trainees with burnout curriculum. Innovative curricula focused on aware-
seek help due to perceived stigma, negative per- ness of burnout, self-care (reduction of stress and
sonal experiences and social and cultural factors,83 fatigue), mindfulness, strategies for taking tests,
which means that early identification and treatment maintaining health and personal interests, work-life
of trainees with burnout is difficult. balance, dealing with suffering and medical error,
debt management and adaptive coping strategies
What organisational-level strategies might be (e.g. positive reframing, problem solving, etc.) may
helpful? be useful for primary prevention.6,8,56,67,69,75,76,84–87
A curriculum that helps trainees understand how to
Organisations need a multi-faceted approach that support peers in distress, and when, why and how to
attends to primary, secondary and tertiary preven- personally intervene when peers are impaired due
tion to reduce the risk of trainees experiencing to a mental health problem, also appears to be
burnout and helps those with burnout recover needed.83 Supporting such cognitive knowledge
(Table 5). with understanding and experience of the process

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L Dyrbye & T Shanafelt

Table 5 Potential ways medical schools, residency programmes, academic medical centres, accrediting organisations and organised
medicine can promote a culture of wellness

Wellness curriculum
Implement and evaluate effectiveness of a wellness curriculum for doctors in training*,†
Provide funding and necessary support‡
Include promotion of personal mental health within core competency and milestone framework§
Require wellness programming§
New educational strategies
Adapt pass or fail grading in years 1 and 2 (preclinical years)*
Reorganise a large group of students into smaller learning communities to build group cohesion and social support*
Provide opportunities for meaningful patient care roles and continuity with preceptor*
Address work-compression†,‡
Include evaluation of patient mix, organisation of rotation, opportunity for meaningful work, adequacy of supervision, perceived
support, learning climate and other controllable factors during programmatic evaluation*,†
Monitor and respond to absences to support trainees during major life events and facilitate detection of distress*,†
Organise social activities to foster peer‒peer and peer‒faculty relationships*,†
Subsidise access to fitness facilities*,†,‡
Implement career advice† that includes contract negotiation, medical billing, office management, health care reform and similar practice
topics for senior residents to ease transition from training into medical practice†
Promote culture of no tolerance of harassment through novels ways of monitoring and responding to reports of harassment and
suboptimal role-modelling behaviours*,†
Implement faculty staff development to raise awareness and facilitate a positive learning environment with effective, timely feedback,
and enable them to detect and respond to emotional distress in trainees*,†,‡
Develop a compensation strategy that enables faculty members to prioritise education of trainees (e.g. reasonable workload when
supervising, and compensation plans to offset lowered productivity)§
Screening tools
Make tools available that individuals can use to self-calibrate*,†,‡,§,¶
Screen for distress in a group of medical trainees using a third party*,†,‡
Access to care
Empower and educate trainees to prioritise their own health through adequate access to care and an adequate absenteeism policy*,†
Structure required curricular time and work assignments to allow for time-off during a typical workday*,†
Assess for perceived and feared discrimination due to mental health problems and implement response*,†
Support national efforts to expand the mental health provider workforce*,†,‡,§,¶
Advocate for reporting requirements (state licensing boards, hospitals, clinics and malpractice insurance carriers) to ask about current
impairment from a mental health condition, rather than past or current diagnosis or treatment*,†,‡,§,¶
Tackle stigma toward mental health problems and barriers to seeking help by educating trainees and faculty staff about confidentiality
policies and procedures; monitor and respond to reports of discrimination due to mental health problems*,†,‡
Ensure adequate access to conveniently located mental health counsellors on and off campus who are not involved in trainees’
academic assessment or promotion*,†,‡
Help local and national initiatives targeting negative attitudes about mental illness and treatment*,†,‡,§,¶

* Medical schools; † residency programmes, ‡ academic medical centres, § accreditation organisations (e.g. Liasion Committee on Medical
Education, Accreditation Council for Graduate Medical Education), ¶ organised medicine (e.g. American Medical Association, Association
of American Medical Colleges).

of behavioural change can help translate knowledge Medicine.88 Facilitated small-group meetings with
into action, as illustrated by the experience at colleagues to address such topics (e.g. self-care,
Northwestern University Feinberg School of meaning in work, dealing with suffering, mindful

142 ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2016; 50: 132–149
 Burnout across the continuum of doctors’ training

practice and work-life balance) have been shown to changes to the training or practice environment
be useful in a randomised clinical trial involving demonstrates a shared commitment to addressing
doctors at the Mayo Clinic.88 Extra-curricular strate- the issue.
gies with some supportive outcome data include
Vanderbilt School of Medicine’s comprehensive Adopting a pass or fail grading scheme during the
medical student wellness programme and the Mayo first 2 years of medical school is an example of an
Clinic Graduate School of Medical Education’s evidence-based organisational change to reduce
team-based, incentivised exercise programme.89,90 burnout and improve well-being.53–55 Fortunately,
studies have found that switching to a pass or fail
Inserting such a curriculum into the existing under- approach in year 1 and year 2 does not decrease
graduate and graduate medical education pro- medical knowledge scores on standardised tests or
grammes has numerous challenges. Wellness clerkship performance.54,55 Although not directly
programming and curricula, however, could fulfill studied, using criterion-based grading rather than
Liaison Committee on Medical Education require- norm-based grading may facilitate a collegial learn-
ments (accreditation standard 12.3)91 for US and ing environment during the clinical years that could
Canadian medical schools and potentially new promote well-being. Reorganising medical students
ACGME Clinical Learning Environment Review from a single large group into smaller learning com-
(CLER) Pathway92 requirements for education on munities has been shown in a single institution
strategies for managing burnout and fatigue. study to reduce stress, anxiety and depression.96
Obtaining the necessary resources and infrastruc- Organising retreats and social activities may foster
ture to optimally design, implement, evaluate and relationships and peer support.56,66 Longitudinal
sustain such initiatives is likely to be difficult. clerkships may provide greater opportunity for con-
Widespread adoption of self-care as a core compe- tinuity with a preceptor and facilitate more mean-
tency, as recognised by the Canadian Royal College ingful relationships, higher support and more
of Physicians and Surgeons,93 the UK General Medi- substantive involvement in patient care.97 Whether
cal Council94 and some US medical schools,88 would students participating in longitudinal clerkships or
facilitate development of evidence-based curricula other educational experiences where students learn
and thoughtful assessment strategies, and send the while measurably improving health care98 leads to a
important message to learners that self-care is an lower risk of burnout or other forms of distress
essential part of being a doctor. Inclusion of self- remains to be determined.
awareness of emotional limitations and appropriate
help-seeking in the 2013 milestones95 developed by Programmatic evaluation is a key way for medical
the ACGME and the American Board of Pediatrics schools and residency programmes to optimise the
is evidence that the concept of self-care is becoming learning environment by identifying and addressing
a fundamental principle in US graduate medical controllable factors that impact the well-being of
education. trainees (e.g. organisation of rotations, patient mix,
opportunity for meaningful work and emotional
The effectiveness of any new curriculum, however, support, adequacy of supervision, and role mod-
should be subject to a rigorous evaluation to ensure elling by faculty staff2,58). Attention to the sequence
efficacy and optimal resource allocation. Such evalu- of clinical assignments can help ensure learners are
ations should be held to the same standards of evi- adequately prepared for the next level of responsi-
dence required elsewhere in medicine. Reductions bility while allowing for the level of challenge
in burnout or improvements in well-being should needed for intellectual stimulation and learning to
be demonstrated and study designs must include occur. The ACGME CLER Pathway92 is designed to
appropriate comparator or control groups and evaluate and improve the clinical learning environ-
address volunteer bias. ment within US teaching hospitals, medical centres
and health systems. As such it is hoped to better
New educational strategies ensure that residents have effective supervision,
work in a supportive culture and have a manageable
Providing training regarding how to deal with work- workload – all of which have the potential to reduce
related stress in the absence of a simultaneous effort burnout.
to identify and address factors contributing to burn-
out can increase cynicism (e.g. ‘this is your prob- Although challenging,99 eliminating harassment will
lem’). By contrast, a cohesive and simultaneous indirectly reduce burnout.16,65 Given reports of
effort that pairs such training with structural mistreatments and barriers to reporting to

ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2016; 50: 132–149 143
L Dyrbye & T Shanafelt

authorities despite existing efforts, new or acceler- and practising doctors.103–105 The Physician Well-
ated institutional efforts are needed to more Being Index helps doctors self-calibrate and reflect
effectively address trainee harassment, discrimina- on behavioural changes to improve personal well-
tion and belittlement. Doing so is likely to require a being.81 A web-based version of this tool is now
culture change as existing multipronged strategies being evaluated in both medical students and doc-
have not effectively addressed this problem.71,99,100 tors across multiple centres. This tool enables stu-
dents or doctors to: (i) receive immediate feedback
Initiatives for faculty staff development should on how their current level of well-being compares
inform staff about the extent of the problem, com- with medical students and doctors nationally, (ii)
mon drivers of burnout, how to identify and refer ascertain whether their level of well-being puts
trainees with burnout and how to maintain confi- them at a higher risk of potentially serious personal
dentiality. As supervisor behaviour relates to trainee and professional repercussions, (iii) track changes
burnout, staff development should ensure that core in their personal well-being over time, and (iv)
faculty members have the requisite teaching skills access just-in-time local and national resources
needed to establish an optimal learning climate, designed to both promote and nurture well-being
provide effective feedback and foster reciprocal rela- and provide support for a variety of concerns expe-
tionships.66,85,86 Reacting to students’ and residents’ rienced by doctors in training (e.g. burnout, fati-
evaluations of faculty staff with individualised gue, financial concerns, relationship issues, career
remediation plans targeting problematic faculty staff decision making, resilience, etc.). Medical schools
behaviours or reassignment of teaching duties is and residency programmes can access and down-
also necessary.71 Given that medical education still load aggregate school-level reports on their trainees
relies heavily on the apprenticeship model, faculty showing the number using the tool, mean score by
staff discussing and personally modelling self-care year and sex, mean score over time, resources
strategies will strengthen norms for future doctors accessed, and how trainees’ scores compare with
that support limit-setting, help-seeking and work-life national data.
balance. Doing so could help establish a culture of
wellness that reduces burnout among faculty Access to care
members.
Although self-assessment tools may facilitate recogni-
Screening tools tion of distress and awareness of how to access help,
they are unlikely to fully overcome barriers to help-
Given the high prevalence of distress and challenges seeking among trainees. An absentee policy that
with self-calibration,81 secondary prevention strate- allows time-off for personal medical appointments
gies to promote early identification of burnout and during clinical hours is important to facilitate access
prevention of serious personal or professional con- to care. Trainees should have access to mental
sequences should be put in place.101,102 This health providers who are not involved in their aca-
approach is congruent with the ACGME CLER demic assessment or advancement process. Ideally,
expectation of monitoring medical trainee burnout trainees should be provided ‘in-network’ options for
as a strategy to optimise patient safety.92 Such off-campus or external mental health care providers
approaches may include self-assessment tools for use to minimise concerns regarding confidentiality and
by individuals or by medical schools and residency stigma related to seeking care for mental health
programmes to screen for distress and identify those issues.83,106 A recent national study found that medi-
most likely to benefit from individualised coun- cal students are less willing to seek professional help
selling or other support resources. The latter for a serious emotional problem than both the gen-
approach would likely require involvement by an eral US population and age-matched peers.83 A
independent third party, such as a student health large proportion of medical students in this cohort
service or an employee assistance programme. Trai- reported that they had observed faculty staff and fel-
nees who screen positive for a substantial burden of low students breeching the confidentiality of other
distress should be directed or referred to their pri- students’ mental health issues and engaging in dis-
mary care doctor or mental health provider for fur- criminatory behaviour toward students with emo-
ther assessment. tional problems. The students also expressed
concern that disclosing mental health issues would
One available self-assessment tool, the 7-item Medi- adversely impact their residency training opportuni-
cal Student and Physician Well-Being Index, has ties as well as patients’ views of them. Perhaps
now been validated in medical students, residents related to these factors, in a recent national study

144 ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2016; 50: 132–149
 Burnout across the continuum of doctors’ training

medical students were less willing to report a col- these aims will help foster the competency, dedica-
league impaired due to mental health problems tion and professionalism of future doctors, both
than one impaired due to alcohol or substance during the training process and over the course of
abuse.18 their careers.

Residents may be reluctant to seek help for a men-

tal health issue due in part to concern it may result Contributors: LD and TS: made substantial contributions to
in loss of privileges or even their license to practice the conception and design of the work, or acquisition,
medicine.82 To address this potential barrier to analysis or interpretation of data for the work; drafted the
seeking help, state licensing boards, hospitals, clin- work or revised it critically for important intellectual con-
ics and malpractice insurance carriers should be tent; gave final approval of the submitted version; and
transparent on how data regarding mental health agree to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integ-
will be used and only inquire about current impair-
rity of any part of the work are appropriately investigated
ment due to a mental health condition, rather than
and resolved.
a past or current diagnosis or treatment.49 In addi- Acknowledgements: none.
tion, academic medical centres, accreditation orga- Funding: none.
nisations and organised medicine need to confront Conflicts of interest: the authors mention the Medical Stu-
a professional culture that is indifferent to personal dent and Physician Well-Being Index. The Mayo Clinic
wellness, suggests that work should always be priori- holds copyright on MSWBI and PWBI. The authors and
tised over personal needs, and discourages doctors the Mayo Clinic have a financial interest in these tech-
from acknowledging their personal struggles and nologies. No royalties have been received to date.
vulnerabilities.30 Research using the MSWBI and PWBI has been reviewed
by the Mayo Clinic Conflict of Interest Review Board and
is being conducted in compliance with Mayo Clinic con-
flict of interest policies.
CONCLUSION
Ethical approval: not applicable to this review.

Today burnout is prevalent during the process of

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