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23 Developing aHealthy Learning Environment
237
that can be helpful to follow. The receiver can also ensure
that feedback is usable by seeking out feedback, requesting
just one thing to work on at a time, and taking notes, if
needed, to avoid feeling overwhelmed.
Feedback should be given frequently and repeatedly [41].
That said, the giver should consider the immediate context
when deciding to provide feedback. Largely the suggestion
is that the sooner the better while memories are intact.
However, the challenges of the busy physician schedules and
multiple roles present unique challenges to doing so. It is
typically not appropriate to provide a resident or medical student with critical feedback in front of patients or colleagues.
Instead, setting aside a time, perhaps a one-off based on
events or regularly scheduled, to provide private feedback
would be more appropriate. These scheduled times can be
introduced while setting the stage with the expectation that
the resident will receive feedback during a specic time
allowing the resident to come prepared. One program utilizes Feedback Fridays during which the Family Medicine
Inpatient Service Attending meets individually with each
resident on Friday after seated rounds to provide each team
member with feedback and also elicit their feedback about
the week. Additionally, the emotional context of the receiver
should be considered. If you know that the receiver just lost
a patient or has eight patients to see in 2hours and is already
behind by 35minutes, reconsider providing feedback at that
time and look for another opportunity.
When a feedback giver is considering the context of feedback they are ensuring feedback is provided in private, has
considered the emotional state of the receiver and have considered the potential emotional consequences of the feedback. Similarly, a receiver who is considering context may
ask to schedule feedback when privacy can be maintained
and may consider the giver’s schedule when requesting additional feedback.
Growth Oriented andEncouraging
Returning to Heen and Stone’s [44] psychological triggers, an
identity trigger occurs when feedback threatens the way the
learner sees themselves. The identity triggers can be a result
of the learner distorting feedback to mean more than just the
words that were written or spoken with the intention of
improving their performance. For example, a receiver may
magnify feedback, assume the intentions of the feedback provider, catastrophize the implication of the feedback, berate
themselves because they should have known better or lter
out any positive feedback, focusing only on the criticism.
Feedback results are optimized when the feedback itself
doesn’t pose a threat to the receiver’s self-esteem, and is
encouraging, specic and oriented toward goal setting [41].
To achieve encouraging, growth oriented feedback the
giver should encourage receiver self-reection and a growth
mindset, normalize not knowing and negotiate goal setting
with the receiver. Too, the receiver should engage with the
feedback looking for opportunities to utilize specic recom-
mendations and practice new skills. Receivers should be
aware of cognitive distortions that may cause them to magnify the meaning or implications of feedback. Developing a
growth mindset where learning is possible rather than a xed
mindset where feedback equates to failure is critical for a
feedback receiver to optimally use the information provided.
Encourages Reection
Reection should be encouraged because self-reection can
encourage deeper learning and develop critical thinking
skills and judgment. Further, we tend to believe our own
thoughts more than what others tell us. Wald and colleagues
[42] found that self-reection encouraged greater connection
with emotional experiences, to the perceived benet of personal and professional development, which has historically
not been a focus in medical education.
To encourage reection, a feedback giver might use probing, open-ended questions while the receiver may maintain a
growth mindset to avoid cognitive distortions about performance. The giver may explore the culture components of the
interaction being assess to identify any implicit biases while
the receiver may proactively recognize implicit bias before,
during or after interactions. The giver may also model selfreection by discussing their own experiences and reactions.
The Pendelton Model described in Table 23.1 may assist
with ensuring feedback encourages reection.
Maintains theRelationship
A relationship of mutual respect, positive interactions, and
trust in the giver and their motives facilitates the reception
of feedback. Telio, Ajjawaii, and Regehr [39] suggest that
an “educational alliance,” similar to the therapeutic alliance,
be developed between learners and teachers. A positive relationship between the giver and receiver in which they know
each other well also promotes more objective feedback [41].
The importance of a positive relationship is further highlighted by Heen and Stone’s [44] third psychological trigger, the relationship trigger, in which the receiver struggles
to receive feedback due to lack of respect or trust in the
motives of the giver. In this case, the feedback may be disregarded, even if it is accurate and could be helpful, or the
receiver may respond to critical feedback by criticizing the
giver.
Time invested in developing respectful relationship can
facilitate effective feedback. The feedback giver may model
requesting and receiving feedback graciously while communicating the purpose of feedback to the receiver. Eliciting the
receiver’s perspectives about the feedback and attending to
non-verbal cues nurtures a respectful relationship. If an
impasse is reached, the giver may suggest another source
provide the feedback or end the discussion if it is no longer
productive. Similarly, a receiver may identify relationship
triggers, separate feeling about the giver from the content of
the feedback and actively engage in the conversation to glean
the useful information to be shared.
238
K. Miller et al.
Dr. Phillips was in his rst year of faculty in the
family medicine program. He was rounding on inpatient service patients with the family medicine interns
and an intern from the psychiatry residency program.
Dr. Phillips’ initial impression was that the psychiatry
resident came across as haughty, arrogant and defensive. He noted that whenever he gave her feedback
about her interactions with patients, she didn’t seem to
be paying attention and so he gave her more and more
feedback. At the end of the rotation the psychiatry resident asked Dr. Phillips to talk about the rotation. They
were at the nursing stating on the oor and the resident
started by stating that Dr. Phillips was intimidating and
that her experience on the rotation was to disengage.
Dr. Phillips was taken aback because the issue was
obviously that the resident was defensive since he had
never gotten this feedback before and considered himself to be approachable. He responded by angrily stating that he received the resident as defensive and that
she didn’t seem to take feedback well and if she was
going to make it in medicine that she needed to learn
how to take feedback more constructively. The conversation went back and forth until Dr. Phillips ended the
conversation and stated that he needed to move on to
other patients. Each left frustrated and hoping to never
encounter each other again.
Dr. Phillips as the feedback receiver and the resident as the feedback giver could have used several
strategies to improve the outcome of the discussion.
Had the resident suggested that they meet in private as
she had some feedback about the rotation she wanted
to give, Dr. Phillips may not have felt put on the spot
and would have been prepared to receive feedback.
The resident also should have focused on Dr. Phillips’
behavior rather than attributing the feedback to a personality characteristic. Once recognizing that the resident was delivering feedback, Dr. Phillips should have
been mindful of the psychological triggers he was
encountering, primarily around the relationship with
the resident and how the feedback t into his sense of
identity and separated the feedback from the person
rather than becoming defensive. He could have
reected on his interactions with this resident,
acknowledged that this resident was helping him
become a better teacher, asked for examples of what
seemed intimidating and solicited suggestions on how
the resident thought he could work on becoming more
(continued)
approachable. The outcome with these adjustments
would have been a more productive conversation in
which Dr. Phillips gained some insight into how he is
perceived by others, some strategies for becoming
more approachable and the relationship became one of
collaboration.
Models forGiving Feedback
Table 23.1 provides some examples of models that can be
used when giving feedback.
Addressing Implicit Bias
The human brain is incredibly complex and exceptionally
busy. It is taking in new data and information at all times,
processing it, interpreting it and deciding what to do with it.
One of the ways the brain processes information is by organizing it into schemas which are short cuts, or broad categories to compartmentalize information. While such categories
may be helpful, they can lead to errors when a lack of appreciation of the differences in items leads to mis- categorization.
For example, a young child who has just seen a dog for the
rst time, and learns “this is a dog”, later comes into contact
with a cat, and incorrectly calls it dog. There are many similarities between the dog and the cat, and without much more
detail, experience, or appreciation of their differences, their
brain has categorized them as the same thing.
Similarly, biases result from making inaccurate generalizations about a person based on very broad categorizations.
Sometimes there is awareness of these biases; however when
they lie outside of immediate awareness, they are referred to
as implicit bias. “Implicit bias is a form of bias that occurs
automatically and unintentionally, that nevertheless affects
judgements, decisions, and behaviors”.
To combat implicit biases, they must rst be uncovered,
identied and acknowledged. The Implicit Association Test
(IAT) was created by Project Implicit out of Harvard
University for this purpose [34]. The website contains free
tests on a variety of common implicit biases including obesity, race, religion, and more. Results can provide information on the test-taker’s afnity or lack thereof for said topics
or groups. Taking an IAT (or several) might be one way family medicine faculty can fully explore and uncover a potential implicit bias that could be impacting how they teach and
work with residents.
Another way of uncovering implicit bias is in learning
what common biases exist and monitoring oneself to recognize how perceptions and thoughts of others may be impacted
23 Developing aHealthy Learning Environment
239
Table 23.2
Type of bias Description Example
Afnity A tendency to treat a resident more favorably when
Attribution Attributing either personal/characteristic/ or
Conrmation Drawing a conclusion about a resident very early
Conformity A tendency for others’ ideas about a resident to
Halo Effect One positive aspect of a resident gets generalized to
Horns Effect One negative aspect of a resident overshadows all
Perception Judging or treating others based on often inaccurate
by these biases. Table23.2 includes some common types of
bias that can inuence interactions with others.
to actively combat it. First, seek models that challenge biases.
For example, noticing generalizations made about a particular subgroup that may stem from an implicit bias, such as
‘women are bad at math’, can be combated by actively seeking out women mathematicians or others that are in direct
contrast to that internal (incorrect) image. When confronted
with information that does not t within a schema, those
schemas start to break down.
diverse people, activities, concepts, ideas, etc. help add data
that often challenge existing schemas. A great deal of bias is
developed out of a lack of knowing, understanding, or appreciating. It’s easy to make judgmental assumptions about others, when there is little known about them. Taking the time to
get to know an individual person, the layers of complexity of
who they are, what they do, and how they got where they are
Types of Bias
faculty like or have more in common with them
external/situational factors to a resident’s
performance.
and then selecting and focusing on data that
supports only that conclusion, often ignoring other
data to the contrary
shape our own
all that they do or all that they are, even if they are
actually not as skilled in all areas
aspects of how they are perceived
stereotypes or assumptions
Once implicit bias has been identied, steps must be taken
Second, being immersed in experiences that include
Male faculty assigning more desirable cases to male
residents
That resident didn’t get the assignment done because they
are lazy versus they must have had some kind of family
emergency.
Faculty decide a resident is a problem, and actively look
for errors in their notes, ignoring notes that are done well
After several meetings with the Clinical Competency
Committee where a certain resident was discussed, all
faculty adopt the same opinion of that resident even if they
initially had no opinion or one that differs
The friendly resident gets evaluated as having better
medical knowledge, even if their exam scores suggest they
are below their peers
A resident fails one exam and begins to be evaluated more
negatively on all competencies, beyond medical
knowledge
Faculty assume residents from international medical
schools will perform below US school graduates
• Am I asking more/less questions of this resident? Why?
• Have I made efforts to connect with this resident? Why or
why not?
• Do I feel that I have things in common with this resident
and how might that impact how I treat them?
• How am I dividing up the work? What type of work and
what level of complexity am I assigning to my residents?
Is it equitable? Why or why not?
• Am I offering assistance to my residents in the same way?
When do I decide to jump in and help versus observe and
let them take the lead? Are there any patterns to this that I
fall into?
• How do I evaluate my residents? Who tends to do ‘best’
on my rotation?
• What feedback do I give to my residents? Is it similar
across residents or are there differences? Why?
• Do I focus on different skills and qualities for different
residents based on gender, race, ethnicity, age, back-
ground, ability.
make it much easier to see their humanity and the role that
context has played. More broadly, the more exposure to differences, the more easily accepted new and different perspectives become. This also builds an appreciation for a
worldview that celebrates the fact that not everyone is the
same.
Third, self-reection may help a faculty to actively work
to combat implicit bias. Self-reection may help uncover
patterns of inequities which can be further explored and
understood through the lens of implicit bias, for the purpose
of correcting those patterns. Here are some example selfreection questions that can be useful:
Dr. Molly, a family medicine faculty member, was
known for her preference for residents who had graduated from US medical schools. Residents shared that
they experienced Dr. Molly assigned most clinical
cases on rounds to the US graduates. When international graduates were given cases, Dr. Molly always
shadowed them closely and jumped in, interrupting
their clinical interview or physical exam frequently
before they had a chance to nish. When confronted
with this feedback from the program director, Dr.
(continued)
240
Molly is unsure, but wants to explore this and correct
any inequities if they are occurring. She engages in
some self-reection questions and reviews the concept
of perception bias. Dr. Molly then decides she needs
more exposure to international residents but, wants to
do so with one of her faculty colleagues who is also an
international graduate. Dr. Molly hopes to challenge
some implicit bias she may have by learning more
about bias, identifying how her teaching may be inu-
enced by her biases, and seeking out activities that
challenge and debunk her biases.
Addressing implicit bias must involve mindfulness.
Mindfulness is about paying attention on purpose, slowing
down, taking oneself off of autopilot, and engaging in a non
judgmental, beginners’ mind. All of these components are
profoundly impactful when building trust among learners,
and certainly also when combating implicit bias [24]. Since
we are more likely to be inuenced by implicit bias when we
are rushed, stressed, and looking for shortcuts, having tools
to reduce stress, slow down, and approach a task or learner
with curiosity can be of immense help in combating any
implicit bias that might be lurking beneath the surface of our
awareness.
Eective andEquitable Teaching
Teaching takes place at both the micro- and macro-level. In
family medicine residency training, the individual encounters between faculty and residents or residents and medical
students make up the micro-level. Larger, systems-based
strategies that form the macro-level can also have a profound
impact on the learning environment and therefore the resident. It is important to consider the full range of strategies
and skills, from micro-to macro-level, for a comprehensive
approach to providing effective and equitable teaching.
Micro-Level
Part of teaching in a more effective and equitable way
includes identication and combating of implicit biases and
attention to the type of questions the residents are asked.
Moving residents beyond the simple memorization of facts
requires higher level questioning at the time of teaching.
Pylman and Ward developed six different types of high level
questions, derived from Bloom’s Taxonomy, that can be
asked to prompt residents to think more in depth and creatively about the content they are learning, ultimately leading to greater mastery of the content [35]. Such questions can
K. Miller et al.
be applied to clinical topics, wellness discussions, residency
or career goal setting, and more. Table23.3 summarizes the
questions with examples to demonstrate their applicability.
When faculty begin using the high level questions, a personal
equity check should be done as well. The personal equity
check asks faculty to self-reect on the following: What
kinds of questions are you asking of each of your residents?
Do you use one kind of question more or less with certain
residents? Why? Howmight that affect their learning?
Macro-Level
Taking a large step back from the micro-level of teaching, it
is important to review the systems, policies, structures, and
schedules that make up residents’ experience. There are,
unfortunately, many opportunities for inequities, inefciencies, and unfullled learning objectives to make their way
into rotations, curricula, and the overall resident experience.
Medical educators may have the subjective perspective that
they are teaching all residents in a similar and consistent
manner, but humans are often poor evaluators of our own
performance.
At the macro-level, it is important to look at systems/processes and ensure they are updated, relevant, equitable and
enforced. When there isn’t a system or process in place, there
is more room for implicit bias and inequity to creep into
decision-making. Having an agreed upon process is a great
way to ensure all are being treated equally. Tracking that process further ensures that equity is being upheld.
A program director often had to make decisions on
which resident to pull from their service to cover
another busier clinical service. With every intention of
being fair and equitable, the director started hearing
complaints from residents that some were being pulled
more than others. Certain this wasn’t the case, but with
no way to prove that, the director decided to imple-
ment a Pull Policy and Tracking Sheet. The Policy out-
lined who was going to be pulled in what order and the
Tracking Sheet was updated every time a resident was
pulled. This allowed all residents to see the process,
understand how the director went about making the
decision of who to pull, and allowed everyone to rou-
tinely check to ensure pulls were happening in an equi-
table manner.
Additional residency systems or processes that warrant a
policy and tracking system include paid time off approval
process, elective and away rotation approvals, processes
related to disciplinary action, performance improvement
plans, or remediation, faculty advisor/mentor assignments,
23 Developing aHealthy Learning Environment
Table 23.3 High level questions
Question
type [35]
Create Produce new
Evaluate Justify a
Analyze Draw
Apply Use
Understand Explain ideas
Remember Recall facts
Denition
[35] Application Clinical discussion Example
Invites the learner to develop a
or original
work
stand or
decision
connections
among ideas
information
in new
situations
or concepts
and basic
concepts
new or original piece of work
Allows the learner to explore the
reputability of the information in
front of them or justify a
decision they have made. This
can help them develop the
critical appraisal skills that are
so pertinent in medicine and
enhance their condence in their
decisions
Deepens learners’ understanding
of topics by helping them
appreciate their complexity and
the many factors that inuence
them
Helps broaden your learners’
understanding of a topic. They
help guide a learner to
appreciate how something they
have learned can be useful in
novel situations as well
Helps the learner take one step
further beyond simple
memorization of information.
They elicit many more details
which can uncover a learner’s
thought process as they explain
a concept using their own
language
Some of the simplest and often
the most common questions used,
and allow the teacher to engage in
a quick assessment of the learner’s
knowledge or attention to detail.
These are not bad questions to
ask, but are less likely to be
questions that allow a learner to
develop a more comprehensive
understanding of a topic or
transfer their knowledge into other
meaningful gains
How would you design a
curriculum for your peers to
help them understand HIV?
Do you think this patient would
make a good Case Report and if
so, how would you go about
writing this up?
What kind of schedule could
you create with your patient to
help them navigate their
challenging medication
regimen?
How can you support your
diagnosis?
What information do you have?
What are your critiques of this
journal article?
Do you think this patient is an
accurate historian? Why or why
not?
What are possible reasons for
altered mental status?
Why would we diagnose
Bipolar instead of Major
Depressive Disorder?
Can you compare and contrast
Type I and Type II Diabetes?
How are they similar and how
are they dissimilar?
What components of the
evaluation might demonstrate
abnormalities related to
cognitive functioning?
When you start rounding at the
nursing home, how can you use
what you learned on medical
oors to ensure efcient care of
patients?
How could you use UpToDate
when you start your Emergency
Medicine rotation?
How do antidepressants work?
What role does the pancreas
play in diabetes?
How might you classify the
severity of a patient’s
depression based on a PHQ9
score of 20?
What is a PHQ9?
How old is this patient?
Does this patient have a history
of stroke?
Wellness
discussion
Example
What SMART
goal can you
develop to
promote increased
resiliency during
your Night Float
rotation?
When you have
multiple
competing
demands, how do
you cope?
What is one new
way you have
been working to
promote
well-being and is
it working or not?
Now that you’re
on Night Float,
how can you use
fatigue mitigation
strategies that you
learned on
previous
rotations?
How do you
understand duty
hours?
When are you
taking your PTO/
vacation?
241
Residency/career goal
setting Example
What is the design and
methodology of your
Quality Improvement
project?
How do you think the
medical student is doing
in terms of their medical
knowledge and patient
care skills?
What do you think is
different between
outpatient versus
inpatient work, and what
does that differentiation
mean for you and your
desired future career?
What study skills did you
use throughout medical
school and which ones do
you think would be most
helpful as you prepare for
the In Training Exam
(ITE)?
Can you explain what
Professionalism is?
What is one goal from
your Individualized
Learning Plan?
242
K. Miller et al.
and many others. It can be helpful to be on the lookout for
larger systems-level interventions that can be implemented
into the residency program to enhance the effectiveness and
equitability of the residents’ learning and overall
experience.
Struggling Learnersand Physicians inNeed
It would be remiss to have a chapter about creating and
developing a healthy learning environment without discussing what to do when learners are falling behind in some way.
Learners in need of remediation have been labeled in a multitude of ways, from struggling learners, struggling residents
[20], trainees in difculty [43], to physicians in need [6]. A
simple, yet clear denition of a struggling learner is “a medical learner who does not meet the expectations of the program” [21]. Jeannette Guerrisio, a leader in the eld of
medical learners and remediation states, “I think of remediation as help for a learner who needs more than the standard
curriculum to achieve competence in all of the required
domains” [13].
Expectations of educational and skill attainment are crystallized through ACGME core competencies and milestones.
Successful remediation has been shown to be dependent on
various factors; however, the ability of the physician in need
to acknowledge their own gaps and willingness to undertake
remediation to enhance their skills may predict the success
of remediation [33]. A psychologically safe and healthy
learning environment, may predispose a learner to engage in
remediation.
factors as well as the learner’s perception of the Clinical
Learning Environment are utilized.
Each newly matched intern is sent online tools to complete prior to July 1. In addition to critical thinking, the validated surveys also are directed toward evaluating emotional
intelligence, perfectionism, emotional styles, academic
scores, well-being, and learning preferences. Examples of
the tools given include the Insight Assessment (critical thinking), the VARK (learning style), Frost Multidimensional
Perfectionism Scale, an NBME or related specialty examination (medical knowledge baseline) the Schuette Self Report
Emotional Intelligence Test (SSEIT), Satisfaction with Life
survey, the Emotional Styles Questionnaire and once interns
arrive, they are given an OSCE at Michigan State University
Learning Center. Each intern is paired with an Academic
Health Psychologist for the year, who helps the interndevelop
a Learning Plan for Success and serves as a support person.
A summary document is sent to the program director to
become the start of theintern’s individualized learning plan.
The actual evaluation results are not seen by the program
director. The summary document is approved by the resident
prior to being sent. Multiple resources have been obtained
and are available within the system to help with any action
plans. For example, a resident may need resources to adjust
to a new area, nd medical care, or complete cognitive training for success on exams[12].Every residency has a different set of resources that may exist or be needed to address
early identication of physicians in need. However, early
identication of need can be the key to success for medical
learners.
Taking aProactive Approach
While it is vitally important for resident physicians to understand expectations, have a willingness to be an active learner,
and have faculty who are interested in teaching and helping
physicians in need, addressing social determinants in health
issues can be the linchpin for success. One unrecognized
health disparity group is resident and fellow physicians.
Multiple articles have identied health factors including
burnout depression, suicide, chronic fatigue, and inability to
access care due to work hours, as contributing to decreased
meaning in residentwork, which negatively affects patient
care [12]. Remediation is, unfortunately, a looking back processrather than the desired proactive approach.
McLaren Health Care Division of Academic Affairs,
Determinants of a Healthy Learner and Learning Environment
(DHL)developed a proactive approach to remediation which
incorporated empathy for the learner as the driving principle
[12]. Separate evaluations of the learner, incorporating biological, socioeconomic, psychological, behavioral, and social
Conclusion
Educators impact the learning and development of learners,
whether for the better or for the worse. It is in the bestinterest of learners,residency programs and patients, to protect
our learners’ psychological safety, develop learner trust,
and individualize learner experience to match learning
needs. Educators must hold and model a growth perspective, applying it toboth learners and ourselves. In doing so,
educators should develop awareness into biases and how
they may impact perceptions of learners and teaching patterns. In providing feedback, educators aim to accurately
understand the learner and utilize an approach that encourages reection, reduces defensiveness, and maintains the
relationship. As a part of this process, it is also the role of
the educator to actively identify struggling learners and
proactively develop a plan for remediation. As we do with
our learners, we close this chapter by asking you to reect
and identify how you can implement some of the aforementioned concepts. What is one thing you can start to do
today?
23 Developing aHealthy Learning Environment
243
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Resident andFaculty Well-Being
andBurnout
LaurenBrown-Berchtold andCaitlinMatthis
24
Key Points
• Residency training programs have a responsibility to
address well-being as a critical component of education,
as well as provide access to condential and affordable
mental health assessment and treatment, according to the
Accreditation Council for Graduate Medical Education
(ACGME) Common Program Requirements.
• Burnout signicantly increases the risk of patient safety
events and patient dissatisfaction.
• Burnout costs the US healthcare system $4.6 billion dollars each year due to physician turnover and reduced
hours.
• Stigma toward mental health concerns and care needs to
be discussed and addressed to improve physician mental
health outcomes.
• Concerns about career and licensing questions are common, but national recommendations and legislation over
the last 5 years have led to signicant changes in how
mental health is addressed by many medical boards.
• Gratitude, mindfulness, cognitive behavioral therapy
(CBT), and physician coaching are effective interventions
for well-being promotion.
• Most residents want program directors to ask about wellbeing, unrelated to job performance concerns, and are
more likely to seek help if their program director or chief
resident recommends it.
• Initial residency action recommendations: Create a wellbeing committee responsible for constructing a wellness
curriculum and coordinating well-being initiatives;
Evaluate burnout prevalence and contributors among residents and faculty; Have mental health resources in place.
• Residency leadership must invest in their own leadership
development as a residency well-being intervention.
Introduction
It should come as no surprise that physician burnout has
become a large concern in the medical community. The number of burned-out physicians continues to rise in all specialties, particularly in family medicine. There are many reasons
why we desperately need and deserve self-advocacy for sustainable change, including moral and ethical, nancial, and
patient safety reasons. Moreover, the Accreditation Council
for Graduate Medical Education (ACGME) has given a particular mandate and regulations regarding the obligation of
residency training programs to address well-being [1].
As leaders, you have likely seen the toll burnout and other
mental health concerns can impose on both faculty and residents. It is imperative that you have a solid understanding of
what burnout is and how it may appear in those around you.
This chapter provides a brief background including the historical evolution of the understanding of physician wellbeing, its impact on several stakeholders, and risk factors for
and signs of burnout. We then discuss the ongoing concern of
the stigma surrounding mental health, as well as real and perceived licensing barriers for physicians who seek mental
health aid or treatment. We will conclude by discussing
evolving best practices for addressing burnout and promoting well-being with a focus on recommendations for residency training programs.
L. Brown-Berchtold (*)
Department of Family Medicine, San Joaquin General Hospital,
French Camp, CA, USA
e-mail: labrown8@gmail.com
C. Matthis
Faculty, Family Medicine Residency, Washington Health System,
Washington, PA, USA
e-mail: cmatthis@whs.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_24
Denitions ofBurnout andWell-Being
The World Health Organization describes burnout as an
“occupational phenomenon,” characterized by emotional
exhaustion, depersonalization, and decreased sense of
accomplishment [2]. This was rst described in the 1970s as
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L. Brown-Berchtold and C. Matthis
a condition that affected the helping professions. The rst
formal assessment of burnout was the Maslach Burnout
Inventory (MBI), an extensive questionnaire rst published
in the 1980s and still widely used today. However, there are
a variety of tools that can be used to measure and assess
burnout [3]. Two single-item measures of burnout, adapted
from and validated against the MBI, assess emotional
exhaustion and depersonalization. These single-item measures have respondents answer the phrases, “I feel burned
out from my work” and, “I have become more callous toward
people since I took this job” along a 7-point Likert scale
spanning from “Never” to “Daily”. Responses of at least
“Once a week” or more frequently are considered indicative
of burnout according to that domain.
The Physician Work Life Survey, also known as the mini Z, is another commonly used tool that uses a single-item
measure to assess burnout while also assessing for work contributors and areas of possible change. There are now tools
that examine engagement and composite well-being, including the Well-Being Index (WBI) and the Stanford Professional
Fulllment Index. All of these measurements have various
strengths and weaknesses, including cost, length, and
complexity.
Well-being cannot be considered a goal unless it is dened
and known as something more than simply the absence of
distress. There are multiple dimensions of well-being, commonly thought to include emotional, physical, intellectual,
and social domains as well as others. Physician well-being
does not have one universally recognized denition but can
be considered a mental construct with common characteristics such as vigor, engagement, and life satisfaction. One
denition proposes that, “Physician wellness (well-being) is
dened by the quality of life, which includes the absence of
ill-being and the presence of positive physical, mental,
social, and integrated well-being experienced in connection
with activities and environments that allow physicians to
develop their full potentials across personal and work-life
domains” [4].
In 2017, the ACGME began to require programs to attend
to resident well-being through the Common Program
Requirements. These state that, “programs…have the same
responsibility to address well-being as other aspects of resident competence” [5].This means that the well-being of residents should be just as important as any other component of
their training. The Common Program Requirements frame
this goal in terms of maintaining joy in medicine, responsibility for caring for team members, and professionalism.
root of this problem? Although this is an unanswerable
question, some people trace this back to William Osler,
one of the founders of modern medical training in the
United States. During a speech for a medical school graduation in 1889, he claimed that imperturbability and equanimity were the two most important characteristics of a
physician. These have been interpreted as a recommendation of emotional detachment from one’s patient [6]; additionally, these characteristics may have helped set up the
image of a superhuman physician, making those who can’t
live up to this ideal feel like failures for simply being
human.
Regardless of the root of physician burnout, we can still
trace the arc of and approach to this condition. Dr. Tait
Shanafelt, one of the earliest researchers of and advocates
for physician well-being, described three “eras” of physician well-being in his 2021 article, “Physician Well-being
2.0: Where Are We and Where Are We Going?” [7]. The rst
is described as the “Era of Distress”, which predated 2005.
During this time, questions of physician well-being were
largely not on the radar. Although providers had more
autonomy, they were also isolated, neglected, and given
unachievable expectations of perfectionism and total
altruism.
The current era is described as that of “Well-Being 1.0”.
This has become known as the time for awareness and data
gathering. Additionally, this has been a time of large shifts
within healthcare, including an increased female workforce,
the implementation of the electronic health record, work
hour restrictions, and the rise of employed practice models
and measures of physician performance and quality of care.
While awareness of the importance of physician well-being
increased, the blame for burnout was largely placed on the
physicians themselves [7].
Shanafelt describes the nal target era as “Well-Being
2.0”. While he argues that some “vanguard institutions”
began this evolution around 2017, others were and still are
behind in this process. The goal of this era is to stop placing
blame on physicians and accept our human nature with compassion. It is meant to allow us to cultivate community and
share responsibility for physician well-being. This must
include a structural change to make well-being a core organizational strategy with validated instruments for assessments and adequately compensated leadership [7].
Impact ofBurnout
Background
While the discussion of burnout began relatively recently
in medical culture, burnout itself has been thought to be
present, although ignored, for much longer. What is the
The unfortunate truth is that burnout, particularly in the wake
of the COVID-19 pandemic, continues to rise [8, 9].
Physicians experience more burnout than their age-matched
peers with equivalent professional degrees, even after adjusting for hours worked per week [10]. Recent studies demonstrate that up to 55–65% of family physicians experience at