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24 Resident andFaculty Well-Being andBurnout
247
least one symptom of burnout, with similar burnout rates for
residents and attending physicians [8, 9, 11].
Burnout has a signicant impact on physicians themselves, their patients, and the healthcare system as a whole.
Burnout can lead to substance use, [12] impact personal relationships [13], and lead to depression and suicidality [8]. It is
important to understand that burnout and depression are
related, and each condition can potentially lead to the other
[14]. Depression and other mental health concerns are prevalent among students, residents, and attendings. Depressive
symptoms among medical students increase by nearly 15%
during medical school [15], and nearly 30% of residents may
experience depression or depressive symptoms [15, 16].
During COVID-19, evidence suggests that physicians across
all age groups had rates of depression at 25% [15]. More
than 15% of ER physicians met criteria for PTSD prior to the
pandemic, whereas up to 31% of physicians met criteria for
PTSD during the COVID-19 pandemic [17, 18]. Alternatively,
it has been shown that better mental health leads to increased
work satisfaction and decreased burnout [19].
After some increase in the risk of suicide during medical
school, suicidal ideation increases signicantly during the
intern year [20]. Physician suicide is a relatively understudied area compared to suicide in the general population,
although it is known that male and female physicians die by
suicide at rates 40% and 130% higher than the general public, respectively [21]. Physicians differ from the general population in that a job problem is much more likely to have
contributed to death by suicide [19].
Systematic reviews and meta-analyses have found that
burnout doubles the risk of patient safety events along with
doubling the chances of patient dissatisfaction [22]. It is then
no surprise that there is a large economic impact on the
healthcare system as a whole related to burnout. In 2019, the
conservative case-based estimate was that around $4.6 billion dollars in cost each year was related to physician turnover and reduced hours due to burnout [23]. Around $260
million of this is related to burnout-related turnover of primary care physicians alone [24]. Studies have found that
physicians with burnout are twice as likely to leave their current position within the next 2years [25]; burnout may lead
to an increase in absenteeism as well as a reduction in work
hours [20, 26]. In the face of a physician shortage that is only
expected to grow, the impact of burnout will contribute to a
continued decrease in capacity for patient care with concomitant patient safety risks [20, 26].
Risk Factors
Some of the many risk factors for burnout may impact physicians throughout their careers, while others are unique to
trainees. The culture of medicine should be considered a uni-
versal risk factor. Physicians commonly believe they should
be unaffected by the myriad difculties encountered in worklife daily, while also suffering from, “a predominant core
belief that one’s own pain and suffering, occurring in service
to the art or science of medicine, should be quietly tolerated”
[27]. One concrete example of this is presenteeism, or coming to work while sick [20].
Work factors include the use of EHR and after-hours documentation, lack of autonomy and inefcient workow, production pressure, and work compression [20, 27, 28]. These
can lead to decreased time to enjoy the patient-doctor relationship; one strong predictor of burnout is spending less
than 20% of work time on one’s most meaningful activity
[29]. Organizational factors include poor leadership, lack of
recognition or appreciation, lack of opportunity for advancement, and lack of social support [28]. Individual factors that
place someone at higher risk of burnout include physicians
who are female, in the rst 7 years of practice (“early
career”), have children, or have a non-medical signicant
other [28].
While the profession of medicine is demanding regardless
of career stage, residents have particularly little autonomy
due to hierarchical training norms. In addition to the universal risk factors discussed above, trainees-specic experiences can also leave them vulnerable to developing burnout
[30–33]:
• First year of residency
• Dissatisfaction with clinical faculty
• Training during and exposure to COVID-19
• Poor quality residency well-being programs
• Lack of time for activities outside of work
• Conicting responsibilities between work and home
Specic factors that may increase the risk of burnout for
faculty physicians include decreased time for teaching,
resulting from work compression, as well as a shift in work
burden from residents to faculty due to resident work hour
restrictions [20].
Development andSymptoms
A variety of models have been proposed with regard to burnout development and the so-called stages of burnout. An
early concept suggested twelve discrete stages, beginning
with the desire to prove oneself, progressing to the denial of
emerging problems, and ultimately leading to depersonalization, depression, and burnout syndrome [34]. Many subsequent models have suggested a relatively stepwise and linear
development of burnout over time, albeit in a simplied or
condensed fashion [34, 35]. Other burnout development theories have emphasized the imbalance between the resources
248
L. Brown-Berchtold and C. Matthis
and demands of one’s job, thereby highlighting the context
and the occupational origin of the syndrome. One such
model is the Areas of Worklife, which emphasizes this potential mismatch in six particularly important realms: workload,
control, reward, community, fairness, and values [14].
Regardless, burnout should not be thought of as developing in one particular way or along one particular path. There
is no one description of a person experiencing burnout,
which can make recognition difcult. It is imperative for all
physicians to be cognizant of the possibility of this syndrome
in themselves and in their colleagues; program directors
must be particularly mindful of possible symptoms, as well
as educate their faculty and residents. However, we should
remember that it is possible to exhibit symptoms of burnout,
which are nonspecic and can vary widely, without experiencing the syndrome of burnout. If there is a signicant concern, consider initiating a swifter and more thorough
assessment. While not exhaustive, symptoms may include
[14, 34–36]:
• Irritability or anxiety, neglect of personal needs, procras-
tination, and cynicism
• Behavioral changes, including concerns regarding job
performance or interpersonal communication
• Somatic symptoms including fatigue and insomnia, head-
aches, muscle pain, and frequent illnesses, mental and
emotional exhaustion or illness such as depression
• Substance use
Help-Seeking Behaviors ofClinicians
Given the scope of this problem and the risks of unaddressed
burnout and mental health diagnoses, it might be natural to
assume that physicians would seek out help if needed.
However, that is not the case. Instead, Dyrbye et al. [37]
found that, “residents…were on average more reluctant to
seek professional care for a serious emotional concern than
similarly aged adults and the general U.S. population.” This
has been echoed by numerous studies that evaluated helpseeking behaviors of physicians at all career levels:
• 70% of respondents would theoretically prefer to report a
mental health issue to friends rather than a professional
[38].
• Nearly 50% of female physicians believed they had previ-
ously met criteria for mental illness but had not sought
treatment [39].
• Nearly 40% of physicians were reluctant to seek help for
a mental health concern [40].
• Less than 25% of interns with screen-positive for depres-
sion started treatment, and less than 50% of academic
physicians with depression sought treatment [15].
• Among surgeons with recent suicidal ideation, only 26%
had sought professional help [41].
• Early in the COVID-19 pandemic, it was reported that
only 13% of clinicians sought out pandemic-related mental health concerns; among ER physicians facing skyrocketing rates of stress, almost 50% were not comfortable
seeking mental health treatment [42].
• Physicians with a history of depression are less likely to
seek help [43].
Barriers toMental Healthcare
Our profession must ask: why do the healers in our society
not seek healing themselves? Key reasons for avoiding professional care have been repeatedly elucidated in the literature. Some of the most alarming and preventable barriers are
stigma surrounding mental health and licensing concerns;
these will be discussed in detail below. Other barriers,
though, remain myriad.
Lack of time and need for time away from work is one of
the most commonly cited and prevalent barriers [15, 33,
44–46]. In discussing the results of a study regarding burnout
and female physicians, one author theorized that time pressure may be more intense due to “family commitments,” [44]
which is itself a gender-based and potentially stigmatizing
assumption. With regards to residents specically, those who
had not attended a health appointment during work hours
presumed that it would be quite difcult to discuss such an
appointment with a supervising physician; however, 40% of
surveyed residents had been able to attend a health appointment during work hours with supervisor support [37].
Other barriers include concerns about condentiality, as
well as concerns about career progression, which were more
common among female physicians and persons with a history of depression [15, 42–44]. Many physicians are unclear
on the usefulness of interventions, and report lack of awareness of support resources such as Employee Assistance
Program (EAP), as well as lack of knowledge about how to
contact these services [44–46]. Concerns about nances
have been reported, including the cost of treatment and as
well as worries about the ability to get malpractice and/or
disability insurance at reasonable rates if counseling has previously been sought [42, 44]. Other barriers include a negative workplace culture and overall expectations of doctors, as
well as the idea that physicians may have a hard time switching from a doctor role to a patient role [44].
Stigma
The term “burnout” may itself be stigmatizing or blaming.
As a result, some prefer the term “moral injury” or “moral
24 Resident andFaculty Well-Being andBurnout
249
distress,” conveying that job-related factors may be unavoidable and can cause physicians to act in ways inconsistent
with their values, thereby leading to this condition [47].
Overall, it is essential to recognize that ongoing and pervasive mental health stigma has created wide-ranging issues
that impact the physician model of help-seeking for mental
health. The prevalence of this issue, particularly as a commonly cited reason for not seeking help, is alarming [15, 38,
44–46]. Weiss etal. noted, “stigma, generated both internally
and from others, is a multifaceted phenomenon that
discourages those with emotional distress from seeking professional help for their symptoms” [48].
Stigma may be known by many other names, and maybe
expressed as embarrassment, shame, or unwillingness to talk
about needs. This may appear as concern about appearing
weak or letting down patients or colleagues [43–45]. In a
2020 report, the American College of Emergency Physicians
reported that 73% of ER physicians expect stigma at work
for seeking treatment [49]. As one’s perception of stigma
increases, there is an associated increase in concern about
seeking help for, and a decrease in actually nding help for,
for a mental health concern [43]. This may relate to the concept of self-stigma, or the internalization of perceived stigma,
as something that is prevalent among physicians; i.e., our
internal experience of shame and worry prevents us from
seeking care, even in the absence of external pressures or
barriers [44]. This may result in part from societal issues,
such as the media dramatizing crimes committed by persons
with mental illness, which is then supplemented by the medical education environment [15, 37, 38].
This phenomenon impacts medical trainees at all levels.
Medical students have been shown to exhibit stigma toward,
and reluctance to obtain, mental health care; this is exacerbated among students with burnout or depression [15, 37,
38]. Stigma is a common reason for residents to avoid seek-
ing professional care for emotional concerns [27, 37, 50].
One study demonstrated that more than 50% of pediatric fellows believed others would think less of them for using
counseling services [48]. A former program director
expanded on this theme, discussing how residents would,
“[refuse] to get help due to stigma…[they] would often wait
until world was crumbling around them before getting assistance.” [39].
There is an association between trainees with current
burnout and a greater perception of stigma toward mental
and emotional health [48]. Doctors agree that depression is
stigmatized within the medical profession [43]. Female physicians tend to be particularly concerned about stigma and
condentiality issues with regards to seeking care for either
medical or mental health concerns, and male physicians are
less likely to seek counseling overall [46].
Some have hypothesized that physician suicide is underrecognized because of miscoding on death certicates, lead-
ing to inaccurate aggregate data, due to inherent stigma in
the medical community [19]. One essential component of
decreasing the risk of physician suicide is access to early
diagnosis and treatment, which requires widespread efforts
to reduce stigma: “ironically, we put our lives in jeopardy to
save our careers—even though suicide is career ending”
[15]. Open conversations about depression and suicide are
necessary components of stigma reduction, so that trainees
are not left with the impression that burnout is acceptable
while other mental health concerns are not [27].
Stigma is something which must be systematically deconstructed in order for our profession to progress. As one
example, the Society for Teachers of Family Medicine
launched a campaign to destigmatize mental health in late
2022. There are a variety of stigma reduction interventions
related to mental health and the workplace, initiated in an
attempt to change knowledge, attitudes, or behavior [51–54].
There is no clear-cut answer on the most effective strategy,
although social contact, which facilitates contact between a
stigmatized group and a group displaying stigma, has strong
evidence of effect in the short term [53, 54]. It is important to
recognize that stigma is perpetuated when members of a
group allow it to continue or perpetuate it. Physicians can
each do their part to destigmatize mental health care by
choosing to purposefully praise, rather than judge, our peers
and trainees who seek out support and treatment, as well as
sharing their own stories if they feel safe and comfortable
doing so. Faculty can display particularly powerful professional modeling to their residents in this way.
Licensing Issues andRecommendations
Up to 60% of physicians considering seeking mental health
care cite licensure concerns and career implications as a barrier to obtaining care [39–41, 46]. In 2016, one study reported
that less than 10% of physicians with a mental health diagnosis had reported that diagnosis to the state medical board
[39]. Another study examined the link between physician
help-seeking behaviors and state board licensing questions;
physicians were less likely to seek treatment for mental
health conditions in states where licensing applications were
not restricted to assessment of current impairment alone
[40]. Dyrbye et al. [37] found that 45% of residents were
fearful about career implications if they went on medical
leave, and 30% were reluctant to seek professional help for
an emotional concern.
From where have these concerns arisen? It seems counterintuitive that physicians should believe that the institutions
designed to enable physician training and license to practice
should be viewed with such mistrust. In fact, in a 2001 lawsuit regarding termination of a resident physician, the court
determined that the Americans with Disabilities Act does
250
L. Brown-Berchtold and C. Matthis
protect residents [55]. However, in 2007, 37% of state medical boards reported believing that a diagnosis of mental illness alone was enough to sanction a physician, and 37% of
boards reported handling physicians receiving psychiatric
care differently from those receiving medical care [56]. In
2009, a majority of state medical licensing applications were
shown to be in violation of the ADA, potentially causing
physicians to avoid seeking care in an attempt to not disclose
[57]. In 2017, it was shown that mental health concerns were
subject to greater scrutiny than physical health concerns on
licensing applications [58].
This has led to an underground belief among the medical
profession, a hidden curriculum if you will: if you must seek
care, don’t let “them” nd you. Go out of town, use cash, use
a different name. In 2022, Dr. Jilani [59] wrote in devastating
fashion about the culture of fear bred by concerns about
career implications, likely due in large part to the scrutiny by
medical board licensing applications, saying, “I’d rather be
the doctor who confesses all instead of the one who buries
the memories of dead children in bottles of bourbon or
syringes of fentanyl.” One survey reported physician quotes
such as these [39]:
• “These regulations prevent physicians from seeking care
and increase suicide. They prevented me from seeking
care and instead I quit residency.”
• “I have known many colleagues to date who have not
sought help when needed due to concerns about retalia-
tion against their licensure, credentialing, reputation,
etc.…in at least one case [it] contributed to suicide.”
FSMB Recommendations Regarding Licensing Questions
In response to the above concerns, and the fact that board
questions were inadvertently encouraging unsafe behaviors
like delay or avoidance of treatment in an attempt to protect
patient safety, the Federation of State Medical Boards
(FSMB) convened a workgroup in 2016. A comprehensive
document was released and adopted as policy by the FSMB
in 2018, detailing recommendations on how changes to the
licensing process can allow medical boards to protect both
physicians and patients while encouraging physicians to nd
help if needed [60].
As summarized by Saddawi-Konefka,[61] the relevant
FSMB recommendations for licensing questions about mental health are as follows:
1. “Only if impaired” (if mental health questions are asked,
they are limited to conditions resulting in impairment);
2. “Only current” (if mental health questions are asked, they
are limited to questions about conditions within the last
2years);
3. “Safe haven nonreporting” (if mental health questions are
asked, safe haven nonreporting is offered;i.e., allowing
physicians to not report diagnoses or treatment history if
they are being monitored by and are in good standing
with a Physician Health Program);
4. “Supportive language” (inclusion of supportive or normalizing language regarding seeking mental health care).
These recommendations are succinctly summarized with
language provided by the FSMB, which states, “Where
boards wish to retain questions about the health of applicants
on licensing applications, the FSMB recommends that they
use the language: ‘Are you currently suffering from any con-
dition for which you are not being appropriately treated that
impairs your judgment or that would otherwise adversely
affect your ability to practice medicine in a competent, ethical and professional manner? (Yes/No)’”[60].
Unfortunately, early movement toward implementation of
these recommendations was relatively slow moving. A 2021
JAMA review [61] revealed that only one state was consistent with all FSMB recommendations, and many states were
adherent to two or fewer recommendations.
Dr. Lorna Breen Healthcare Provider
ProtectionAct
On April 26, 2020, Dr. Lorna Breen died by suicide. She was
an emergency medicine physician in NewYork City who
was severely impacted by the earliest days of the COVID-19
pandemic [62]. In response to this tragic loss, the Dr. Lorna
Breen Heroes’ Foundation was formed, with a mission to,
“reduce burnout of health care professionals and safeguard
their well-being and job satisfaction” [63].
Subsequently, the United States Congress passed the Dr.
Lorna Breen Health Care Provider Protection Act on March
18, 2022. This law established grant funding to improve mental and behavioral health among health care providers, and to
fund mental and behavioral health training for medical trainees and practitioners. In addition, this law requires the
Department of Health and Human Services to work to encourage and support physicians seeking support and treatment for
mental health concerns, as well as sharing best practices on
suicide prevention and mental health promotion. Finally, HHS
was charged with studying and developing policy recommendations on the removal of barriers to mental health care and
treatment [64]. This legislation aligns with the USSurgeon
General report, which advocates for the removal of punitive
policies for seeking mental health care, and with the National
Academy of Medicine, which identies, “supporting mental
health and reducing stigma as a priority area” [65].
In the wake of such signicant advocacy and policy recommendations, change to licensing applications has accelerated. As of October 25, 2023, the Dr. Lorna Breen Heroes’
Foundation reported that 26 state medical boards qualied as
Wellbeing First Champions. These boards qualify by meeting
one of the following criteria [66], which are designed to align
with the previously discussed FSMB recommendations:
24 Resident andFaculty Well-Being andBurnout
251
• “Ask one question consistent with the Federation of State
Medical Board’s recommended language that addresses
all mental and physical health conditions as one, with no
added explanations, asterisks, or ne print”;
• “Refrain from asking probing questions about an applicant’s health altogether”;
• “Implement an Attestation Model that uses supportive
language around mental health and offers ‘safe haven’
nonreporting options to physicians who are receiving
care.”
These early national changes are encouraging. However,
it is unknown how closely the credentialing processes for
individual healthcare organizations align with FSMB recommendations [65]; this needs to be an area of evolving study
and, likely, change.
Physician Health Programs (PHP)
Physician Health Programs (PHPs) are a common way that
assistance and monitoring is provided to state medical boards
with regards to physician safety to practice. As of 2019,
some PHPs continued to practice restrictive approaches
toward physician mental health including limiting access to
information, consideration of any reported condition within
a substance use treatment model, and nancial burden [67].
A survey respondent from another study reported, “All of my
fears were realized when I did report it. I was placed in a very
strict and punitive PHP that didn’t allow me to take meds
written by my doctor for anxiety and insomnia. I am now not
practicing at all because of this” [39]. Despite these concerns, innovative PHPs approaches have been described,
including easy access to services and “safe havens” as
described above [67].
Well-Being Promotion andBurnout
Prevention
In addition to the need for cultural and legislative changes
that decrease stigma and allow physicians to feel secure in
their licensing, there are a variety of actions that individuals
and training programs can take, as well as broader institution-, region-, and nation-wide recommendations.
Resilience is frequently discussed as a preventive strategy. In some cases, this concept has been weaponized against
physicians, who may be told that they need to “be resilient”
or “build resiliency” to x burnout. However, the evidence
demonstrates that physicians have higher levels of resilience
than the general population and that burnout occurs in physicians regardless of resilience [68]. In a more useful approach,
others have reviewed a collection of “resilience strategies”
that may be useful for individuals seeking out self-care practices. These include gratication (connection and communication, meaning, purpose), resilience building practices,
(self-reection, time for oneself, self-compassion, spirituality), and useful attitudes (acceptance, exibility, selfawareness) [69, 70].
The practice of gratitude is one discussed in a variety of
arenas. With regards to physicians, twice-weekly gratitude
journal entries over 4 weeks led to decreased depressive
symptoms and perceived stress, benets which lasted for at
least 2 months after the intervention ended [71]. Other
gratitude- based interventions have also demonstrated that
the positive effects last longer than the intervention itself, as
has mindfulness cultivation [20]. The practice of appreciative inquiry is normally thought to be an organizational
model which takes a positive approach to systems change,
but can also be used in regards to personal development and
growth [72].
Physician coaching, with the aim of improving day-today interactions in the work environment, shows signicant
promise, and may also be seen as more relevant and less stigmatizing than counseling by some physicians [27, 45, 46]. It
has been shown to decrease burnout and increase quality of
life after relatively few sessions, although it does not appear
to decrease rates of depersonalization or increase engagement and meaning in work [73].
Cognitive behavioral therapy tools were evaluated in The
Intern Study, meant to address burnout, depression, and suicidal ideation. These were delivered via a web-based platform, and had an association with decreased suicidal ideation
in interns [20]. The idea of self-compassion, principally
developed by Kristin Neff, includes three principles: selfkindness vs self-judgment, common humanity vs isolation,
and mindfulness vs over-identication. Use of a web-based
self-compassion cultivation program demonstrated decreased
depression and stress [20].
Individual-Level Actions
It’s important to recognize that burnout is primarily a systemlevel issue that requires system-wide changes. With this said,
individual actions for well-being promotion and burnout prevention remain important, so that physicians who want to
effect systemic change have the bandwidth to do so. These
are useful for both faculty and trainees to utilize.
Residency-Level Recommendations
andResources
While the ACGME has stressed the importance of physician
well-being as a residency training program priority, studies
have shown that, as a whole, we have not been successful in
achieving these goals. The AAMC recently released a publi-
252
L. Brown-Berchtold and C. Matthis
cation that showed that, although a majority of institutions
(88%) had well-being initiatives in place, the breadth of
these initiatives varied widely [74]. Only about 50% of organizations reviewed had a well-being champion; only about
1/3 of those champions received any formal training and
many did not have any FTE allocation for this work. This
impacts the well-being of both faculty and residents. In 2022,
the Society of Teachers of Family Medicine (STFM) reported
that nearly half of surveyed residents reported the quality of
their wellness program as fair to poor, and that a poor-quality
residency wellness program actually increased their risk of
burnout [32]. While these ndings are disheartening, it does
mean there is extensive room for improvement, which
requires thoughtful time and attention.
The Common Program Requirements do not provide limiting instructions on what to implement, allowing each program to implement what is needed for them. There must be
an ongoing emphasis on the graduate medical educationresponsibility to support physician well-being and offer
support for mental illness via open dialogue [27, 55]. Studies
have shown that well-being is not a “one size ts all”, but
that tailored and individualized programs will have greater
success due to a greater sense of control and engagement
[75, 76].
With that being said, it is helpful to have some guidance
to navigate resources, as there is no shortage of frameworks
for creating well-being initiatives. Two resources that may be
particularly useful are from the Association of Family
Medicine Residency Directors (AFMRD) and the National
Academy of Medicine.
After the publication of ACGME Common Program
Requirements in 2017, AFMRD published a Well-Being
Action Plan to help guide program directors [77]. This action
plan lists 17 areas to focus on that can improve resident and
faculty well-being while also meeting the Common Program
Requirements, including items such as:
• Identifying wellness champions and starting a wellness
committee
• Measuring well-being and obtaining anonymous
feedback
• Residency vocabulary expansion to include wellness
• Providing mental health services with condential and
safe disclosure
• Optimizing work schedules and improving the learning
and work environment
• Promoting interprofessional teamwork
• Developing wellness spaces and time to connect and
reect
• Creating a wellness curriculum
The National Academy of Medicine created the National
Plan for Health Workforce Well-being in 2022 [78]. This
comprehensive action plan is organized into seven priority
areas of focus. There are specic goals within each area,
along with charts that include who should be involved in
each initiative (the “players”) and actionable steps to achieve
these goals. Each section is then supplemented with a large
number of additional resources organized by particular topics. These resources are meant to be a sort of menuthat one
can go through to pick those that most pertain to your
institution.
While having such extensive guidance is incredibly useful, it can also feel overwhelming when trying to determine
where exactly to start. If a residency is building their wellbeing efforts from the ground up, we recommend beginning
in the following key areas:
1. Create a well-being committee (including a well-being
champion) that include residents and faculty with respon-
sibility for constructing a wellness curriculum and coor-
dinating well-being initiatives.
2. Evaluate burnout prevalence and contributors among res-
idents and faculty.
3. Have mental health resources in place and easily
accessible.
These three interventions will allow a solid foundation on
which to build further well-being initiatives, and further
guidelines and toolkits for implementation may be found via
the ACGME website. Even if a training program’s current
well-being curriculum is already robust, virtually every program should be able to nd something in these recommendations that can help expand or improve current offerings.
Interestingly, an expert review of the AFMRD toolkit recommendations found that the intervention itself matters less
than obtaining buy-in and support from participants [79].
Other initiatives include starting a resident-specic program, including counseling, as an alternative to use of a
generic Employee Assistance Program. The specicity of
these programs has resulted in higher utilization of services
and has demonstrated positive impact [46]. Another broad
set of options include peer wellness coaching or peer support
programs. These have been used in undergraduate and medical schools, as well as in residency programs and with attending physicians [27, 80]. AMA provides a free module on how
to create and implement such a program [81]. Finally, optout wellness counseling as a part of medical school and residency curriculum is recently gaining traction. Although the
details may appear differently according to program implementation, this idea proposes that trainees should be scheduled by the program for wellness counseling sessions and
given the day off to attend the appointment, although they
can decline and choose to work instead [82].
Impact ofLeadership Behaviors
Multiple studies have demonstrated that the leadership
behaviors of direct physician supervisors correlate with
24 Resident andFaculty Well-Being andBurnout
253
burnout and job satisfaction. In 2015, Shanafelt etal. [83]
showed that a 1-point increase in leadership scores was associated with a 3.3% decrease in likelihood of burnout and a
9% increase in likelihood of satisfaction. Additionally, physicians reported less intent to leave their current position
when their supervisor had higher leadership scores [84]. In
another compelling study, Dyrbye etal. [85] demonstrated
that higher supervisor leadership scores were linked to lower
odds of burnout and higher organizational satisfaction
2years later.
The leadership scoring system referenced by these authors
is called the Mayo Clinic Participatory Management
Leadership Index, which has been revised to a 9-item instrument. Questions measure inclusion, empowerment, and nurturing professional development. These principles reveal
insight into what physicians want from their supervisors: that
is, a caring person who is interested in the physician as a
person rather than someone who simply generates revenue.
It was later demonstrated that, as a leader’s burnout score
increased, their leadership score decreased [86]. However, an
increase in their leadership behavior score was associated
with both an increase in both a leader’s professional fulllment score as well as more robust self-care practices, such as
self-valuation and sleep prioritization. Shanafelt etal. [86].
argues that, “collectively, these studies provide evidence that
a leader’s occupational well-being primarily affects the wellbeing of their team indirectly by eroding leader
effectiveness.”
While the above referenced studies did not explicitly
study residents, Dyrbye etal. [87] demonstrated that there is
a correlation between resident burnout and perception of
faculty-resident relationships and faculty professional behaviors. While different measures were used for this study, the
questions echo those of the Mayo Clinic Leadership Index,
inquiring about the respect, support, and care for residents
demonstrated by faculty. These leadership studies are incredibly important for faculty and program directors to understand. Given that perceived leadership behaviors have such
consistent and reproducible impact on burnout, professional
fulllment, and intent to leave, we argue that residency leadership must invest in their own leadership development as a
residency well-being intervention.
Examining theHidden Curriculum
The culture of medicine as a whole, and of individual residency programs in particular, can serve to help or hinder
physician well-being. The concept of the hidden curriculum,
or those lessons that are implicitly taught, is something that
many in academic medicine are familiar with as a formative
component of medical education [88]. Stigma implicit within
the hidden curriculum was blatantly evident in the medical
literature as recently as 2000, with discussion about and formal denition of “problem residents.” [89]. With regards to
well-being, there is a fair argument to be made that the hidden curriculum, “subverts seeking treatment by teaching that
mental disorders should remain hidden” [15], which may
explain why as many as 50% of medical students believe that
program directors would not match a student with a mental
health concern.
STFM agrees that program directors and faculty should
strive to be role models on this topic, stating, “As a leader,
your self-care practices can set the tone for a psychologically
safe environment that allows trainees to prioritize their wellbeing. Conversely, your practices may implicitly demonstrate that mental health is not a priority of the program.”
[90].
We suggest that programs intentionally work to reveal
this pervasive hidden curriculum, and instead practice vulnerability and compassion as, “new norms of professional
courtesy” [15]. A method to facilitate the neutral exploration
of workplace culture has been previously described [91]. The
culture of medicine can change, particularly if physicians
openly share about their own mental health concerns and
need for treatment or support, as well as encouraging others
to practice self-care and reach out for support [27, 44].
Increasing psychological safety, praising and supporting
help-seeking behaviors, and encouraging self-care are all
necessary changes that faculty can help promote [37].
Program directors in particular should be involved in discussing and assessing the well-being of the members of the
program. A signicant majority of residents do want program directors to ask about well-being, unrelated to job performance concerns; most residents support informally asking
about well-being, with somewhat fewer residents supporting
formal screening [45]. Residents also report that they are
more likely to seek help if their program director or chief
resident recommended it [45, 46]. Other factors that help
facilitate physicians seeking help if needed include a positive
work environment and the availability of support services
[44].
One concrete culture change includes supporting time for
personal care, both health-related and otherwise, during
business hours and outside of paid time off. Multiple studies
demonstrate that this support is both appreciated and helpful,
which is intuitively correct given that lack of time is cited as
the biggest barrier to obtaining mental health care in particular [45, 46]. The Common Program Requirements now
require that residents be allowed to attend health care
appointments during work hours [5]. To implement this,
some training programs have placed an open half-day in their
intern orientation schedule, with the expectation that every
intern starts their residency with a primary care physician
254
L. Brown-Berchtold and C. Matthis
appointment, while others have instituted a half-day off per
quarter to allow for appointments to be made in advance.
Institution, State, andNational Considerations
A variety of high-level factors play a role in burnout and
other mental health concerns. Within institutions, these
include production pressure, lack of control, work compression, behaviors of senior leadership, and institutional culture
[20, 92]. Nation-wide, contributors include concerns regarding reimbursement for care, certication organizations, clerical pressure and electronic health records, and insurance
issues and restrictions [20, 92]. Advocacy with local,
regional, and national institutions to address these factors
must be considered a burnout prevention initiative.
Organizational interventions are effective at reducing physician burnout and should be put into place alongside individual approaches to achieve the best outcomes [20, 76, 93].
Similar to the need to develop program-level well-being curricula in collaboration with individual members to increase
engagement, system-level interventions and improvements
should be selected via co-production, with the input of both
patients and healthcare workers [94].
Structured opportunities to process and decompress must
be made available on an institutional scale. Possibilities
include Balint groups and stress management training, as
well as formal debriefs after trauma and other events impacting clinicians [20, 44]. One growing offering includes
Schwartz rounds and similar forums for these concerns to be
discussed [20, 44, 58]. These options should occur at a time
and place that is accessible.
In 2017, Shanafelt etal. outlined effective organizational
initiatives for the executive suite to consider. These actions
are broad, scalable, and customizable. The recommendation
to acknowledge and assess the problem on an institutionwide scale cannot be overemphasized [92]. Other recommendations include implemented targeted work unit
interventions, promoting exibility and work-life integration, and cultivating community at work. This review notes
that providing resources to promote self-care (such as EAPs)
should not be the cornerstone of well-being efforts by institutions, although they frequently are treated as such.
More recently, a recent JAMA Health Forum article [95]
found that clinicians most desired intervention by management to address issues like, “insufcient nurse stafng,
insufcient clinician control over workload, and poor work
environments,” while ranking wellness and resilience programs as least desirable. Disappointingly, more than 40% of
physicians did not endorse condence that management
would either listen or work to resolve these concerns. This
data was collected from more than 5000 physicians spanning
multiple career stages; residents and fellows comprised 16%
of this cohort. Healthcare leaders must give credence to this
data and work to restore trust among their employed healthcare workers.
Stigma itself must also be approached from a systems
perspective, and institutions need to pay attention to how
they themselves may deconstruct or reinforce stigma. Other
barriers, including ongoing change with regard to licensing
questions, must continue to be eliminated [20, 37]. Medical
and family physician organizations, including STFM, the
American Academy of Family Physicians (AAFP), and the
American Medical Association (AMA), are working to lead
the way on broad change across the country [65].
Addressing Burnout andMental Health
Conditions
Training programs must be ready to address burnout and other
mental health concerns when, not if, they arise among residents and faculty members. The ACGME Common Program
Requirements make clear that it is, “the responsibility of the
program…[to provide] access to condential, affordable mental health assessment, counseling, and treatment, including
access to urgent and emergent care 24 hours a day, seven days
a week”[5]. This begins with training members of the program
on the responsibilities they have to address these concerns, the
resources that are available, and the mechanisms by which to
report any concerns condentially [55].
Programs and, ultimately, the program director have a
responsibility to address and support physicians who may be
experiencing a mental health problem. However, program
directors themselves tend to underestimate the prevalence of
burnout among their residents [33]. While keeping their own
biases in mind, PDs should remember that physicians are
relatively unlikely to seek help if needed, and are even less
likely to seek out help if experiencing burnout or depression,
as discussed in detail above [48]. Fears about reports to the
medical board are prevalent, and 25% of residents incorrectly believe that burnout alone would be a reportable condition [33]. One study demonstrated that only 33% of
residents would contact EAP if they felt unwell, but 62%
would reach out to EAP if this was recommended by their
program director [45]. This is encouraging data, showing
that program directors can make a meaningful difference in
the lives of their residents by showing an interest in and guidance on mental health care.
Residency leadership may wonder how they can objectively identify a resident in distress. It’s important to remember that episodic stress is different from a mental health
concern or condition. One tool that can be useful to provide
support to a colleague in the immediate moment is Stress
First Aid for Healthcare Professionals; information on this
tool can be found through AMA Steps Forward [96]. The
24 Resident andFaculty Well-Being andBurnout
255
resident-specic Physician Well-Being Index is a screening
tool that can identify trainees in such distress that their job
performance may be impacted [97].
If a concern is identied, leadership and/or the faculty
advisor should meet with the resident or faculty member in
question to understand the situation and contributing factors.
In the absence of impairment, a recommendation to seek
evaluation and treatment may be sufcient, and condential
access to this treatment should be ensured [15]. However,
one might consider mandating an evaluation if the concern
compromises patient care, violates policy (either programmatic or institutional), or blocks training progress [55].
Simultaneously clarifying and ensuring condentiality,
where able, may help residents feel more comfortable with
communication around their experiences and thoughts on
help-seeking [45].
However, trainees, faculty, and program leadership may
still feel unsure about downstream effects of seeking treatment. If program directors feel uncertain about their state
medical board licensing application questions and reporting
procedures, STFM recommends reaching out proactively to
set up a meeting with a Graduate Medical Education resource
at the medical board. Explore what questions would be asked
in the face of voluntary treatment, mandated evaluation, or a
leave from training for a mental health concern. STFM also
recommends evaluating the relationship of the state medical
board and state PHP, with a particular eye toward when the
state PHP mandates reporting and what mental health questions exist on the licensing application [90]. This will allow
recommendations to be given to physicians with mental
health concerns from a place of knowledge and condence.
Finally, in the event that a program director does face
questions regarding a trainee’s mental health that are inconsistent with FSMB recommendations, STFM recommends
responding with the following: “The American Academy of
Family Physicians, American Medical Association, Dr.
Lorna Breen Heroes’ Foundation, and Federation of State
Medical Boards recommend removing all intrusive questions
about past medical history and to ask only about a physician’s current health and tness to safely practice medicine.
I am not aware of any current condition that impairs Dr. X’s
judgment or that would otherwise adversely affect their ability to practice medicine in a competent, ethical, and professional manner” [90].
ABFM Time Away fromResidency/Family Leave
Policy
In 2020, the American Board of Family Medicine (ABFM)
updated their policy regarding family leave and boardeligibility. This was done in an effort to provide increased
support to family medicine residents in the eventuality of
requiring leave beyond the norm, such as vacation or sick
time, during training. The initial change was meant to provide language supporting parental leave in particular without
necessarily extending residency, although this is ultimately
the decision of the program director and the Clinical
Competency Committee (CCC). However, the policy additionally states that “Family Leave” can also refer to leave as
a result of, “a resident’s own serious health condition requiring prolonged evaluation and treatment” [98]. Additionally,
the policy claries that, “Decisions about what constitutes…
serious health condition is best left to the Program Director
and their institutional policies. ABFM intends to leave those
decisions at the local level where they are best able to be
individually made” [98].
In the event that a resident physician requires care for a
mental health concern that signicantly impacts their ability
to continue working, a leave of absence from training based
on the ABFM Family Leave Policy may be appropriate. It’s
important to note that a person may require this time away
without meeting the threshold of impairment, and that the
ability to take time to obtain necessary care prior to reaching
such a threshold is essential to protecting the lives of residents and the patients they serve. With that said, program
directors should keep in mind that this policy does not supersede policies of the residency program or the sponsoring
institution, and they should seek clarication on how this
policy could be utilized prior to the presentation of an urgent
need for implementation.
Approach totheImpaired Physician
The impaired physician presents a danger to themselves and
their patients, and action must be taken. Programs should
know their institution’s policy regarding impaired physicians, particularly regarding protocols to obtain immediate
evaluation and treatment that protects the physician’s personal safety; this requirement is also stated in the ACGME
Common Program Requirements [5].
Signicant concerns regarding safety and impairment
may be identied by other trainees, faculty, or other staff
members in the hospital. Program leadership must be contacted, and the physician must be removed from patient care
duties and possibly placed on medical leave [46]. The Family
Medical Leave Act (FMLA) is one pathway that may be
appropriate in this instance, as well as the ABFM Family
Leave Policy as discussed above. The physician should be
referred for a tness for duty evaluation; many EAPs can
perform this evaluation, although individual states and institutions may have other evaluators available or preferred. If
evaluation is mandated in this fashion, it is important to clar-
256
Fig. 24.1 Checklist for Referral for Psychiatric Evaluation.
(Reproduced with permission from: Thomas CR. Deciding to Refer
Residents for Psychiatric Evaluation. J Grad Med Educ. 2017
Apr;9(2):151–153. https://doi.org/10.4300/JGME- D- 17- 00027.1)
ify the consequences for refusal, such as suspension, nonpromotion, and non-renewal of training contract [55]. Please
see Fig.24.1 for a sample checklist for this process.
One brief note on impaired physician policies: just as
some PHPs address all reportable conditions through a substance use lens, some institutional policies will do the same.
If there is no pathway for mental health concerns in your
institution’s protocol, consider developing this with your
graduate medical education department. This will allow
response, rather than reaction, when an impaired physician is
identied.
Conclusion
In order to successfully move toward the Well-being 2.0 era
as described by Dr. Shanafelt, physicians must, “change the
way we dene what it means to be a ‘good doctor’ by
acknowledging our humanity and our human vulnerabilities,
and we must encourage medical students and residents to
ally with us to become champions in these efforts, advocating for themselves and their futures in medicine” [27].
Program directors, faculty, and residency programs at
large should see the continued attention on physician wellbeing and the lack thereof as an urgent call to action, including a need for broad shift in medical culture. Change is both
L. Brown-Berchtold and C. Matthis
necessary and non-negotiable, and family medicine physicians are leading the way across the country. By ghting
stigma, changing medical licensing requirements, addressing the hidden curriculum, and implementing evidencedriven interventions, we can protect our residents and our
colleagues while envisioning a better future.
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