Burnout in residency: a statewide study.

Objective: To determine the prevalence of burnout in residents in obstetrics and gynecology through the use of a validated tool.

Methods: The Maslach Burnout Inventory Human Services questionnaire is a previously validated tool that measures burnout. Obstetrics and gynecology residents from Texas were invited to participate in this study in 2002. The Maslach Burnout Inventory Human Services questionnaire and a demographic survey were distributed to each resident. Responses were anonymous and returned by mail. Contingency coefficient and [chi square] tests were used for analysis; values of P < 0.05 were significant.

Results: Residents (n = 368) from 17 programs in Texas were surveyed. Responses were received from 14 programs (82.4%), with 136 surveys (37%) returned. Overall, 38.2% reported high emotional exhaustion, 47.1% reported high depersonalization, and 19.1% reported reduced personal accomplishment. The number of residents experiencing true burnout (high emotional exhaustion, high depersonalization, and low personal accomplishment) was 17.6% (n = 24).

Conclusions: High levels of emotional exhaustion and depersonalization occur in some residents. Burnout in residents included in this study was approximately 18%.

Key Words: burnout, gynecology, obstetrics, residents

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Occupational burnout is defined as a state of exhaustion characterized by cynicism about the importance or value of one's occupation. (1,2) The syndrome of burnout includes emotional exhaustion, depersonalization, and reduced personal accomplishment. (1,2) In 1981, Maslach, Jackson, and Leiter (1) developed a standardized survey to assess burnout in health professionals, the Maslach Burnout Inventory-General Survey (MBI). This instrument has been used to study burnout among residents in internal medicine and family practice. (3,4,7) Although residency in obstetrics and gynecology has been traditionally characterized as a stressful time, (5,6) there are no studies assessing burnout in residents in obstetrics and gynecology using a standardized instrument. The objective of this study was to determine the rate of burnout in residents in obstetrics and gynecology in Texas by using a validated instrument.

Materials and Methods

This study was approved by the Committee for the Protection of Human Subjects at the University of Texas Health Science Center Houston. All resident physicians in obstetrics and gynecology programs in Texas were invited to participate by mail. All participants were asked to complete the MBI and a short demographic survey. The MBI is a previously validated, self-administered questionnaire that includes 22 Likert scale questions and takes approximately 15 minutes to complete. (1) The survey measures three components of burnout. Depersonalization is quantified on a scale of 0 to 30; scores greater than 10 indicate a high level of burnout in this subscale. Emotional exhaustion is measured on a scale of 0 to 54; scores greater than 27 indicate a high level of burnout. Personal satisfaction is measured on a scale of 0 to 48; reduced personal accomplishment is noted if scores are less than 33. Residents who scored high in depersonalization and emotional exhaustion and low in personal satisfaction were considered to be experiencing burnout. (2) All responses were anonymous and confidential. Completed surveys were returned by mail. The MBI was scored according to published standards furnished by the Consulting Psychologists Press and entered into Stat-View statistical analysis software (version 5.0.1, SAS Institute, Research Triangle, NC). Contingency coefficient and [chi square] test were used for statistical analysis; a value of P < 0.05 was considered significant.

Results

Surveys were mailed to all 368 residents in the 17 obstetrics and gynecology programs in the state of Texas. Responses were received from 14 programs (82.4%). A total of 136 surveys (37%) were returned. Seventy-one percent of respondents were female and 29% were male. Racial/ethnic breakdown of subjects was 56.6% white, 16.2% Hispanic, 13.2% Asian, 6.6% black, and 7.4% other. Fifty-four percent were married and 26% had children. Fourteen percent reported working fewer than 80 hours per week, 47% between 80 and 90 hours, 36% between 90 and 100 hours, and 3% worked more than 100 hours per week. Twenty-eight percent were in their first year of training, 28% in their second year, 22% in their third year, and 22% in their fourth year. Overall, 38.2% reported a high level of emotional exhaustion (score [greater than or equal to]27), 47.1% reported a high degree of depersonalization (score [greater than or equal to]10), and 19.1% reported reduced personal accomplishment (score [less than or equal to]33). High emotional exhaustion was correlated with depersonalization (cc = 0.46, P < 0.0001) and with reduced personal accomplishment (cc = 0.30, P < 0.01). High scores on the depersonalization subscale were also associated with reduced personal accomplishment (cc = 0.30, P < 0.008). Approximately 18% of residents showed evidence of true burnout with either moderate or high scores in emotional exhaustion and depersonalization and low scores in personal accomplishment. Emotional exhaustion was significantly more common in women (OR, 4.0; 95% CI, 1.59-9.8, P < 0.01). Emotional exhaustion was less common at the intern level (19% versus 46% in all other years, P < 0.01), as was depersonalization (29.7% versus 53.6%, P < 0.025). There was no correlation between marital status, children at home, or work hours with burnout as measured by any subscale.

Discussion

A literature search through PubMed (1966 to 2003), using the search terms "burnout," "residency," "residents," and "training," revealed few studies about burnout in residents, (2,4,7) and no studies about burnout in obstetrics and gynecology. Our results indicate that many residents in obstetrics and gynecology exhibit some if not all characteristics of the burnout syndrome. Burnout data concerning other fields of study finds burnout rates as high as 76% in internal medicine residents. (2) The reasons or triggers for burnout among residents in obstetrics and gynecology were not ascertained by this study.

Residents in obstetrics and gynecology have traditionally had long work hours and the demanding work schedule associated with a surgical specialty. (6) However, our results indicate that burnout in residents in obstetrics and gynecology in Texas was less common than among a group of 115 residents in internal medicine. (2) In that study, 76% of residents showed some evidence of burnout through the use of the MBI. Therefore, although previous research suggests that the amount of work relative to the amount of time available to complete that work may contribute to burnout, there may be other physical and mental stressors or personality traits that are associated with increased predisposition to develop burnout. (3) A limitation of our study is that although most programs in the state participated, only 37% of all surveys were completed and returned despite reminders and attempts to facilitate their completion. It is possible that some of the nonrespondents were too "burned out" to participate; however, this cannot be determined from the data.

This study found that women were more likely to show evidence of burnout. Since residency positions in obstetrics and gynecology have become increasingly filled by women, it is possible that increased burnout may lead to increased attrition during residency or in the early years of practice.

Our finding that interns were less likely to report burnout than upper level residents is consistent with currently accepted constructs of burnout in Health and Human Services in that burnout increases with increasing responsibility. (1,3) This may be one of the reasons that work hours were not significantly correlated with burnout, since interns work longer hours but have less responsibility. Some research suggests that burnout occurs as a response to work overload in the workplace. (1,3) It remains to be seen if the new work hour limitations mandated by the Accreditation Council for Gradute Medical Education will result in decreased burnout among residents.

Conclusion

The effects of burnout on the individual are wide and varied. (1,3) Burnout affects the individual, their coworkers, and the people they serve. Burnout results in increased absenteeism and decreased productivity. Eventually, the burnout syndrome increases turnover and lowers effectiveness for those who remain in their profession. Individuals experiencing burnout perpetuate burnout in those around them. Their interactions can undermine the satisfaction of those who work around them. This study did not have enough power to determine whether residents who showed high burnout were more likely to be clustered within individual programs. Program directors in obstetrics and gynecology residency programs should be aware that burnout might affect residents in their programs. Further studies are needed to improve identification of at-risk residents and factors that may trigger burnout, so that changes may be implemented to improve resident well-being.

The man that hath no music in himself;
Nor is not moved with concord of sweet sounds,
Is fit for treasons, strategems, and spoils;
The motions of his spirit are dull as night,
And his affections dark as Erebus.
Let no such be trusted. Mark the music.
--William Shakespeare, Merchant of Venice

Accepted March 11, 2004.

References

1. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologist Press; 1996.

2. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:39.

3. Shanfelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358-367.

4. Purdy RR, Lemkau JP, Rafferty JP, Rudisill JR. Resident physicians in family practice: who's burned out and who knows? Fam Med 1987;19:203-208.

5. Schneider KM, Monga M, Kerrigan AJ. Stress in residency: reality or myth? Am J Obstet Gynecol 2002;186:907-909.

6. Defoe DM, Power ML, Holzman GB, et al. Long hours and little sleep: work schedules of residents in obstetrics and gynecology. Obstet Gynecol 2001;97:1015-1018.

7. Rafferty JP, Lemkau JP, Purdy RR, Rudisill JR. Validity of the Maslach Burnout Inventory for family practice physicians. J Clin Psychol 1986;42:488-492.

RELATED ARTICLE: Key Points

* Thirty-eight percent of residents reported a high degree of emotional exhaustion.

* Forty-seven percent of residents reported a high degree of depersonalization.

* Eighteen percent of residents met criteria for the burnout syndrome.

* Burnout did not correlate with work hours, marital status, or having children.

* Female residents were more likely to show evidence of burnout.

Joseph A. Garza, MD, Karen M. Schneider, MD, Pamela Promecene, MD, and Manju Monga, MD

From the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Texas Medical School Houston, Houston, TX.

This study was approved by the Committee for the Protection of Human Subjects at the University of Texas Health Science Center Houston.

Reprint requests to Karen M. Schneider, MD, Assistant Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Medical School Houston, 6431 Fannin 3.604, Houston, TX 77030. Email: [e-mail]