Canadian Psychiatric Association
Brief Communication
Burnout among Canadian Psychiatry Residents: A National Survey L’e´puisement professionnel chez les re´sidents canadiens en psychiatrie : une enque´te nationale
Association des psychiatres du Canada
The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(11) 732-736 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716645286 TheCJP.ca | LaRCP.ca
David Kealy, PhD1, Priyanka Halli, MD1, John S. Ogrodniczuk, PhD1, and George Hadjipavlou, MA, MD, FRCPC1
Abstract Objective: Burnout is a serious problem for health care providers that has implications for clinical practice and personal health. While burnout is known to affect residents, no studies have examined the prevalence or impact of burnout among Canadian psychiatry residents. Method: Residents in all Canadian psychiatry training programs were surveyed between May 1, 2014, and July 1, 2014. The survey included a well-validated, single-item measure to assess symptoms of burnout, several demographic questions, and Likert-scale items to assess residents’ appraisals of empathic functioning and strategies for coping with stress from patient encounters. Results: Responses were obtained from 400 residents, for a response rate of 48%. Twenty-one percent (N ¼ 84) of residents reported symptoms of burnout. Burnout was reported more frequently by residents in postgraduate year 2 than by those in other years and was associated with engagement in personal psychotherapy during residency. No association was found between burnout and age, gender, or location of residency program. Residents who endorsed symptoms of burnout reported higher levels of compromised empathic functioning, were less likely to consult with supervisors about stressful clinical experiences, and were more likely to engage in unhealthy coping strategies. Conclusions: Symptoms of burnout affect one-fifth of Canadian psychiatry residents. The associations between burnout symptoms and problematic clinical and personal functioning suggest areas of concern for those involved in the training of Canadian psychiatry residents. Abre´ge´ Objectif : L’e´puisement professionnel est un proble`me se´rieux pour les prestataires de soins de sante´ qui a des implications dans la pratique clinique et la sante´ personnelle. Bien qu’il soit connu que l’e´puisement professionnel touche les re´sidents, il n’y a pas eu d’e´tude sur la pre´valence ou l’effet de l’e´puisement professionnel chez les re´sidents canadiens en psychiatrie. Me´thode : Les re´sidents de tous les programmes canadiens de formation en psychiatrie ont e´te´ interroge´s entre le 1er mai 2014 et le 1er juillet 2014. Le sondage comprenait une mesure valide´e a` un seul item pour e´valuer les symptoˆmes d’e´puisement professionnel, plusieurs questions de´mographiques, et les items de l’e´chelle de Likert pour e´valuer les estimations des re´sidents du fonctionnement empathique et des strate´gies d’adaptation au stress d’apre`s leurs rencontres avec les patients. Re´sultats : Les re´ponses ont e´te´ obtenues de 400 re´sidents, soit un taux de re´ponse de 48 %. Vingt-et-un pour cent (N ¼ 84) des re´sidents ont de´clare´ des symptoˆmes d’e´puisement professionnel. L’e´puisement professionnel a e´te´ signale´ plus fre´quemment par les re´sidents de 2e anne´e que par ceux des autres anne´es, et e´tait associe´ avec un engagement en psychothe´rapie personnelle durant la re´sidence. Aucune association n’a e´te´ constate´e entre l’e´puisement et l’aˆge, le sexe, ou 1
Department of Psychiatry, University of British Columbia, Vancouver, British Columbia
Corresponding Author: David Kealy, PhD, UBC Department of Psychiatry, University of British Columbia, Vancouver, BC V6T 1Z3, Canada. Email: [email protected]
La Revue Canadienne de Psychiatrie 61(11)
733
l’emplacement du programme de re´sidence. Les re´sidents qui indiquaient des symptoˆmes d’e´puisement professionnel de´claraient des niveaux plus e´leve´s de fonctionnement empathique compromis, e´taient moins susceptibles de consulter leurs superviseurs au sujet de leurs expe´riences cliniques stressantes, et plus susceptibles d’adopter des strate´gies d’adaptation malsaines. Conclusion : Les symptoˆmes d’e´puisement professionnel touchent un cinquie`me des re´sidents canadiens en psychiatrie. Les associations entre les symptoˆmes d’e´puisement professionnel et le fonctionnement clinique et personnel proble´matique sugge`rent des domaines pre´occupants pour les responsables de la formation des re´sidents canadiens en psychiatrie. Keywords burnout, psychiatry, residency, psychiatry resident, resident training, empathic functioning, consultation with supervisors
Clinical Implications Symptoms of burnout are prevalent among psychiatry residents and are associated with reduced empathy and problematic strategies for coping with patientrelated stress. Psychiatry training programs should implement strategies to address and prevent burnout.
Limitations A single-item burnout measure is not inclusive of a wider range of burnout symptoms. The cross-sectional nature of the survey does not reveal the direction of associations. Burnout is an occupational syndrome characterized by emotional exhaustion, feelings of cynicism and detachment toward patients, and a reduced sense of personal accomplishment.1 Among health care providers, burnout is a serious problem associated with increased medical errors, decreased capacity for empathy, and deviation from best practice guidelines.1-6 Burnout is also harmful to practitioners; it is often linked with anxiety, depression, substance use, and suicidal ideation.1,6,7 Psychiatry residency training is a transitional period that warrants particular attention to the issue of burnout. The combination of long work hours, on-call obligations, financial strain, and increased clinical responsibility can place a heavy burden on residents as they learn the complexities of psychiatric practice. Moreover, psychiatry residents are exposed to emotionally taxing experiences such as violent patients and patient suicide.8-10 Attention to burnout during residency is also important given the potential to implement proactive preventive and management strategies early in physicians’ careers.11 Surprisingly, few studies have systematically examined the prevalence of burnout among psychiatry residents, and none have looked at the prevalence across multiple institutes. A small U.S. study found that 40% of psychiatry residents endorse burnout—less than residents in other medical and surgical specialties but more than those in family practice.12 Another U.S. study found lower rates of burnout among residents in psychiatry compared with family medicine (incidence of burnout was not reported).13 A study
in the Netherlands, however, found the 29% incidence of burnout among psychiatry residents to be the highest of 6 specialties studied.14 These incongruent data suggest that the impact of training may be quite variable across nations and thus of limited generalizability to Canadian residents. To our knowledge, no study to date has evaluated the rate and implications of burnout among Canadian psychiatry residents. The present study was designed to determine the prevalence and associated features of burnout symptoms among Canadian psychiatry residents. As part of a larger study on residents’ engagement in personal psychotherapy,15 we surveyed residents across all training programs in Canada about their experience of burnout symptoms as well as their appraisal of their current empathic functioning and strategies for coping with stressful patient encounters.
Methods The survey items in this study were included in a 43-item questionnaire on personal psychotherapy that was distributed to all of the 839 active psychiatry residents in Canada between May 1, 2014, and July 1, 2014.15 The survey was pilot-tested by resident representatives and reviewed by the Coordinators of Psychiatric Education (COPE) before electronic distribution through each program’s resident COPE representative. A raffle to win a $1000 gift certificate was offered to incentivize participation. The survey was anonymous, and residents’ contact information could not be linked to their responses. The study was approved by the University of British Columbia Research Ethics Board. The present study inquired about residents’ (a) basic demographic information; (b) use of personal psychotherapy; (c) levels of burnout symptoms; (d) appraisal of empathic functioning; and (e) strategies for coping with stress from patient encounters. In the interest of brevity and increased response rates, symptoms of burnout were assessed with a single item (see Table 1) that has been validated in previous studies as being highly correlated with the Maslach Burnout Inventory emotional exhaustion scale.16,17 Likert-scale items were used to assess residents’ appraisals of empathic functioning and coping strategies. Standard descriptive statistics were used to characterize the sample. Consistent with previous research,17 the burnout item was dichotomized, with scores on the lower 2
734
The Canadian Journal of Psychiatry 61(11)
Table 1. Demographic information and responses to burnout survey among Canadian psychiatry residents, N ¼ 400. Demographic and burnout responses Age 30 years 31-35 years 36 years Gender Female Male Year of training PGY-1 PGY-2 PGY-3 PGY-4 PGY-5 and fellowship Location of residency Western provinces Maritime provinces Ontario Quebec Received psychotherapy during residency Yes No Responses to burnout scale I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help. The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot. I am definitely burning out and have 1 or more symptoms of burnout, such as physical and emotional exhaustion. Occasionally, I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out. I enjoy my work. I have no symptoms of burnout.
No. of residents (%) 212 (53.1) 141 (35.3) 47 (11.8) 277 (69.3) 123 (30.8) 76 (19) 88 (22) 88 (22) 85 (21.3) 63 (15.8) 116 (29) 33 (8.3) 158 (39.5) 91 (22.8) 171 (42.8) 229 (57.3) 4 (1)
7 (1.8)
73 (18.3)
246 (61.5)
70 (17.5)
categories indicating no symptoms of burnout and scores on the higher 3 categories affirming at least 1 symptom of burnout. Associations between burnout symptoms and categorical variables were assessed using chi-square tests. MannWhitney U tests were used to compare between residents who endorsed burnout and those without burnout symptoms with regard to the Likert-scale items (significance set at P < 0.01 to adjust for multiple tests).
Results A total of 400 residents returned the survey, with responses from every program across Canada, yielding a response rate of 48%. Demographic data and responses to our burnout scale are reported in Table 1. Respondents’ gender distribution was similar to that of Canadian residents generally (64.3% female). Twenty-one percent (N ¼ 84) of residents reported symptoms of burnout. Chi-square tests found no association between burnout symptoms and age, gender, or location of residency program. A significant association was noted between burnout symptoms and year of training (w2 ¼ 12.22, df ¼ 4, P ¼ 0.016), with symptoms of burnout reported more frequently by postgraduate year (PGY)-2 residents at 31%, followed by PGY-3 at 27%, PGY-4 at 18%, PGY-5 at 16%, and PGY-1 at 8%. An association was also found between personal psychotherapy during residency and symptoms of burnout (w2 ¼ 5.09, df ¼ 1, P ¼ 0.024); of those who reported burnout symptoms, 54% had undertaken personal psychotherapy during residency. Mean scores for Likert-scale items regarding empathic functioning and coping strategies are reported in Table 2 according to residents’ endorsement of burnout symptoms. Analysis with Mann-Whitney U tests found significant differences between residents who reported symptoms of burnout and those who did not with regard to empathic functioning, consultation with supervisors, and use of unhealthy coping mechanisms. Residents endorsing burnout symptoms were
Table 2. Psychiatry residents’ appraisal of empathic functioning and reported strategies for coping with work-related stress, N ¼ 400a. Mann-Whitney U test Burnout symptomsb No burnout symptomsb (N ¼ 84) (N ¼ 316) Empathic functioning Considering your last week of clinical work, do you feel you are losing your capacity to respond empathically? Coping strategies for stressful clinical encounters Yoga or other mindfulness practice Consult with fellow psychiatry residents Consult with supervisors Talk with friends Unhealthy strategies
U
z
P
2.46 (1.56)
1.41 (1.28)
18 137
5.58
Brief Communication
Burnout among Canadian Psychiatry Residents: A National Survey L’e´puisement professionnel chez les re´sidents canadiens en psychiatrie : une enque´te nationale
Association des psychiatres du Canada
The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(11) 732-736 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716645286 TheCJP.ca | LaRCP.ca
David Kealy, PhD1, Priyanka Halli, MD1, John S. Ogrodniczuk, PhD1, and George Hadjipavlou, MA, MD, FRCPC1
Abstract Objective: Burnout is a serious problem for health care providers that has implications for clinical practice and personal health. While burnout is known to affect residents, no studies have examined the prevalence or impact of burnout among Canadian psychiatry residents. Method: Residents in all Canadian psychiatry training programs were surveyed between May 1, 2014, and July 1, 2014. The survey included a well-validated, single-item measure to assess symptoms of burnout, several demographic questions, and Likert-scale items to assess residents’ appraisals of empathic functioning and strategies for coping with stress from patient encounters. Results: Responses were obtained from 400 residents, for a response rate of 48%. Twenty-one percent (N ¼ 84) of residents reported symptoms of burnout. Burnout was reported more frequently by residents in postgraduate year 2 than by those in other years and was associated with engagement in personal psychotherapy during residency. No association was found between burnout and age, gender, or location of residency program. Residents who endorsed symptoms of burnout reported higher levels of compromised empathic functioning, were less likely to consult with supervisors about stressful clinical experiences, and were more likely to engage in unhealthy coping strategies. Conclusions: Symptoms of burnout affect one-fifth of Canadian psychiatry residents. The associations between burnout symptoms and problematic clinical and personal functioning suggest areas of concern for those involved in the training of Canadian psychiatry residents. Abre´ge´ Objectif : L’e´puisement professionnel est un proble`me se´rieux pour les prestataires de soins de sante´ qui a des implications dans la pratique clinique et la sante´ personnelle. Bien qu’il soit connu que l’e´puisement professionnel touche les re´sidents, il n’y a pas eu d’e´tude sur la pre´valence ou l’effet de l’e´puisement professionnel chez les re´sidents canadiens en psychiatrie. Me´thode : Les re´sidents de tous les programmes canadiens de formation en psychiatrie ont e´te´ interroge´s entre le 1er mai 2014 et le 1er juillet 2014. Le sondage comprenait une mesure valide´e a` un seul item pour e´valuer les symptoˆmes d’e´puisement professionnel, plusieurs questions de´mographiques, et les items de l’e´chelle de Likert pour e´valuer les estimations des re´sidents du fonctionnement empathique et des strate´gies d’adaptation au stress d’apre`s leurs rencontres avec les patients. Re´sultats : Les re´ponses ont e´te´ obtenues de 400 re´sidents, soit un taux de re´ponse de 48 %. Vingt-et-un pour cent (N ¼ 84) des re´sidents ont de´clare´ des symptoˆmes d’e´puisement professionnel. L’e´puisement professionnel a e´te´ signale´ plus fre´quemment par les re´sidents de 2e anne´e que par ceux des autres anne´es, et e´tait associe´ avec un engagement en psychothe´rapie personnelle durant la re´sidence. Aucune association n’a e´te´ constate´e entre l’e´puisement et l’aˆge, le sexe, ou 1
Department of Psychiatry, University of British Columbia, Vancouver, British Columbia
Corresponding Author: David Kealy, PhD, UBC Department of Psychiatry, University of British Columbia, Vancouver, BC V6T 1Z3, Canada. Email: [email protected]
La Revue Canadienne de Psychiatrie 61(11)
733
l’emplacement du programme de re´sidence. Les re´sidents qui indiquaient des symptoˆmes d’e´puisement professionnel de´claraient des niveaux plus e´leve´s de fonctionnement empathique compromis, e´taient moins susceptibles de consulter leurs superviseurs au sujet de leurs expe´riences cliniques stressantes, et plus susceptibles d’adopter des strate´gies d’adaptation malsaines. Conclusion : Les symptoˆmes d’e´puisement professionnel touchent un cinquie`me des re´sidents canadiens en psychiatrie. Les associations entre les symptoˆmes d’e´puisement professionnel et le fonctionnement clinique et personnel proble´matique sugge`rent des domaines pre´occupants pour les responsables de la formation des re´sidents canadiens en psychiatrie. Keywords burnout, psychiatry, residency, psychiatry resident, resident training, empathic functioning, consultation with supervisors
Clinical Implications Symptoms of burnout are prevalent among psychiatry residents and are associated with reduced empathy and problematic strategies for coping with patientrelated stress. Psychiatry training programs should implement strategies to address and prevent burnout.
Limitations A single-item burnout measure is not inclusive of a wider range of burnout symptoms. The cross-sectional nature of the survey does not reveal the direction of associations. Burnout is an occupational syndrome characterized by emotional exhaustion, feelings of cynicism and detachment toward patients, and a reduced sense of personal accomplishment.1 Among health care providers, burnout is a serious problem associated with increased medical errors, decreased capacity for empathy, and deviation from best practice guidelines.1-6 Burnout is also harmful to practitioners; it is often linked with anxiety, depression, substance use, and suicidal ideation.1,6,7 Psychiatry residency training is a transitional period that warrants particular attention to the issue of burnout. The combination of long work hours, on-call obligations, financial strain, and increased clinical responsibility can place a heavy burden on residents as they learn the complexities of psychiatric practice. Moreover, psychiatry residents are exposed to emotionally taxing experiences such as violent patients and patient suicide.8-10 Attention to burnout during residency is also important given the potential to implement proactive preventive and management strategies early in physicians’ careers.11 Surprisingly, few studies have systematically examined the prevalence of burnout among psychiatry residents, and none have looked at the prevalence across multiple institutes. A small U.S. study found that 40% of psychiatry residents endorse burnout—less than residents in other medical and surgical specialties but more than those in family practice.12 Another U.S. study found lower rates of burnout among residents in psychiatry compared with family medicine (incidence of burnout was not reported).13 A study
in the Netherlands, however, found the 29% incidence of burnout among psychiatry residents to be the highest of 6 specialties studied.14 These incongruent data suggest that the impact of training may be quite variable across nations and thus of limited generalizability to Canadian residents. To our knowledge, no study to date has evaluated the rate and implications of burnout among Canadian psychiatry residents. The present study was designed to determine the prevalence and associated features of burnout symptoms among Canadian psychiatry residents. As part of a larger study on residents’ engagement in personal psychotherapy,15 we surveyed residents across all training programs in Canada about their experience of burnout symptoms as well as their appraisal of their current empathic functioning and strategies for coping with stressful patient encounters.
Methods The survey items in this study were included in a 43-item questionnaire on personal psychotherapy that was distributed to all of the 839 active psychiatry residents in Canada between May 1, 2014, and July 1, 2014.15 The survey was pilot-tested by resident representatives and reviewed by the Coordinators of Psychiatric Education (COPE) before electronic distribution through each program’s resident COPE representative. A raffle to win a $1000 gift certificate was offered to incentivize participation. The survey was anonymous, and residents’ contact information could not be linked to their responses. The study was approved by the University of British Columbia Research Ethics Board. The present study inquired about residents’ (a) basic demographic information; (b) use of personal psychotherapy; (c) levels of burnout symptoms; (d) appraisal of empathic functioning; and (e) strategies for coping with stress from patient encounters. In the interest of brevity and increased response rates, symptoms of burnout were assessed with a single item (see Table 1) that has been validated in previous studies as being highly correlated with the Maslach Burnout Inventory emotional exhaustion scale.16,17 Likert-scale items were used to assess residents’ appraisals of empathic functioning and coping strategies. Standard descriptive statistics were used to characterize the sample. Consistent with previous research,17 the burnout item was dichotomized, with scores on the lower 2
734
The Canadian Journal of Psychiatry 61(11)
Table 1. Demographic information and responses to burnout survey among Canadian psychiatry residents, N ¼ 400. Demographic and burnout responses Age 30 years 31-35 years 36 years Gender Female Male Year of training PGY-1 PGY-2 PGY-3 PGY-4 PGY-5 and fellowship Location of residency Western provinces Maritime provinces Ontario Quebec Received psychotherapy during residency Yes No Responses to burnout scale I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help. The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot. I am definitely burning out and have 1 or more symptoms of burnout, such as physical and emotional exhaustion. Occasionally, I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out. I enjoy my work. I have no symptoms of burnout.
No. of residents (%) 212 (53.1) 141 (35.3) 47 (11.8) 277 (69.3) 123 (30.8) 76 (19) 88 (22) 88 (22) 85 (21.3) 63 (15.8) 116 (29) 33 (8.3) 158 (39.5) 91 (22.8) 171 (42.8) 229 (57.3) 4 (1)
7 (1.8)
73 (18.3)
246 (61.5)
70 (17.5)
categories indicating no symptoms of burnout and scores on the higher 3 categories affirming at least 1 symptom of burnout. Associations between burnout symptoms and categorical variables were assessed using chi-square tests. MannWhitney U tests were used to compare between residents who endorsed burnout and those without burnout symptoms with regard to the Likert-scale items (significance set at P < 0.01 to adjust for multiple tests).
Results A total of 400 residents returned the survey, with responses from every program across Canada, yielding a response rate of 48%. Demographic data and responses to our burnout scale are reported in Table 1. Respondents’ gender distribution was similar to that of Canadian residents generally (64.3% female). Twenty-one percent (N ¼ 84) of residents reported symptoms of burnout. Chi-square tests found no association between burnout symptoms and age, gender, or location of residency program. A significant association was noted between burnout symptoms and year of training (w2 ¼ 12.22, df ¼ 4, P ¼ 0.016), with symptoms of burnout reported more frequently by postgraduate year (PGY)-2 residents at 31%, followed by PGY-3 at 27%, PGY-4 at 18%, PGY-5 at 16%, and PGY-1 at 8%. An association was also found between personal psychotherapy during residency and symptoms of burnout (w2 ¼ 5.09, df ¼ 1, P ¼ 0.024); of those who reported burnout symptoms, 54% had undertaken personal psychotherapy during residency. Mean scores for Likert-scale items regarding empathic functioning and coping strategies are reported in Table 2 according to residents’ endorsement of burnout symptoms. Analysis with Mann-Whitney U tests found significant differences between residents who reported symptoms of burnout and those who did not with regard to empathic functioning, consultation with supervisors, and use of unhealthy coping mechanisms. Residents endorsing burnout symptoms were
Table 2. Psychiatry residents’ appraisal of empathic functioning and reported strategies for coping with work-related stress, N ¼ 400a. Mann-Whitney U test Burnout symptomsb No burnout symptomsb (N ¼ 84) (N ¼ 316) Empathic functioning Considering your last week of clinical work, do you feel you are losing your capacity to respond empathically? Coping strategies for stressful clinical encounters Yoga or other mindfulness practice Consult with fellow psychiatry residents Consult with supervisors Talk with friends Unhealthy strategies
U
z
P
2.46 (1.56)
1.41 (1.28)
18 137
5.58
