How to Prevent Burnout in Medical Residents: Literature Review

Background: Healthy settings involve a holistic and multidisciplinary method that integrates actions towards risk factors. In hospital settings, a high level of stress can lead to depression, anxiety, decreased job satisfaction and lower loyalty to the organization. Objective: This study was to perform a systematic literature review and meta-analysis of the prevalence of burnout among medical residents to develop strategies to support residents’ personal and professional development. Methods: The Medline database was searched with burnout and resident search words. Inclusion criteria of articles for review were published in an English-language peer-reviewed journal from January 2010 to October 2018.Total 12 eligible studies were included in literature review. Results: We identified 12 studies including 9796 participants, conducted across the world and covering different specialties which include Oncology, EM, Otolaryngologist, Psychiatry, General surgery, Pediatrics, Neurosurgery and Radiology. All the 12 studies included 11 articles on descriptive cross-sectional studies and 1 article on analysis of variance, longitudinal study. Review results mainly pointed out the significance high prevalence and the need for systematic measures for prevention medical residents’ burnout. Conclusion: These studies revealed high level of burnout among medical residents, whose stresses were mainly from working situation, emotional pressure and demands from patients. Action plan for resident burnout syndrome prevention is to develop a better training program and enhance medical resident well-being.


Introduction
Burnout is a work-related syndrome that is characterized by high levels of emotional exhaustion and depersonalization, and a reduction in the level of personal accomplishment, which are all driven by workplace stressors [1]. The term burnout was introduced by psychologist Herbert Freudenberger in 1974 in an article entitled "Staff Burnout," in which he discusses job dissatisfaction caused by professional stress [2]. This syndrome has severe adverse consequences including substance abuse, disruptive behavior, lack of energy, low job satisfaction, absenteeism, worthless, impatience, divorce, depression, suicidal thinking, and even suicide [3]. The assessment of burnout syndrome among physicians is performed in a standardized manner using the Maslach Burnout Inventory (MBI), a validated instrument consisting of 22 items that measure scores for 3 dimensions associated with burnout, which is characterized by high scores for emotional exhaustion and depersonalization, and/or low scores of personal accomplishment [4].
Resident burnout is a major concern because it has serious consequences on patient outcomes and on the personal lives of medical residents. Therefore, the objective of this study was to perform a systematic literature review and meta-analysis of the prevalence of burnout among medical residents to develop strategies to support residents' personal and professional development.

Materials and Methods
The Medline database was searched with burnout and resident search words. Inclusion criteria of articles for review were published in an English-language peer-reviewed journal from January 2010 to October 2018, study was conducted no earlier than 2010 and search words appear in the title and/or abstract. Studies were excluded if they did not focus primarily on burnout of residents.
The entire systematic review process was conducted by the author. The initial search identified 185 articles. Articles were further screened using the above inclusion criteria, and 39 were selected.
Twenty-seven of these were excluded due to lack of focus on resident burnout. This resulted in a total of 12 articles for analysis in this review (Figure 1).

Results
Search results are shown in Figure 1. Systematic review included 11 articles on descriptive cross-sectional studies and 1article on analysis of variance, longitudinal study. This literature review was focused on the prevalence of burnout comparison among different medical specialties residents in different countries to develop strategies to support residents' personal and professional development.
Studies surveyed in analysis are shown in Table 1.

Discussion
During the medical residency training years, compared to other periods of professional development, medical residents must adjust to tougher workloads, higher professional self-expectations, and increased demands from patients [5]. Burnout among medical residents is highly prevalent. High educational demands, long working hours, sleep deprivation, on-call alert, lack of autonomy, a high level of work-home interference, a lack of reciprocity in professional relationships and uncertainty about the future are common explanations. Many studies have shown medical residents from various specialties, internationally, experienced moderate burnout. The prevalence of medical residents who met the criteria of burnout on MBI ranged from 17% to 76%. If medical residents are made aware of potentially detrimenta1 personal characteristics, and adjust their behavior and coping styles accordingly, they may better meet the various challenges in their medical career. Failing to cope with the stress will have negative impact on their work performance and the quality of patient care. This review covered the incidence of burnout during resident period and based on these results we are able to offer possible solutions for health care institutions. 21% fulfilled the criteria for moderate to severe Burnout. General surgery represented the specialty with the lowest number of residents suffering from burnout, followed by obstetrics and gynecology and any supportive specialty.

Blanchard et al. (2010) [6]
Descriptive, cross-sectional study , MBI N=340 response rate 60% Oncology residents,b France To assess the prevalence and causes of burnout among oncology residents.
The burnout level is high (44%) amongst oncology residents. It probably discourages vocations for oncology.

Takayesu et al. (2014) [7]
Descriptive, cross-sectional study , MBI N=289 response rate 75% Emergency medicine (EM) residents, USA To assess the prevalence of burnout among EM residents and the individual-level factors associated with burnout.
Burnout is highly prevalent (65%) in EM residents. Interventions should be targeted at 1) improving resident autonomy 2) supervision and instruction on medical decision-making and 3) social supports to reduce work-home conflicts during training. To present findings from a national survey to determine the prevalence of burnout among general surgical trainees and to identify sociodemographic and program characteristics associated with burnout.
The high rates(60%) of burnout among general surgery residents are concerning given the potential impact of burnout on the quality of patient care. Efforts to identify at-risk populations and to design targeted interventions to mitigate burnout in surgcal trainees are warranted.
Baer et al. (2017) [12] Descriptive, cross-sectional study, MBI N=258 response rate 53% Pediatric residents, USA To determine the prevalence of burnout, and examine the association between burnout and self-reported patient care attitudes and behaviors among pediatric residents.
Burnout is highly prevalent(39%) among pediatric residents and is associated with self-reported negative patient care attitudes and behaviors. Residency programs should develop interventions addressing burnout and its potential negative impact on patient care. To establish burnout prevalence, associated demographic and program-related factors, and degree of burnout in New England radiology residents relative to residents in other specialties.
A high degree of burnout, increasing over the postgraduate years, was present in more than one-third of responding radiology residents but was present in a smaller percentage relative to residents across other specialties. To study burnout among pediatric residents at King Abdulazaiz University Hospital in Jeddah, Saudi Arabia.
More than 70% of residents experiencing severe burnout. Moreover, pediatric residents in our institute experienced higher levels of depersonalization than their peers nationally and internationally.
Burnout refers to a state of fatigue and emotional exhaustion which may cause poor adaptation inducing detachment that develop in response to stress at work. Burnout syndrome is a significant problem in the healthcare system, especially in residents because the pressure of work during residency training remains very high, especially as residents are expected to be proficient clinicians, educator, and administrators at the end of residency-training period.
The impact of burnout symptoms on the work capacity and reduction of healthcare quality is important which may directly relate to patient's safety. Therefore, there is the need for designing action plans for burnout prevention and creating a healthy environment in hospitals. Residents are frequently exposed to highly stressful and emotional situations at work, such as high patient workload, unfriendly work environment, lack of recreational services in hospital. reasons. Blanchard et al. [6] indicate that the high level of burnout probably discourages vocations for Oncology [7][8]. The lack of manpower will cause a vicious cycle and aggravate the burnout syndrome. Miyoshi et al. [9] found that participants with burnout have a higher risk become depressive state, which was measured by

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Copy@ Chi-Wen Juan SDS [10][11][12]. Simultaneously, Baer et al. [12] also report that there is association between the proportion of burnout and self-reported negative patient care attitudes and behaviors [13]. Among those specialty included in these 12 studies, the EM residents seems to be the highest burnout prevalence. Takayesu et al. [7] suggest that intervention should be targeted at a) Improving resident autonomy b) Supervision and instruction on medical decision-making and c) Social supports to reduce work-home conflicts during training [14].
However, work environment is also an important issue. Aldress et al. [8] and Vendeloo et al. [15] both accentuate the learning environment plays an important role in reducing the burnout risk among residents [16][17][18][19]. Therefore, aim for decrease level of burnout and provide residents with a less stressful work environment should be a priority. However, factors affecting medical residents prone to burnout need multi-dimensional evaluation in order to reduce the devastating consequences of burnout. In an effort to address widespread burnout and unwellness, our goal is to develop a better training program and enhance medical resident well-being.
The major factors associated with medical resident well-being are autonomy, building of competence, strong social relatedness, and sleep time away from work. Perseverance is predictive of well-being, and greater well-being is associated with increased medical resident empathy [20]. For enhancing medical residents well-being, in addition to organizational efforts to reduce work stress, we should need to identify the sources of stresses which the medical residents perceived, to understand the levels of stress outcome as feelings of burnout, to explore the influencing factors, including personal characteristics to medical resident burnout in order to identify residents at risk of burnout early and to provide timely management [21].

Conclusion
These studies revealed high level of burnout among medical residents, whose stresses were mainly from working situation, emotional pressure and demands from patients. The low burnout residents showed more positive characteristics and active coping styles. Therefore, the lower of burnout syndrome, the better residents can meet the various challenge. Speaking to Taiwan, government dedicate to making residents apply to the Labor Standard laws to protect our residents from burnout syndrome on 2019.We can foresee the future of adequate balance of workload and patients safety in Taiwan.