AUTHOR
By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
SUMMARY POINTS
- In total, 340 interns from 15 pediatric training programs participated in this randomized clinical trial to determine whether a specialized mindfulness intervention was effective in reducing symptoms of burnout in pediatric interns. A primary goal of the study was to work the mindfulness curriculum into the interns’ normal schedules.
- The intervention was an hour-long mindfulness curriculum conducted monthly for seven months. The active control was a social luncheon.
- Evaluation of burnout was conducted at baseline, six months, and 15 months into the study.
- An analysis of the results showed evidence of increased symptoms of burnout in both groups without statistical separation.
SYNOPSIS: This randomized clinical trial involving pediatric interns and a mindfulness intervention modified to fit into clinical schedules did not show an advantage over an active control in reducing symptoms of burnout.
SOURCE: Fraiman YS, Cheston CC, Cabral HJ, et al. Effect of a novel mindfulness curriculum on burnout during pediatric internship: A cluster randomized clinical trial. JAMA Pediatr 2022;176:365-372.
The 2020 International Classification of Diseases (ICD) 11 QD85 defines burnout as a syndrome conceptualized as resulting from chronic workplace stress and mindfulness as the quality of awareness that occurs through intentionally focusing on present moment experiences in an accepting and nonjudgmental manner.1
Burnout is a term introduced in 1974 by psychologist Herbert Freudenberger to describe the physical and emotional exhaustion and numbness experienced by workers in demanding professions and is a risk for physicians at all stages of training.2 With data from multiple studies indicating that burnout in medical providers is associated with poor outcomes, efforts to understand how to address and/or prevent burnout as early as possible are increasing.2,3
Mindfulness techniques or exercises that assist with a “nonjudgmental state of awareness in the present moment” are the only evidence-based interventions to reduce burnout included in the Accreditation Council for Graduate Medical Education wellness initiative.4 These interventions may be as simple as breathing exercises, or they may be more complex, such as a yoga routine or meditation, but all of them incorporate self-awareness and a focus on the moment.1,3
However, time barriers and other factors make it difficult to integrate mindfulness practice into a residency program.5 Recognizing this, Fraiman et al conducted a multicenter randomized clinical trial among 15 pediatric residency programs to determine whether there was a significant reduction in burnout symptoms among pediatric interns following a monthly mindfulness exercise designed to fit seamlessly into the intern curriculum vs. a social lunch, which served as the control.
The mindfulness component was one hour long and consisted of a meal followed by a moment of silence, a mindfulness exercise, and a debriefing period. There was no facilitator training, and attendance was encouraged, but not required.
The active control social lunch also was delivered over a one-hour time and did not include any mindfulness or didactic experience.
Emotional exhaustion (EE) is a hallmark of burnout and was the primary outcome in this investigation.6 EE is defined as “a state of mind where an individual feels overextended and mentally and emotionally drained.” The level of participant EE was measured by responses to the Maslach Burnout Inventory at baseline, six months, and 15 months. Secondary outcomes included measures of depersonalization, empathy, and sense of personal accomplishment.7 The Maslach Burnout Inventory is a scientifically validated, self-completed questionnaire to measure risk of burnout by assessing functioning in three main areas: EE, depersonalization, or a pervasive sense of detachment from patients and their feelings of personal efficacy or self-worth.7
Out of the 359 interns agreeing to participate in this study, 340 returned the questionnaires at baseline, 273 completed and returned the forms at month 6, and only 195 completed this task at month 15. In multivariable statistical analysis, there were no noticeable differences between the groups completing the study and those who dropped out of the pool.
RESULTS
The intervention and control groups had statistically similar EE scores at baseline — the intervention group had a mean score of 28.2, and the control group mean score was 25.9. Notably, an EE score of 27 or higher is significant for burnout; the mean score at baseline for all participants was 27.2, with a range from 7-63, indicating the probability of burnout prior to the study in at least a portion of the respondents.
Six months into the study, the scores for all participants had risen to 35.4 and 28.3 in the intervention and control group, respectively. There was no statistical difference able to be detected between the groups. At 15 months, participants in both arms remained with elevated mean EE scores without a statistical difference (33.8 in the intervention group and 32.9 in the control group).
Secondary outcomes included depersonalization and a sense of personal accomplishment. Combining these scores with the EE score gave a total “burnout” score. Table 1 shows the percentage of each arm in “burnout” at each survey period.
Table 1. Burnout Scores |
||
| Intervention Arm (Mindfulness Exercises) | Active Control (Social Lunch) | |
Baseline |
74.4% with burnout |
60.3% with burnout |
Month 6 |
92% with burnout |
80.5% with burnout |
Month 15 |
86.7% with burnout |
88.3% with burnout |
COMMENTARY
This multicenter randomized clinical trial failed to show an advantage in preventing or combatting burnout with a mindfulness curriculum integrated into training vs. a social lunch for pediatric interns early in training.
Interestingly, this finding is different from other studies of mindfulness experiences during training. Several studies have shown direct benefit to residents with mindfulness interventions, including a decrease in self-reported stress levels and an increase in well-being.5,7-9
It is possible that several unique aspects of the Fraiman et al intervention account for the lack of perceived efficacy, including that there was no trained facilitator, and that the intervention was relatively brief (one hour monthly in this study) compared to some of the other trials. These features, however, were deliberately built into the design of the Fraiman et al intervention because the goal of this trial was to see if a mindfulness intervention designed to fit into a busy clinical year of residency was effective. The results suggest that this specific intervention may need further or different modifications.
It also is worth considering that, although the intervention group started the study with a higher mean burnout score than the control group, this pattern did not continue. In fact, by the end of the study, 86.7% of the intervention group had positive burnout scores, compared to 88.3% of the control group. According to statistical analysis by Fraiman et al this difference is not statistically significant, but these results may bear further study.
Burnout, as noted previously, was a term first used in 1974. Researchers at the time described a triad of symptoms typically seen with burnout: EE, depersonalization, and a perception of ineffectiveness or a reduced sense of personal accomplishment in response to workplace stressors.2
Initially linked with professionals working in chemical dependency, the phenomenon began to be recognized in a variety of professions. However, it was not until 2015 that the ICD-10 Clinical Modification recategorized burnout from an amorphous concept to a mental state, complete with a description and billable code. In 2019, controversy ensued when the World Health Organization (WHO) reclassified burnout from a mental state to an occupational syndrome in the ICD-11, resulting in a clarification from WHO that burnout is not yet considered a medical diagnosis per se.10
In a nod to research of the past, ICD-11 describes burnout in three dimensions: “feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy.”10
Definitions of key terms and measures regarding burnout are not yet standardized, hindering efforts to compare studies and to evaluate efficacy of treatment. Signs of burnout, such as emotional depletion and poor energy, overlap with mental health diagnosis (depression and anxiety, for example), leading some to wonder if burnout is a subtype of a mental health disorder.10,11
Burnout in physicians is associated with an increased risk of medical errors, decreased quality of care and reduced patient satisfaction. Without intervention, physicians with burnout are at an increased risk of both developing health complications and of leaving the profession. While wellness most likely plays a role in avoiding burnout, it is clear from many studies that wellness measures alone are not a panacea for burnout. This is not surprising, since recent investigations have identified a link between burnout and specific workplace factors, rather than individual characteristics or even type of work.
Studies indicate that strong organizational measures and support, in conjunction with personal wellness efforts, are the most powerful intervention.5,7-11 These findings also may partially account for the negative findings in the current study.
One striking unfortunate positive result from this study was the high level in burnout at baseline for the entire group at the beginning of year 1 of residency. This result has potential implications for the healthcare workforce and, given what we know about the effect of burnout on providers, may imply a need to combat or at least raise awareness about burnout during medical school years.
Clinically, this study can serve as a reminder to the integrative provider of the importance of considering burnout in patients presenting with exhaustion, especially in patients employed in high-risk occupations. Additionally, with more than 60% of first year residents scoring in the burnout range, self-awareness and monitoring for signs of this syndrome may be a good choice for all providers. Finally, the results highlight the need for more research in the field of burnout to gain a better understanding of preventive interventions and management of this potentially debilitating syndrome.
REFERENCES
- [No authors listed]. Jon Kabat-Zinn: Defining mindfulness. Mindful.org. Published Jan. 11, 2017. https://www.mindful.org/jon-kabat-zinn-defining-mindfulness/
- Schaufeli WB. Burnout: A short scio-cultural history. In: Neckel S, Schaffner A, Wagner G, eds. Burnout, Fatigue, Exhaustion. Palgrave Macmillan, Cham:2017;105-127.
- Baminiwatta A, Solangaarachchi I. Trends and developments in mindfulness research over 55 years: A bibliometric analysis of publications indexed in Web of Science. Mindfulness (N Y) 2021;12:2099-2116.
- Mian A, Kim D, Chen D, Ward WL. Medical student and resident burnout: A review of causes, effects, and prevention. J Fam Med Dis Prev 2018;4:094.
- Accreditation Council for Graduate Medical Education. Improving physician well-being, restoring meaning in medicine. https://www.acgme.org/what-we-do/initiatives/physician-well-being/
- Fendel JC, Aeschbach VM, Göritz AS, Schmidt S. A mindfulness program to improve resident physicians’ personal and work-related well-being: A feasibility study. Mindfulness (N Y) 2020;11:1511-1519.
- Emotional exhaustion. https://www.sciencedirect.com/topics/nursing-and-health-professions/emotional-exhaustion
- Puranitee P, Saetang S, Sumrithe S, et al. Exploring burnout and depression of Thai medical students: The psychometric properties of the Maslach Burnout Inventory. Int J Med Educ 2019;10:223-229.
- Kriakous SA, Elliott KA, Lamers C, Owen R. The effectiveness of mindfulness-based stress reduction on the psychological functioning of healthcare professionals: A systematic review. Mindfulness (N Y) 2021;12:1-28.
- Berg S. WHO adds burnout to ICD-11. What it means for physicians. American Medical Association. Published July 23, 2019. https://www.ama-assn.org/practice-management/physician-health/who-adds-burnout-icd-11-what-it-means-physicians
- Hewitt DB, Ellis RJ, Hu Y-Y, et al. Evaluating the association of multiple burnout definitions and thresholds with prevalence and outcomes. JAMA Surg 2020;155:1043-1049.
This randomized clinical trial involving pediatric interns and a mindfulness intervention modified to fit into clinical schedules did not show an advantage over an active control in reducing symptoms of burnout.
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