Residents' burnout, exhaustion and debt affect their medical learning

Burnout and educational debt are associated with lower scores among residents taking the Internal Medicine In-Training Examination (IM-ITE). And some of the lower-scoring students are unable to catch up with their peers by the end of residency, according to a new study.

To measure how well-being correlates with medical knowledge during residency, researchers used 2008 and 2009 IM-ITE scores and the 2008 IM-ITE survey. There were 16,394 residents surveyed, representing 74.1% of all eligible internal medicine residents, including U.S. and international medical graduates. Results appeared in the Sept. 7 Journal of the American Medical Association.

Overall quality of life was measured by self-assessment on a scale of 1 (“As bad as it can be”) to 5 (“As good as it can be”). Low quality of life was defined as the lowest two categories. Burnout was assessed using two measures adapted from a longer survey. Emotional exhaustion was assessed by the question, “How often do you feel burned out from your work?” and depersonalization by the question, “How often do you feel you've become more callous toward people since you started your residency?” Each question was answered on a 7-point Likert scale with response options ranging from “never” to “daily.”

About 15% of residents classified their quality of life as “as bad as it can be” or “somewhat bad” (99% CI, 14.1% to 15.6%). At least weekly symptoms of emotional exhaustion were reported by 7,394 residents (45.8% [99% CI, 44.8% to 46.8%]). Weekly symptoms of depersonalization were reported by 4,541 (28.9% [99% CI, 27.9% to 29.8%]). Overall, at least one symptom of burnout was present in 8,343 of 16,192 residents (51.5% [99% CI, 50.5% to 52.5%]). Greater educational debt was associated with the presence of at least one symptom of burnout (61.5% of those with debt more than $200,000 vs. 43.7% of those with no debt; odds ratio, 1.72 [99% CI, 1.49 to 1.99]; P<0.001).

Decreased quality of life and increased frequency of burnout symptoms were associated with lower IM-ITE scores, most notably in the 242 residents (1.5%) reporting quality of life that was “as bad as it can be” (mean score, 57.6 vs. 60.3 for residents reporting quality of life “as good as it can be” [difference, 2.7 points; 99% CI, 1.2 to 4.3; P<0.001]). IM-ITE scores also were lower for the 600 residents (3.7%) with daily feelings of emotional exhaustion (mean score, 57.8 vs. 62.0 for residents never feeling burned out from work [difference, 4.2 points; 99% CI, 2.5 to 5.9; P<0.001]).

Residents reporting debt greater than $200,000 had mean IM-ITE scores 5.0 points (99% CI, 4.4 to 5.6; P<0.001) lower than those with no debt. As a point of comparison, these differences were as large as the increases normally seen as residents progress from their first to second postgraduate year (4.1 points; 99% CI, 3.9 to 4.3) and their second to third postgraduate year (2.6 points; 99% CI, 2.4 to 2.8).

Burnout was less common among international medical graduates than among U.S. medical graduates (45.1% vs. 58.7%; odds ratio, 0.70 [99% CI, 0.63 to 0.77]; P<0.001). This effect persisted after adjusting for debt. Researchers suggested that international medical graduates in the U.S. may be more resilient because they've already successfully completed a complex and highly competitive selection process for U.S. residency positions. The study authors also noted that all members of the study cohort began training after duty hour limits went into effect in 2003, so burnout remains an issue despite these regulations.