BURNOUT IN PEDIATRIC RESIDENTSINSIGHTS FROM THREE YEARS OF LONGITUDINAL

NATIONAL SURVEY DATA

John D. Mahan, MD, Kathi Kemper, MD, MPH, Paria M. Wilson, MD, MEd, Betty B. Staples, MD, Hilary McClafferty, MD, Chuck J. Schubert, MD, Alan

Schwartz, PhD, Janet R. Serwint, MD, Maneesh Batra, MD, For the Pediatric Resident Burnout – Resilience Study Consortium

All authors have documented that we have no financial relationships to disclose or Conflicts of Interest (COIs) to resolve

Background:Burnout in Pediatric Residents

Significant problem for professionals (poor health) and patients (poor care)

Prevalence: 40-74%• Studies limited by small sample sizes;

limited assessment of demographic characteristics and risk factors

• National prevalence? Trends? Impact of stress? Phase versus Behavioral state?

• Value of understanding individual, program and system factors to target future interventions

McClafferty Pediatrics 2014; Pantaleoni, Acad Pediatr 2014; Dyrbye, Acad Med 2014, Baer Pediatrics 2017

Study Questions:1. What is the prevalence of burnout

among pediatric residents from 2016-2018?

2. What demographic, personal, program, experience risk/protective factors are associated with burnout cross-sectionally?

3. What factors are longitudinally associated with burnout, stress, and confidence providing compassionate care?

Established in 2015 by authors (Steering Committee)

Goals: 1. To improve pediatric resident resilience,

compassion, confidence in providing calm, compassionate care and wellness

2. Describe the epidemiology of burnout3. Test interventions that positively impact

burnout, resilience, empathy, compassion, and wellness

Pediatric Resident Burnout-Resilience Study Consortium (PRB-RSC)

Participating Institutions & Residents

Year Number Institutions

% Eligible ResidentsParticipating

2016 34 61% of 2723

2017 43 66% of 3273

2018 49 61% of 3657

Albert Einstein College of MedicineAll Children’s Hospital Johns Hopkins MedicineAnn & Robert Lurie Children’s Hospital ChicagoBaylor College of Medicine/Texas Children’sBoston Children’s HospitalBrown University/Hasbro Children’sCarolinas Medical CenterCase Western/Rainbow Babies and Children'sChildren’s Hospital of PhiladelphiaCincinnati Children’s Hospital Medical CenterCrozer-Chester Medical CenterDartmouth-Hitchcock Medical CenterDuke UniversityIndiana UniversityInova Fairfax Medical CampusJefferson Hospital for ChildrenJohns Hopkins ULouisiana State U Maine Medical CenterMayo Clinic College of MedicineMedical College of WisconsinMount Sinai ElmhurstNew York PresbyterianOhio State U/Nationwide Children'sRush U Med Ctr

Tufts Medical CenterU of Alabama U of ArizonaU of California DavisU of Chicago/ Corner U of Colorado/Denver Children's

Participating Institutions

UCLA/ MattelUC San Diego/RadyUCSF U Florida/ShandsU of Illinois- ChicagoU of KansasU of LouisvilleU of MichiganU of MinnesotaU of New Mexico UNC HospitalsU of Oklahoma- OCU of Oklahoma- TulsaU of Pittsburgh U of South Alabama U of Washington/Seattle Children's

Virginia Tech/CarilionWestern MichiganWright State UYale New Haven MedUniversity of Texas/AustinUTMB-Galveston

2016 and 2017 and 2018

Methods

• Anonymous, online survey of all PRB-RSC residents via APPD LEARN from April-June of 2016, 2017, 2018• No exclusion criteria

• IRB approval at each individual institution

• Program directors employed their own recruitment strategies

• Survey tool: 141 items; 12-15 minutes to complete; same questions each year

Methods: Survey Tools

• Burnout (MBI); Stress (Cohen’s PSS); CCC (Confidence in providing Calm, Compassionate Care)

• Demographic (age, gender, marital, debt)• Residency (categorical/combined, PGY, size)• Personal (health, mindfulness, resilience, self-

compassion, empathy: standard measures)• Experience (current rotation, special track, recent error

and/or death, time off for vacation or weekend, work/life conflict)

• Satisfaction and attitudes (support of family, friends, faculty; career choice; collaborative environment; education and mentoring as program priorities)

Analyses

• ANOVA, t-tests for descriptive statistics• To account for clustering in programs: mixed-effects

linear and logistic regression models for factors associated with burnout cross-sectionally

• Longitudinal analysis: logistic for burnout (dichotomous variable) and linear for stress and CCC

• Two-tailed, significance P<0.05

Results:1. Burnout Rates

Year Burnout N (%)2016 925 (56%)

2017 1164 (54%)

2018 1205 (54%)

Stable over 3 years> 50%

2. Risk Factors: Demographics

CharacteristicsFemale 72%Caucasian 72%Mean Age (SD) 29.3 (3.0) Married/partnered 60%Children 16%Total educational debt > US $100,000 62%

No differences between residents who were vs. were not burned out

3. Risk Factors: Residency Characteristics and Burnout

No consistent differences over 3 years in any residency characteristic

(type, year, program size, race/ethnicity )

Type: Categorical (82%) vs. Combined (18%); NSD in any yearPGY: PGY1 higher in 2016 but no other year; PGY2 higher in

2017 but no other year; no differences in 2018

4. Resident Personal Attributes and Burnout:

2018Resident Personal Attributes

No Burnout (n=1036)

Burnout (n=1205) p-value

Sleepiness (ESS) (lower is better) 8.2 10.5 <0.001Mental Health (PROMIS) (higher is better) 47.1 43.7 <0.001Mindfulness (CAMS-R) (higher is better) 30.3 26.4 <0.001Self-Compassion (Neff’s) (higher is better) 3.4 2.9 <0.001Resilience (BRS) (higher is better) 3.8 3.4 <0.001Empathy (Empathic Concern) (higher is better) 23.4 21.8 <0.001Empathy (Perspective Taking) (higher is better) 19.8 18.7 <0.001QOL (higher is better) 7.8 6.5 <0.001Stress (Cohen’s Scale) (lower is better) 13.2 19.1 <0.001Calm, Compassionate Care (higher is better) 68 59 <0.001

Consistent across all 3 years

5. Resident Experiences and Burnout

2018Resident experiences

No Burnout (n=1036)

Burnout (n=1205) p-value

Current rotation 0.004High acuity: NICU/ICU/ER/Inpatient 43% 50%Low acuity: Elective/Ambulatory/Nursery/Research/Other 57% 50%

Last vacation (months ago) 0.03Longer since last vacation in burned out residents

Last full weekend off (weeks ago) 0.0014+ 17% 24%

Work/life conflict in past month 68% 88% <0.001Major Medical Error in last 3 months 10% 20% <0.001

No significant difference with recent patient death or participating in special pathway;

all consistent over 3 years

6. Satisfaction and BurnoutBurned out residents in all 3 years were Less Likely to be

satisfied with (P <0.001): - Career Choice to go into pediatrics- Balance between personal/professional life- Support from family, spouse, friends, faculty, colleagues- Residency Learning Environment

Burned out residents (all 3 yrs) Less likely to agree (P<0.001)“I work in a collaborative rather than competitive environment.”“Resident education is a high priority in my program.”“Resident mentoring is a high priority in my program.”

7. Cross-Sectional Logistic Regression for Burnout, Consistent Across 3 Years

Risk Factors Protective FactorsStress Empathic ConcernSleepiness Self-CompassionDissatisfied with work/ personal life balance

Quality of Life

Major error in past 3 months

Confidence providing Calm, Compassionate Care

8. Longitudinal Analysis for 2018 Predictors for Key Outcomes Independent Variables Associated with Lower Risk of Burnout

2018 BurnoutOdds Ratio (95% CI)

P value

2017 Burnout, 2017 Stress, 2017 CCC, respectively

6.4 (4.0, 10.3) <0.001*

2018 Major Error in past 3 months 2.2 (1.3, 3.5) 0.002*2018 Sleepiness 1.7 (1.4, 2.1) <0.001*2018 Last weekend off 4 or more weekends ago compared with last weekend

1.6 (1.03, 2.5) 0.04*

CI = Confidence Interval

8. Longitudinal Analysis for 2018 Predictors for Key Outcomes

2017 Variables Associated with Lower Risk of Burnout

2018 BurnoutOdds Ratio (95% CI)

P value

2017 Overall quality of life 0.8 (0.6, 0.998) 0.04*

2017 Empathic Concern

0.8 (0.7, 1.0) 0.05*

2017 Self-Compassion 0.9 (0.73, 1.12) 0.42017 Mindfulness 1.0 (0.84, 1.3) 0.72017 Satisfaction with Learning Environment

0.98 (0.8, 1.2) 0.8

CI = Confidence Interval; SE = Standard Error

Limitations

• Program participation in PRB-RSC voluntary

• Dependent on self-reporting• Cross-sectional study design• No data on institutional or cultural

factors, e.g. Electronic Health Record, discrimination, harassment, bullying, availability or integration of social work, psychology, scribes

Conclusions

1. Overall rates of burnout consistently > 50%

2. Strong connection between stress and burnout

3. Attractive targets for intervention include• Personal: sleepiness, empathy, self-compassion, mindfulness

• Residency: major errors, high acuity rotations, timing of time off

3. Future studies - address burnout protective factors• Residency: healthy schedules, training in medical errors responses,

debriefings

• Cultural: civility, discrimination, bullying, harassment

• Institutional/System: electronic health record, scribes, availability/integration of psychologists, social workers

http://pedsresresilience.com

Other PRB-RSC Recent PublicationsNational Landscape of Interventions to Improve Pediatric Resident Wellness

and Reduce Burnout. Wilson PM, Kemper KJ, Schubert CJ, Batra M, Staples BB, Serwint JR, McClafferty H, Mahan JD; Pediatric Resident Burnout and Resilience Study Consortium (PRBRSC). Acad Pediatr. 2017 Nov - Dec;17(8):801-804

Variability of Burnout and Stress Measures in Pediatric Residents: An Exploratory Single-Center Study From the Pediatric Resident Burnout-Resilience Study Consortium. Reed S, Kemper KJ, Schwartz A, Batra M, Staples BB, Serwint JR, McClafferty H, Schubert CJ, Wilson PM, Rakowsky A, Chase M, Mahan JD.J Evid Based Integr Med. 2018 Jan-Dec

Burnout in Pediatric Residents: Comparing Brief Screening Questions to the Maslach Burnout Inventory .Kemper KJ, Wilson PM, Schwartz A, Mahan JD, Batra M, Staples BB, McClafferty H, Schubert CJ, Serwint JR. Acad Pediatr. 2018 Nov 3

Do Mindfulness and Self-Compassion Predict Burnout in Pediatric Residents?Kemper KJ, McClafferty H, Wilson PM, Serwint JR, Batra M, Mahan JD, Schubert CJ, Staples BB, Schwartz A; Pediatric Resident Burnout-Resilience Study Consortium. Acad Med. 2018 Dec 4

Albert Einstein College of MedicineAll Children’s Hospital Johns Hopkins MedicineAnn & Robert Lurie Children’s Hospital ChicagoBaylor College of Medicine/Texas Children’sBoston Children’s HospitalBrown University/Hasbro Children’sCarolinas Medical CenterCase Western/Rainbow Babies and Children'sChildren’s Hospital of PhiladelphiaCincinnati Children’s Hospital Medical CenterCrozer-Chester Medical CenterDartmouth-Hitchcock Medical CenterDuke UniversityIndiana UniversityInova Fairfax Medical CampusJefferson Hospital for ChildrenJohns Hopkins ULouisiana State U Maine Medical CenterMayo Clinic College of MedicineMedical College of WisconsinMount Sinai ElmhurstNew York PresbyterianOhio State U/Nationwide Children'sRush U Med Ctr

Tufts Medical CenterU of Alabama U of ArizonaU of California DavisU of Chicago/ Corner U of Colorado/Denver Children's

Participating Institutions

UCLA/ MattelUC San Diego/RadyUCSF U Florida/ShandsU of Illinois- ChicagoU of KansasU of LouisvilleU of MichiganU of MinnesotaU of New Mexico UNC HospitalsU of Oklahoma- OCU of Oklahoma- TulsaU of Pittsburgh U of South Alabama U of Washington/Seattle Children's

Virginia Tech/CarilionWestern MichiganWright State UYale New Haven MedUniversity of Texas/AustinUTMB-Galveston

2016 and 2017 and 2018