The LaryngoscopeVC 2009 The American Laryngological,Rhinological and Otological Society, Inc.

Monitoring Stress Levels in PostgraduateMedical Training

Justin D. Hill, MD; Richard J. H. Smith, MD

Objectives: The Accreditation Council for Grad-uate Medical Education (ACGME) mandates that res-idency Program Directors (PD) monitor resident well-being, including stress. Burnout, as a measure ofwork-related stress, is defined by a high degree ofemotional exhaustion and depersonalization, and alow degree of personal accomplishment using theMaslach Burnout Inventory-Human Services Survey(MBI-HSS). The purpose of this study is to describethe use of the MBI-HSS as a method of monitoringstress levels in an academic otolaryngology residencytraining program and introduce this survey as a toolfor wider use in meeting ACGME requirements.

Methods: The MBI-HSS was administered toresidents in an academic otolaryngology residencytraining program on three separate occasions: at thebeginning, middle, and end of different academicyears. In addition, at the time of the third administra-tion, the MBI-HSS was completed by faculty and staffin the same department. Surveys were completed andcollected anonymously. Responses were scored againstnormative data from the MBI-HSS overall sample andthe medicine subscale. Low, average, and high levelsof burnout were identified for the individual catego-ries of emotional exhaustion (EE), depersonalization(DP), and personal accomplishment (PA); average lev-els for each category were calculated.

Results: Twenty-two residents completed thefirst survey, taken near the end of an academic year;19 completed the second administration in the middleof the following academic year; and 24 completed thethird survey at the beginning of the subsequent aca-demic year. Thirteen faculty and 23 staff also com-pleted the third survey. We found that three, one, andone residents reported high levels of burnout on thefirst, second, and third surveys, respectively. Thesefigures compare to one faculty member and no staffmembers in the same department reporting high lev-els of burnout.

Conclusions: The MBI-HSS is an establishedand validated tool for identifying burnout in residentphysicians. Residency PDs may find the MBI-HSSuseful as an aid in monitoring resident well-beingand stress. In our own department, we found levels ofburnout comparable to those previously reported forresidents and faculty in this specialty.

Key Words: Stress, burnout, academic,residency, otolaryngology, faculty.

Laryngoscope, 119:75–78, 2009

INTRODUCTIONIn accordance with the common program require-

ments applicable to all specialty and subspecialtyresidency training programs accredited by the Accredita-tion Council for Graduate Medical Education (ACGME),residency programs are required to monitor residentwell-being. While requirements established by the Resi-dency Review Committee (RRC) outline certain aspectsof well-being, such as resident stress levels, mental oremotional conditions inhibiting performance/learning,and drug- or alcohol-related dysfunction, no specificinstruments or methods are mandated or even suggestedfor use in assessing and monitoring the same. ProgramDirectors (PDs) are thus left to decide how to best moni-tor stress among residents in their program. An idealsystem for monitoring stress in this setting wouldinclude a way to objectively quantify, document, andtrack stress levels among residents over time. Burnout,as it relates to occupational stress, is easily evaluatedusing the Maslach Burnout Inventory-Human ServicesSurvey (MBI-HSS), allowing for a method of quantifyingand monitoring resident stress levels as reported by resi-dents themselves. The purpose of this study is todescribe the use of the MBI-HSS as a method of moni-toring stress levels in an academic otolaryngologyresidency training program and introduce this survey asa tool for wider use in meeting ACGME requirements.

The deleterious effects of work-related stress forphysicians and patients have been discussed in the med-ical literature for years, recently with an increasedemphasis on physicians-in-training.1–10 The psychologi-cal construct of burnout, while relatively new, hasreceived much attention in publications regarding occu-pational stress for health-care workers over the last

From the Department of Otolaryngology–Head and Neck Surgery,University of Iowa Carver College of Medicine, Iowa City, Iowa, U.S.A.

Editor’s Note: This Manuscript was accepted for publication July14, 2008

Send correspondence to Richard J. H. Smith, MD, Department ofOtolaryngology–Head and Neck Surgery, University of Iowa Carver Col-lege of Medicine, 200 Hawkins Drive, 21151-A, Iowa City, IA 52242-1078E-mail: richard-smith@uiowa.edu

DOI: 10.1002/lary.20013

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20 years and has become one of the most commonly ana-lyzed manifestations of stress in physicians.1–7,11–13

Accordingly, the MBI-HSS has become an acceptedmethod of identifying the effect of work-related stress, orburnout, in physicians.7

Burnout, as defined by the MBI-HSS, is a syndromecharacterized by a high degree of emotional exhaustion(EE) and depersonalization (DP) and a low degree of per-sonal accomplishment (PA).11 The MBI-HSS measureseach of these three aspects of burnout on a subscalerelated to the frequency of their occurrence. The EE sub-scale assesses feelings that result from beingemotionally overextended and exhausted by one’s work;the DP subscale measures an unfeeling and impersonalresponse toward recipients of one’s service, care, treat-ment, or instruction; and the PA subscale assessesfeelings of competence and success in one’s work withpeople. Numeric scores are generated; however, there isno particular cutoff point at which a subject is consid-ered ‘‘burned out.’’ Rather, scores are compared withnormative data and grouped into low, average, and highdegrees of EE, DP, and PA, reflecting a continuum ofpotential responses to work-related stress. Although thesyndrome of burnout is easily identified with the MBI-HSS, the utility of the survey is often found in its abilityto accurately assess a subject’s position on a spectrum ofresponses to stress that range from low to high degreesof burnout, in contrast to a dichotomous categorizationof ‘‘stressed out’’ vs. ‘‘not stressed out.’’12

While a review of the literature demonstrates sev-eral publications incorporating the use of the MBI-HSSin studies of resident well-being and stress,1–6 we havenot found a description of its use as a simple tool toassist residency PDs in tracking stress levels among res-idents in their program.

MATERIALS AND METHODSInstitutional Review Board approval was obtained for

administration of the MBI-HSS to residents in the Departmentof Otolaryngology–Head and Neck Surgery at the University ofIowa prior to the study period. Surveys were delivered torespondents by hand and by e-mail on the first administrationand by e-mail on subsequent administrations. Completed sur-veys were returned by e-mail or by hand and savedanonymously by secretarial staff otherwise uninvolved with thestudy. No specific, identifying information was reported on thesurvey at any point other than the voluntary inclusion of resi-dent year. Faculty voluntarily included their rank as assistant,associate, or full professor. Staff designated their duration oftime within the department as greater than or less than 5years.

The MBI-HSS evaluates the three subjective componentsof burnout, namely, PA, EE, and DP, through a brief, 22-item in-ventory. Twenty-two statements of subjective attitudes andfeelings toward work, such as ‘‘I feel frustrated by my job’’ arelisted in no particular order, and respondents are asked toassign a frequency to these feelings on a scale ranging fromnever to once a day. In short, respondents link each statementto a score on a Likert scale of 0 to 6 (0, never; 1, a few times ayear or less; 2, once a month or less; 3, a few times a month; 4,once a week; 5, a few times a week; 6, every day), relating thestatement or feeling to the frequency of its perception. In scor-ing the survey, responses are grouped according to category

(EE, DP, and PA) based on a key and added together to gener-ate a score for each category.

Surveys were administered to residents on three separateoccasions, near the end of 2005–06 academic year, in the middleof the 2006–07 academic year, and early in the 2007–08 aca-demic year. Surveys were also administered to faculty and staffwithin the department concurrent with the third resident sur-vey to assess levels of burnout department-wide.

RESULTSTwenty-two residents completed the first survey, 19

completed the second, and 24 completed the third withresponse rates of 76%, 66%, and 83%, respectively. Thefinal survey was also completed by 13 of 13 faculty and23 staff within the Department of Otolaryngology–Headand Neck Surgery. Surveys were scored for residentsand faculty using the MBI-HSS medicine subscale todetermine low, moderate, and high levels of burnout forthe three categories of EE, DP, and PA based on a nor-mative distribution of 1,104 physicians and nursessampled in the development of the MBI-HSS.11 Staffresponses were scored using normative data from theMBI-HSS overall sample set. These two sources of nor-mative data are routinely used as reference points inother studies of burnout.1–6,13 The following cutoff pointswere used in each case: medicine subscale (overall sam-ple), low EE � 18 (16), high EE � 27 (27), low DP � 5(6), high DP � 10 (13), low PA � 40 (39), high PA � 33(31). Average scores for all respondents are listed inTable I. Table II shows the numbers and percentages ofindividuals meeting criteria for high levels of burnout.

Results are listed for the number of respondentsmeeting criteria for the true syndrome of burnout char-acterized by high levels of EE and DP combined withlow levels of PA, as well as those with high EE and DPalone, independent of PA. These numbers are includedas reference points because some authors have catego-rized individuals with high EE and DP alone,irrespective of PA results, as demonstrating high levelsof burnout,8 based on data from the development of theMBI-HSS showing a high correlation between levels ofEE and DP regardless of PA.11

Of the three residents reporting high levels of burn-out on the first survey, two were postgraduate year

TABLE I.

MBI-HSS Subscale Scores for Residents, Faculty, and StaffMembers in the Department of Otolaryngology–Head and Neck

Surgery at the University of Iowa.

Group

Average MBI-HSS Subscale Score (SD)

EE DP PA

Residents

1st Survey 25.13 (7.43) 11.45 (7.12) 38.22 (5.83)

2nd Survey 20.58 (8.98) 10.00 (6.39) 39.74 (6.72)

3rd Survey 20.83 (8.43) 8.38 (4.76) 41.21 (3.44)

Faculty 23.54 (12.45) 9.08 (7.01) 39.00 (7.09)

Staff 18.83 (11.85) 4.74 (4.22) 39.30 (6.23)

MBI-HSS ¼ Maslach Burnout Inventory-Human Services Survey;SD ¼ standard deviation; EE ¼ emotional exhaustion; DP ¼ depersonaliza-tion; PA ¼ personal accomplishment.

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(PGY) 5 residents, while no resident-year data was sup-plied by the third individual. Resident-year informationwas also not supplied by the individual reporting highlevels of burnout on the second survey. High levels ofburnout on the third survey were reported by a PGY 4resident. One assistant professor and no staff memberswere found to demonstrate high levels of burnout. TableIII shows the distribution of subscale scores for each cat-egory among the three groups surveyed.

DISCUSSIONTwo other studies have addressed physician burn-

out within the field of otolaryngology. Johns and Ossoff13

investigated the prevalence of burnout in academicchairs of otolaryngology and attempted to identify fac-tors associated with its development. MBI-HSS scoresdemonstrated high levels of burnout in 3% of partici-pants. Within our department, we found that the rate ofhigh levels of burnout among faculty was similarly low(7.69%, one faculty member).

Golub et al.5 recently published MBI-HSS datafrom surveys sent to all residents in otolaryngologythroughout the United States. With 514 participants,they found a high level of burnout in 10% of residentsnationwide, which is comparable to the 7.69% residentburnout figure we observed over the course of the threesurveys we administered.

Our results indicate that within our department,not all groups involved in delivering care to the samegroup of patients experienced the same degree of burn-out. Physicians in the department demonstrated asignificantly higher degree of burnout than staff, likelyrelated to the differential in overall workload, hoursworked, and responsibilities for patient care. We alsofound that burnout levels changed over time, with thegreatest number of residents experiencing high levels ofburnout near the end of the academic year. Two of thethree residents reporting high levels of burnout at thistime were identified as PGY 5 residents, perhaps indica-tive of the stress of residency combined with thesimultaneous stress of moving on to the next stage ofone’s career. Of note, Golub and colleagues did not find a

significant difference in burnout levels between resi-dents at different levels of training.5

Many changes in residency training have occurredover the last several years. Residency programs and PDsface a formidable list of requirements to maintain ac-creditation. One such requirement mandates thatprograms monitor resident well-being and stress. Webelieve that the MBI-HSS is an effective tool for fulfill-ing this requirement. Use of the survey for this purpose,however, raises an important issue: The MBI-HSS iden-tifies burnout in a simple, validated, reproducibleformat, making it relatively easy to administer andtrack results over time, yet no risk factors for burnoutare identified, no prognosis is offered based on score pro-file, and no suggestions for possible intervention areprovided. The question then remains—what should resi-dency programs do with this information? A brief reviewof the literature and our experience with the survey pro-vides some answers.

Although the concept of burnout has been investi-gated extensively since its conception in the 1970s, datarelated to resident physicians are relatively scarce.Thomas7 conducted a review of 15 articles on residentburnout and found that while studies suggest that highlevels of burnout are common among residents, currentdata are insufficient to identify causal relationshipssuch as demographic or personality characteristics.

TABLE II.Number and Percentage of Individuals Demonstrating High Levels

of Burnout on Each Administration of the MBI-HSS in theDepartment of Otolaryngology–Head and Neck Surgery at the

University of Iowa.

Group

Subscale Groupings

High EE/DP, Low PA High EE/DP

Residents

1st Survey 3 (13.64%) 7 (31.82%)

2nd Survey 1 (5.26%) 4 (21.05%)

3rd Survey 1 (4.17%) 3 (12.50%)

Faculty 1 (7.69%) 3 (23.08%)

Staff 0 (0%) 0 (0%)

MBI-HSS ¼ Maslach Burnout Inventory-Human Services Survey;EE ¼ emotional exhaustion; DP ¼ depersonalization; PA ¼ personalaccomplishment.

TABLE III.

Distribution of MBI-HSS Subscale Scores for Residents, Faculty,and Staff Members in the Department of Otolaryngology–Head

and Neck Surgery at the University of Iowa.

Group

Subscale Categories

EE DP PA

Residents

1st Survey

High 7 14 4

Moderate 12 1 6

Low 3 7 12

2nd Survey

High 8 10 3

Moderate 5 4 6

Low 6 5 10

3rd Survey

High 4 11 1

Moderate 10 7 4

Low 10 6 19

Faculty

High 4 5 1

Moderate 4 3 5

Low 5 5 7

Staff

High 7 1 3

Moderate 7 7 5

Low 9 15 15

MBI-HSS ¼ Maslach Burnout Inventory-Human Services Survey;EE ¼ emotional exhaustion; DP ¼ depersonalization; PA ¼ personalaccomplishment.

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Furthermore, no clear, proven strategies for preventingor treating burnout have been described.

Internal medicine residents in one study evaluatedprogram resources for stress management and identifiedas important having at least four days off per month, an-cillary help, and a night float system. Residents withhigh levels of burnout were less likely to rate presentationson stress, career counseling, and constructive feedback im-portant in stress management.6 Targeted intervention inthe form of stress-management workshops for residentshas been reported in two other studies with conflicting out-comes.14 Likewise, studies of the effects of work-hourrestriction alone have yielded varying data regarding asso-ciated MBI-HSS scores,3,5 although the largest of thesestudies with a sample size of 514 residents did show a sig-nificant positive correlation between hours worked andhigh levels of EE.5 In a recent study, residents definedwell-being as a balance among multiple domains such asprofessional development, relationships, physical andmental health, among others. Participants ranked profes-sional satisfaction and accomplishment ahead of otherdomains in importance, and reported higher levels of well-being when sacrifices in personal domains were viewed astemporary and the rewards of professional satisfactionwere evident in their daily work.10

In our own department, we have made an activeeffort to improve communication between the residencyPD and the residents by way of regular meetings whereresident-directed initiatives related to topics such asincreasing clinic efficiency, improving the operative expe-rience, and decreasing the service-to-education ratio ofmany resident activities are at the center of the agenda.This ‘‘bottom-up’’ approach of addressing problems thatprimarily involve or significantly affect residents hasbeen well received, and we have seen MBI-HSS scoresimprove as increased emphasis has been placed on thisstrategy for changes in the department. We also have amentoring system whereby every resident is assigned afaculty mentor to provide guidance and support in pro-fessional development. We believe these measures serveto increase a sense of control over the work environmentand promote professional accomplishment.

An obvious limitation to the use of the MBI-HSS fortracking resident stress as described in this study designis the anonymity of responses. Truthful responses, how-ever, are predicated upon the concept of anonymity, whichhelps to eliminate potential bias in the survey. Further-more, intervention on an individual level alone fails toaddress systems-based problems contributing to stress.

It is important to note that other methods andinstruments have been described for evaluating andmonitoring well-being and stress in residents;8,10,14 how-ever, data obtained in the development of the MBI-HSSsuggest that high levels of burnout are strongly corre-lated with various indices of personal dysfunction andcan lead to a deterioration in quality of care.11,15 Thestudy by Shanafelt et al.6 also demonstrated suboptimalpatient care practices associated with high levels ofburnout in internal medicine residents. In short, one ofthe strengths of the MBI-HSS is that it not only quanti-fies stress but also provides valuable information about

the health and well-being of the respondent with associ-ated implications for patient care. Therefore, while theoverall number of ‘‘burned out’’ individuals was rela-tively low in our study and other studies with similarpopulations, the implications for patient care remainhigh. In addition, otolaryngology residency PDs have theadded benefit of a reference population for acquired databased on Golub et al.’s study.5

CONCLUSIONSThe MBI-HSS is a validated tool for measuring

work-related stress in the form of burnout and is a usefulinstrument for monitoring stress levels in residents. Resi-dency PDs may find its use helpful in fulfilling theACGME requirement to monitor resident well-being andstress. Use of the MBI-HSS for this purpose has not beendescribed before. In our own department, we found levelsof burnout comparable to those previously published forother residents and faculty within our specialty.

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