Burnout in dermatology residents: a Canadian perspective

Dear Editor, Burnout is a syndrome comprised of emotional exhaustion (EE), depersonalization (DP) and reduced personal accomplishment (PA). It is associated with poor outcomes involving job performance and health.1 Previous studies have reported burnout rates ranging from 18% to 84% during postgraduate medical education (i.e. residency); however, none has focused on dermatology residents (i.e. registrars and trainees).2 Herein, we report the prevalence, predictors and consequences of burnout in Canadian dermatology residents. Ethics approval was obtained from the Conjoint Health Research Ethics Board. A cross‐sectional study was conducted using an anonymous online survey distributed to all Canadian dermatology residents (n = 162). The data collection period was from May to August 2014. Informed consent was obtained online. Weekly activities, stress, protective factors and consequences of burnout were evaluated using a Likert scale. Validated tools were employed to measure burnout [Maslach Burnout Inventory (MBI)]; depression (World Health Organization Well‐Being Index); anxiety (Generalized Anxiety Disorder scale); alcohol abuse (Alcohol Use Disorders Identification Test – Consumption); fatigue and quality of life.3,4,5,6 Standard statistical analyses were utilized to characterize the association between burnout and various levels of training. Using a t‐test or anova, burnout ratings were compared between multiple groups. To limit the number of tests, the anova was performed only for the EE scale of the MBI as it possessed the best reliability coefficient (0·90).3P‐values were calculated using two tails. Significance levels were adjusted with the Benjamini–Hochberg procedure. There were 116 respondents to the survey (72%). Individuals who did not complete the entire MBI (n = 20) were excluded. Therefore a total of 96 residents were analysed yielding a 59% response rate. Responses were received from each of the dermatology programmes across the country and from all stages of training. The top stressor for residents was examinations (including the board certifying examination) (61%), followed by work (27%). Other major stressors included family and relationships, finances, pressure from staff, research obligations and moving. Assessment of weekly activities revealed that all residents dedicated a significant amount of time to studying and working (92–100%). A smaller proportion allocated time for family and friends (70%) or exercise (56%). Moreover, 72% slept < 7 h per night. The MBI survey demonstrated that > 50% of dermatology residents experienced high levels of EE and DP, while 40% had low levels of PA (Table 1). The mean burnout scores were 27·3 (EE), 10·8 (DP) and 35·6 (PA). Approximately 75% of residents agreed or strongly agreed that they had good social supports. However, 58% reported having a good relationship with a staff mentor and only 42% reported receiving constructive monthly feedback. Validated assessments of burnout, anxiety, depression, alcohol abuse, quality of life and fatigue CI, confidence interval. Validated tools were employed to measure burnout [Maslach Burnout Inventory (MBI)], depression [World Health Organization Well‐Being Index (WHO‐5)], anxiety [General Anxiety Disorder scale (GAD‐2)] and alcohol abuse [Alcohol Use Disorders Identification Test (AUDIT)].3,4,5,6aAUDIT possesses high sensitivity, but poor specificity, thus the reported rates are likely overestimated. bAs indicated by respondents on an analogue scale from 0 (‘as bad as it can be’) to 10 (‘as good as it can be’). Validated assessments of burnout, anxiety, depression, alcohol abuse, quality of life and fatigue CI, confidence interval. Validated tools were employed to measure burnout [Maslach Burnout Inventory (MBI)], depression [World Health Organization Well‐Being Index (WHO‐5)], anxiety [General Anxiety Disorder scale (GAD‐2)] and alcohol abuse [Alcohol Use Disorders Identification Test (AUDIT)].3,4,5,6aAUDIT possesses high sensitivity, but poor specificity, thus the reported rates are likely overestimated. bAs indicated by respondents on an analogue scale from 0 (‘as bad as it can be’) to 10 (‘as good as it can be’). The assessments of quality of life, fatigue, anxiety, depression and alcohol abuse are presented in Table 1. The average assessment of residents’ quality of life and energy levels was moderate. Of note, 52% of residents were found to have low or depressed mood and 20% reported having feelings of hurting themselves within the past year. More than 25% of residents had high anxiety levels. Additionally, 45% of residents engaged in heavy or hazardous drinking and 6% had smoked a cigarette in the past month. Correlates of burnout identified in dermatology residents were staff mentoring, constructive feedback, good social support, family and friends, anxiety, depression, energy levels, quality of life (all P < 0·001) and exercising (P = 0·010). Our data reveal that dermatology residents commonly experience burnout, with high rates of EE seen in 54% of residents. As demonstrated in a single‐centre Canadian study, these findings are comparable with resident burnout rates across other specialties.7 When compared with the mean standard scores obtained from the MBI medicine subgroup, dermatology residents demonstrate a trend to higher EE and DP scores, and lower PA scores.3 Our findings also associate burnout with depression, anxiety, fatigue and low quality of life. Negative correlates include increased perception of social supports, spending quality time with family, a supportive clinical faculty, and receiving constructive monthly performance feedback. No specific demographic variables were predictive of burnout. The lack of association with training level may be due to the presence of two peaks of burnout: when entering residency and when studying for the final examination. Additionally, suicidal ideation was assessed with a single nonvalidated question and may have yielded inaccurate findings. Examinations are the top stressor for 61% of dermatology residents. While our research focused on Canadian dermatology residents, most dermatology training programmes hold similar certifying examinations. It is therefore not surprising that many subspecialty examination boards are moving towards a competency‐based model, shifting the focus from examination marks to attainment of milestones. A longitudinal study demonstrated that once interns experience burnout, the majority remained ‘burnt out’ for the duration of their residency.8 Moreover, residents with burnout reported suboptimal patient care practices, with more perceived medical errors and the need to distance themselves from their patients. Dermatology training programmes are academically rigorous: the recognition and prevention of burnout in dermatology trainees should not be overlooked. Programme directors need to address the modifiable determinants of burnout and develop targeted interventions to support residents throughout their training. The authors would like to thank Keltie McDonald (University of Calgary, Department of Community Health Sciences) for her help with the statistical analysis. Funding sources: Canadian Dermatology Foundation. Conflicts of interest: none declared.

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