Anaissie J, Popat S, Mayer WA et al: Innovative Approaches to Battling Resident Burnout in a Urology Residency Program. Urol Pract 2021; 8: 387.

In our manuscript titled “Innovative Approaches to Battling Resident Burnout in a Urology Residency Program,” we demonstrate that leadership-level interventions, informed by resident input, can significantly improve resident wellness.¹ Burnout is a major problem for all physicians in training, with especially high rates among Urology trainees, who report rates greater than 60%.^2,3 With the only data existing coming from interventions targeted at the level of the individual with mixed results, the literature is lacking in the utilization of more systems-based approaches to combat burnout. In this study, we examine how a change in program culture can significantly reduce resident burnout.

Our Resident Wellness Curriculum (RWC) is an initiative developed via faculty and resident collaboration. Program leadership organized a series of privileged and confidential discussions between a Graduate Medical Education (GME) representative and the residents. A report was generated from these meetings, which detailed items of concern and opportunities for improvement. Engagement with GME demonstrated genuine program buy-in to the residents and a substantive commitment to meaningful positive change to GME leadership. The RWC was then born out of a review of this report at our Annual Program Evaluation. As demonstrated in figure 1, it is 5-pronged and includes 1) a faculty-sponsored Resident Wellness Fund (RWF), annually replenished; 2) social groups comprised of 1 faculty and 2 to 3 trainees, with semi-annual events outside of work; 3) a structured longitudinal mentorship program, linking each resident to 1 faculty mentor; 4) resident-organized social outings using the RWF; and 5) wellness education. We introduced this curriculum to our residents in 2017 and utilized 2 validated burnout questionnaires, the Well-Being Index (WBI) and Maslach Burnout Index (MBI), to monitor resident burnout over a 2-year period. The MBI measures burnout across 3 main domains—depersonalization, emotional exhaustion, and personal accomplishment—while the WBI consists of 1 final score.

We analyzed 54 unique survey responses from 4 time points over 3 academic years, completed in a de-identified fashion to ensure confidentiality. We observed initial burnout levels in our program to be high. MBI responses improved in several domains after introduction of the RWC (fig. 1). Mean scores on depersonalization and emotional exhaustion domains improved from high to moderate levels, with a statistically significant decrease in the depersonalization domain by 28% (p = 0.04). Levels of personal accomplishment were preserved in the moderate range. In terms of the WBI score, there was a decrease in reported burnout by 52% (p = 0.006) over the time period. At study end, residents ranked resident-organized social outings as the intervention most meaningful to them.

Figure 1. Structure of Resident Wellness Curriculum.

Figure 2. Change in MBI scores over study duration.

This study demonstrated that the development of a RWC can lead to significant reduction in resident burnout. While our curriculum is unique, the concept that changes at the programmatic level can reduce resident burnout is not. While several program-level changes have been studied, it is only the durable programmatic changes that significantly reduce burnout. Studies looking at brief interventions, such as wellness courses, do not lead to lasting decreases in burnout.^4–6 On the other hand, a study from the psychiatry department at Harvard Medical School described the development and institution of a wellness curriculum, similar in concept to our own, that also led to meaningful reductions in burnout.⁷

It is difficult to determine exactly which component of systematic change “packs the biggest punch” in terms of improving resident wellness. Faculty-funded resident social outings and mentoring relationships have an important underlying principle in common: they promote a culture of resident wellness perhaps because the residents feel more confident that their program genuinely cares about their well-being. The learning environment may be impacted positively for residents when they work with attending physicians they have come to know outside of the operating room. Similarly, entrustability on the side of the faculty may be increased. Feedback may seem more valuable and valued when it comes from leadership with demonstrated investment in their improvement not only as a resident but as a person.

Our residency program integrates resident needs assessments with faculty buy-in and institutional support to effect changes, and we continue to revisit the conversation as the program evolves. In summary, the long-term solution to defeating resident burnout is not as simple as encouraging better sleep and exercise or hosting a guest lecture on wellness; it develops positively when department, program, and institution leaders embrace a culture of cultivating residents’ wellness, supported by consistent actions.