With the increasing trend of burnout among physicians-in-training reaching close to 60%,(1,2) the Accreditation Council for Graduate Medical Education (ACGME) developed recommendations in 2019 requiring training programs to secure the well-being of residents and fellows.(3) These recommendations reiterated the responsibility of the institution to provide “a positive culture in a clinical learning environment that models constructive behaviors, and prepares residents with the skills and attitudes needed to thrive throughout their careers.”(3,p.41) Also, the recommendations underscored the importance of a physicians’ ability to recognize signs of burnout and know how to seek help.(3)
Burnout, an occupation-related phenomenon of experiencing emotional exhaustion, cynicism, and lack of personal achievements, has many contributing factors.(4,5) In the medical profession, these factors include long work hours; excessive workload, bureaucracy, and charting; and lack of respect from colleagues and administrators.(6)
Related to these factors are the characteristics and demands of the physician’s specialty. The process of choosing a specialty, which starts as soon as medical students begin exploring topics and rotations, may affect the risk of burnout, particularly if the specialty area is in alignment with the student’s personality.
Data from the Association of American Medical Colleges (AAMC) on medical specialty selection (2020) revealed that only one-quarter (26%) of medical students maintained the same specialty between matriculation and graduation, and 10–15% changed specialty during residency.(7-10) More than 55% of residents were contemplating a change in specialty or even their career.(11) Those who said they regretted their specialty reported the highest rates of burnout.(12)
Schafer and Shore described choosing a specialty as “assessing one’s fit with perceived attributes of potential specialties, which might include personality, income, lifestyle, intellectual challenge, technological orientation, clinical skills, and potential for research or leadership.”(13, p.27-82)
The mechanism of choice-making relies greatly on using one’s emotional intelligence (EQ).(14,15) Individuals with high EQ skills have been found to be attuned to avoiding risks and engaging in activities that are aligned with personality and profitability.(14,15) The impact of EQ on making a choice is substantial. Medical students and graduates who possess EQ skills may be better able to choose their specialty wisely and with confidence that their abilities are a good match for the specialty. Medical students and graduates often choose their specialty based on recommendations given by mentors, elective rotations, or freely available tools such as the Myers-Briggs personality test.(16)
To date, no studies have examined the impact of medical students’ or graduate students’ EQ skills on burnout based on their decision to change specialty. Thus, the objective of this study is to compare the impact of EQ skills on burnout levels among residents and fellows who did and did not change their specialty. We hypothesize that residents who did not change their specialty practice will report higher levels of EQ skills and experience less burnout compared to residents who did change their specialty preference.
Methods
Setting and participants. A cross-sectional survey was administered from May 17, 2021, through June 30, 2021, at one academic medical center in central Pennsylvania. Recruitment of participants was conducted via a list of email addresses provided by the directors of graduate medical education.
Using a secure online web application REDCap,(17) 628 residents and fellows from 22 residency and 53 fellowship programs were invited to participate. Informed consent was obtained and confidentiality was assured. Participants could opt to participate in a gift card raffle for completing the survey. This study was reviewed and approved by the academic medical center’s institutional review board.
Outcome measures. The survey included two instruments: the Copenhagen Burnout Inventory (CBI) and the Trait Emotional Intelligence Questionnaire-Short Form (TEIQue-SF). The CBI is a validated instrument with high internal reliability and consists of 19 questions divided into three categories: personal-, work-, and colleague-related burnout. Each category is evaluated on two physical and psychological cores: exhaustion and fatigue.(18)
Instruments were scored and totaled per instrument guidelines. Ordinal scores were established with scores from 0 to 49 being minimal burnout, while scores between 50 and 74 were considered moderate, and scores higher than 75 were considered high levels of burnout.(19)
The TEIQue-SF is a 30-item validated instrument that provides a global assessment of four scales: well-being (WB), self-control (SC), sociability (SOC), and emotionality (EM).(20,21) The TEIQue-SF is scored on a 7-point Likert scale ranging from 1 (completely disagree) to 7 (completely agree).(20) Additionally, the survey included a demographic section where participants provided specific background information. The survey ended with an open-ended question asking the participants to describe burnout in their own words. Internal consistency of the measures in this sample was calculated using Cronbach’s alpha and was excellent for both the CBI (0.95) and the TEIQue-SF (0.93).
Statistical Analysis. The student’s t-test and ANOVA were used to test differences in continuous variables. Associations between burnout and EQ traits were evaluated using Pearson correlation coefficients with Fisher Z-transformation to obtain the 95% confidence interval.
To determine if change in specialty moderated the association between EQ and burnout, two linear regression models were built. The base model included EQ scores and change in specialty as predictors of overall burnout scores, and the expanded model added the interaction term between change in specialty and EQ scores. Moderation was indicated if the interaction term was significant and by comparing the adjusted R(2) and Akaike information criterion (AIC).
All data were analyzed using SAS version 9.4 (SAS Institute Inc. Cary, North Carolina). Results from the open-ended question were analyzed through a phenomenological approach using inductive coding methods. Codes were evaluated independently by two study team members (EK and MB) to ensure accuracy and complete consensus.
Results
Of the 628 physicians-in-training invited to participate, 118 (18.79%) completed the survey. Sample characteristics are presented in Table 1. Of these 118 participants, 50 (42.37%) identified as male and 67 (56.78%) as female. Nearly half physicians-in-training were ≤ 29 years old (n = 54; 45.76%) with 79 (66.96%) respondents identifying as White. Further, 111 (94.07%) identified as U.S. citizens while 7 (5.93%) identified as non-U.S. citizens.
All participants held medical degrees (MD or DO) with 5 (4.24%) also having a PhD. The majority of residents who responded to the survey were in their postgraduate training year 1 (n = 29; 32.20%) or year 3 (n = 25; 27.80%), while for fellows, the majority were in year 1 (n = 10; 38.50%) or 2 (n = 11; 42.30%). A slight majority (n = 58; 49.15%) of participants indicated that they worked 70 hours or more on a weekly basis; only 11 (9.32%) reported practicing 40 to 49 hours per week.
A large part of the sample (n = 109; 92.37%) had been accepted in the specialty of their first choice. The number of respondents (n = 49; 41.53%) who changed their specialty choice between matriculation and graduation (M2G) greatly exceeded the number (n = 8; 6.78%) who changed their specialty during residency (R). The data showed that seven respondents changed their specialty at least twice during both M2G and R. Table 2 shows the differences in factors contributing to changing specialty between M2G and R, as both endorsed personality fit as a leading cause (n = 39; 79.59% and n = 5; 62.50%, respectively).
In terms of specialty satisfaction, 52 respondents (45.61%) were very satisfied with their current specialty, and 6 (5.26%) were very unsatisfied. Among those who changed their specialty, 25 (54.26%) reported being very satisfied, and 2 (4.35%) very unsatisfied.
Results from the CBI determined that the majority of respondents were in the low range of burnout (n = 87, 59.18%), 52 (35.37%) were in the moderate category, and 8 were in the highest category for burnout (5.44%). Table 3 demonstrates no significant difference in burnout levels between those who changed their specialty and those who did not. Similarly, the TEIQue-SF subscales showed no difference in EQ levels between those who changed their specialty and those who did not.
Evaluating the differential impact of EQ on burnout between those who changed their specialty and those who did not was conducted through moderation analysis. This analysis showed that a change in specialty does not moderate the effect of EQ on burnout, as the adjusted R(2) of the base model was higher (0.31 versus 0.30) and the AIC of the base model was lower (614.39 versus 616.34). Further, the interaction term between change in specialty and total EQ score was not significant (p = 0.82).
However, the Pearson correlation coefficient (95% confidence interval) showed a moderate inverse association between burnout and EQ (-0.56 [-0.67, -0.41]), indicating that higher levels of EQ could protect against burnout overall. Further, for those who changed their specialty, higher levels of EQ (p = 0.002; Figure 1) and lower levels of burnout (p < 0.0001; Figure 2) were associated with higher levels of satisfaction. Additionally, overall satisfaction with current specialty was significantly associated with higher EQ skills (p < 0.0001; Figure 1) and lower burnout scores (p < 0.0001; Figure 2).
Figure 1. Associations Between Emotional Intelligence and Satisfaction with Current Specialty and Change in Specialty
Figure 2. Associations Between Burnout and Satisfaction with Current Specialty and Change is Specialty
The answers to the open-ended question were categorized into 14 themes: mentors, directors and faculty (leadership); wellness and well-being; communication; schedule flexibility; lack of exposure/educational opportunities; culture and support; autonomy and micromanagement; work hours/load; work-life integration; financial burden; regret; positive reactions; built environment; and effective evaluation. The top five themes associated with burnout were ranked in the following descending order: culture and support (coded 17 times), leadership of mentors, directors, and faculty (coded 7 times), wellness and well-being (coded 7 times), and lack of exposure/educational opportunities (coded 6 times).
Discussion
While there was no statistical difference in burnout or EQ scores between those who changed their specialty and those who did not, higher EQ skills were found to be potentially protective against burnout among physicians-in-training with a moderate inverse correlation between the variables. Additionally, those who changed their specialty and reported high satisfaction with the change had higher EQ and lower burnout scores compared to those who reported less satisfaction.
The research on burnout in medical students and residents indicates that factors affecting their specialty choice are personal compatibility with the specialty, followed by workload and work-life balance.(11,22,23) This is consistent with our findings that personality fit is the leading reason for changing specialty.
The mechanism of decision-making during specialty choice is complex and requires high levels of self-awareness, self-confidence, and self-recognition in order to achieve personal fulfillment.(15,22) EQ as a construct consolidates these major skills.(15) Individuals with high EQ were found to excel in decision making and experience less burnout.(24,25)
Choosing the specialty that is consistent with personality factors and leans toward higher satisfaction may ultimately lead to less burnout. As one responder stated, “I wish I would have known about some of the other areas in medicine prior to doing what I do. I think having more time to myself would make me happier. I think sleeping more would also make me happier. I feel like medicine has stolen the best years of my life and spit right back at me without thanking me for it. All in all, I’d never choose medicine again and I would never recommend it to someone with high intelligence to choose this unforgiving field.”
Even though the findings of this study did not support our hypothesis, several respondents reported in the open-ended question that culture and support, as well as leadership quality of mentors, directors, and faculty, were the leading contributors to burnout in comparison to studies that reported bureaucracy and long work hours to be the primary reasons.(26,27)
Several studies have stressed competent medical leadership as important for achieving high-quality healthcare, well-established communication, and high-performance teamwork.(28-30) Competent leadership qualities include high levels of self-awareness, empathy, cultural sensitivity, and professionalism(31); many respondents in the current study cited these as lacking among leaders.
Respondents described their experience with lack of empathy from program leaders, lack of opportunity to voice their concerns, and lack of respect. One respondent reported a “lack of respect in interactions with other employees — whether residents from other specialties, nursing, social works, fellows/attendings. A lot of our day is spent by people not respecting our decisions and our choices, and there is never a time to debrief and discuss what happens. This leads to internalizing a lot of emotions and frustrations, creating emotional fatigue and burnout.”
Physicians-in-training were demanding more “room for mistakes” and “organized lectures, more mentor relationships and career guidance.” They also asked for “Effective leadership. Support. Wellness” because they believe that the problem is not with the specialty but with the program itself. One respondent said, “Love my specialty. Hate my program.” It was also suggested that the “wellness time should be more tailored to individual needs. If personal time is what is required, then that should be okay. Modules that describe what wellness is do not promote wellness.”
These inputs point to the need for well-developed EQ courses that enhance skills at the interpersonal level. These inputs also point to the importance of equipping physicians-in-training with EQ skills before they begin practicing in the field and that EQ courses should not be limited to physicians-in-training but also to include physicians in the process of becoming leaders.
These findings suggest that an important factor contributing to burnout is culture and support. In many previous studies, this factor was ranked third among factors contributing to burnout, yet it was least-addressed.(27,32) Our research suggests that this factor is as important as limiting work hours and workload.
The assurance of the success of physicians-in-training in working in any healthcare organization relies on emotional culture, which is comprised of exchange and expression of emotions working together in one organization.(33)
Numerous studies have shown the significant impact of emotions on decision making, commitment to program, engagement in activities, and performance.(33-35) When the healthcare organization had strong culture, it was reported that employees became more engaged, had a deeper sense of connection working with other employees, and a unique experience that prevented them from quitting.(33-35) Having regular EQ courses and burnout checkups throughout medical education and training with an emphasis placed greatly on program directors as their EQ skills and burnout level could influence their interaction with their team and ensure positive emotional culture for learners.(30,36) An emotionally less-exhausting culture can also be achieved by enacting a policy mandating that burnout measures be part of the health accreditation system report for institution incentives.
Limitations
Limitations of the study include the relatively small sample size, which could result in response bias. Further, responses represented trainees across different specialties, but due to limited sample size, results were not stratified by specialty, and specialty-specific culture could vary.
Also, this study was administered toward the end of the academic year and during the COVID-19 pandemic; consequently, some of the burnout results could have been elevated due to historical bias. Additionally, this study was conducted at a single academic medical center that offers a variety of residency and fellowship programs; thus, the findings might not be generalizable, as each institute or even department has its own structure and design of its own program.
Another limitation is that the results from the TEIQue-SF reflect self-report measures that could have been affected by respondents who believe they must answer a particular way.(37) Lastly, as this was a cross-sectional analysis, only associations between the variables could be ascertained, and no causal relationships could be explored or assumed.
Future studies might want to control for this limitation by asking peers or supervisors to rate the person’s EQ skills. Additionally, future research should aim to attain a higher response rate as well as include multiple institutions to ensure these trends are not specific to the institution where these data were collected.
Conclusions
EQ skills are important in the process of decision-making and career retention. Combating burnout starts with choosing the specialty that fits one’s personality and continues with sustaining good culture and support during training.
At a personal level, EQ skills and a high satisfaction with specialty are cornerstones to less burnout and successful career experience for physicians-in-training. Future research should investigate EQ skills using a qualitative method, and conduct the investigation at both personal and interpersonal levels. It is also important that each specialty be actively engaged in tailoring the EQ training programs that serve the needs of the department.
Nonetheless, medical schools should also introduce EQ courses earlier in the medical education. Teaching medical students the skills of EQ such as communication, decision-making, understanding and perceiving nonverbal cues from colleagues will significantly prepare them for the next step in the field, which is residency training.
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