Published Ahead of Print on June 30, 2017 as 10.1212/WNL.
0000000000004128
EDITORIAL
Residents dont just look miserable.
they really are
Ann Tilton, MD Is the rite of passage of residency and fellowship a pro-
Laurie Gutmann, MD cess of learning and maturing, or an exhausting and
demoralizing experience that sets the stage for
burnout? What factors can influence the start of
Correspondence to burnout or help to promote wellness? It has become
Dr. Tilton:
atilto@lsuhsc.edu
abundantly clear that physicians face a crisis not only
of regulatory burdens, but also of a lack of well-being
Neurology 2017;89:12 or burnout. This is especially true for neurologists.
This does not begin with the graduation certificate
from residency or fellowship, but instead the indica-
tors for burnout are very much present early in their
trainingduring residency. More than 50% of
physicians in the United States meet the criteria for
burnout, a well-recognized threat to the profession.
Burnout disproportionately affects neurologists, and
in this issue of Neurology, Levin et al.1 reveal that our
next generation of colleagues are equally at risk.
Burnout has 3 defined dimensions: emotional
exhaustion, feeling of cynicism and detachment
(depersonalization), and a sense of being ineffective
at work. This ineffectiveness corresponds to feelings
of low personal accomplishment.2 Burnout has exten-
sive ramifications in both personal (personal conflict
and health issues) and work-related activities (work-
related errors, occupational exposures, and even
motor vehicular accidents).3 Thus, burnout poses
a threat to the safety of both individual physicians
and the patients under their care.
National surveys have confirmed the need for
intervention. The current study looked at 938 of
the 1,823 US fellows and residents in neurology,
receiving an impressive 37.7% response rate.1 It was
a complementary study to a previously published
report looking at adult neurologists, and developed
in the same format.4 The 57-question survey, based
on previously validated instruments, addressed burn-
out and career satisfaction and personal and profes-
sional characteristics. The authors delved into
characteristics such as emotional exhaustion, deper-
sonalization, and perception of personal accomplish-
ments, along with career and subspecialty choices. In
addition, the study explored clerical demands as an
area particularly problematic for fellows.
See page XXX
From Child Neurology (A.T.), Neurology and Pediatrics, LSUHSC New Orleans, LA; and Department of Neurology (L.G.), University of Iowa
Hospitals and Clinics, Iowa City.
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the editorial.
2017 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
The study broadly reflected US neurology trainees
based on the strong response rate and the similarity
between the group of respondents and nonrespond-
ents. The modest numbers preclude further segmen-
tation of the respondents into specific subgroups,
leaving questions such as whether child neurology res-
idents have the same degree of burnout as their adult
counterparts; data of this sort could offer insights,
given the lower levels of burnout in practicing pedia-
tricians compared to neurologists.
High scores on emotional exhaustion or deperson-
alization indicated at least one manifestation of burn-
out. Sixty-seven percent of trainees had substantial
emotional exhaustion and depersonalization; 54%
endorsed accompanying low personal accomplish-
ment scores. Of note, residents endorsed higher
scores in depersonalization and low personal accom-
plishment than fellows did. Indeed, the fact that only
57% of the group evaluated would choose to become
physicians again raises serious concern. Interestingly,
76% would still choose neurology. The fact that
fewer residents and fellows1 than practicing neurolo-
gists4 (57% vs 61.3%) would again choose to become
a physician indicates an early career crisis. In search-
ing for causative factors, worklife balance constitutes
an extremely important aspect of quality of life for
this group. Fewer than 1 in 4 felt that they had ade-
quate time for their personal lives. In addition, the
majority found supportive services inadequate.
So what factors are associated with burnout in the
training group? Various compounding factors can be
considered. Generational issues such as an increased
reliance on technology and a preference for collabora-
tive projects and management style with coaching as
opposed to top-down directives are also suspected as
associated factors in burnout. Moreover, the high-
demand yet fragmented nature of our current health
care system may play a role in reported burnout. To
the early-career physicians assessed in this survey,
meaningful factors identified include worklife
balance, meaning in work, and supportive staff.
Worklife balance was a priority for both residents
and fellows. Of note, women and men gave similar
2017 American Academy of Neurology 1
 responses across all aspects of the study. Meaning in
work was a priority for residents, while supportive
staff was a higher priority for fellows.
What are the next steps? The authors begin to re-
frame the negative findings into opportunities for
remedies. What are the priorities for well-being? For
residents, lower risk of burnout was noted in those
with greater satisfaction with worklife balance and
meaning in work. Interestingly, older residents had
lower risk of burnout. For fellows, those with greater
satisfaction with worklife balance and effective sup-
port staff had lower risk of burnout. This finding
makes sense given that career satisfaction correlated
with meaning in work and worklife balance. Geo-
graphic location (Midwest compared to the North-
east) also had an influence, but no causal relationship
is stated.
This well-constructed, well-written, and timely
article provides compelling evidence that medical
residents and fellows also experience burnout. This
study delves deeper into factors that may have the
most influence. Hopefully, this article can serve as
2 Neurology 89 August 1, 2017
2017 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
a call to action to provide timely interventions
when they are most neededearly in a physicians
career.
STUDY FUNDING
No targeted funding reported.
DISCLOSURE
The authors report no disclosures relevant to the manuscript. Go to
Neurology.org for full disclosures.
REFERENCES
1. Levin KH, Shanafelt TD, Keran CM, et al. Burnout, career
satisfaction, and well-being among US neurology residents
and fellows in 2016. Neurology 2017;89:xxxx.
2. Maslach C, Jackson S, Leiter M. Maslach Burnout Inven-
tory Manual. 3rd ed. Palo Alto, CA: Consulting Psycholo-
gists Press; 1996.
3. West CP, Tan AD, Shanafelt TD. Association of resident
fatigue and distress with occupational blood and body fluid
exposures and motor vehicle incidents. Mayo Clin Proc
2012;87:11381144.
4. Busis N, Shanafelt T, Keran C, et al. Burnout, career sat-
isfaction, and well-being among US neurologists in 2016.
Neurology 2017;88:797808.
 Residents don't just look miserable they really are
Ann Tilton and Laurie Gutmann
Neurology published online June 30, 2017
DOI 10.1212/WNL.0000000000004128

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