Image courtesy: Ana Hategan

Image courtesy: Ana Hategan


Amanda was an obstetrics/gynecology resident nearing the end of her third year of training. (See section Know Yourself, topic Recognizing Burnout, for more details on the case scenario as this is a case continuation.) She was burned out, depressed, and her work and relationships were suffering as a result. She knew something needed to change, but had no idea where to start or where to go for help. Amanda thought about speaking to her program director, but worried about confidentiality and the potential repercussions this could have on both her residency and her ability to secure a job down the road.

Even in considering outside supports, such as seeking a counsellor or psychiatrist herself, Amanda was not sure how she would be able to carve out time for such an appointment, when there already were not enough hours in the day to accomplish what she needed to. She had been hoping to see her family physician for several months now, but between her doctor’s limited and busy schedule, and her own, this continually was put off.

To make matters worse, Amanda felt alone in her program. Whenever spending time with her co-residents, they all spoke of their many accomplishments and extracurriculars, and appeared to be happy and handling the various stresses of residency without difficulty. No one spoke of their challenges as no one wanted to be perceived as weak or vulnerable; however, this meant that Amanda perpetually felt as if there something was wrong with her and that she was the runt of the group.

As we have come to learn, the problem of physician burnout is often multifactorial, involving a mix of environmental stressors, biological vulnerabilities, and coping styles unique to each of us (Wiederhold et al, 2018). Many of these factors are seemingly out of an individual’s control (Dyrbye et al, 2016). This is particularly true for residents, who often have even less input with regards to their schedule, workload, or income, and who face frequent institutional and organizational pressures, such as by being under close supervision, and having to complete various evaluations, exams, and projects all prior to their graduation.

While there is growing awareness of the role that these systems factors play, there is still much work to be done in this arena. We encourage medical students and residents to consider advocating for physician wellness and exploring ways in which they can help be involved in promoting change both within their institutions and with regards to the overall culture of medicine; however, in the meantime, we need to find ways to keep us well.

Though programs and services to aid physicians can vary by institution and region, by building awareness of what does exist and learning what personal wellness practices have been shown to boost wellness and fill up our reserves, we may be better able to fight against burnout. To learn more about some of these strategies and tools available to physicians in Canada and the United States, click on each of the following sections below.

Image courtesy: Ana Hategan

Image courtesy: Ana Hategan

N.B. This is not an appraisal of the efficacy or effectiveness of any of the following programs.

Canadian Medical Association: Physician health

This policy on “physician health” outlines recommendations at the individual and systemic level. It speaks about expectations at the institutional and professional organization level. It also calls to action researchers to develop and study the impact of novel interventions.

CMA guide to physician health and well-being: Facts, advice and resources for Canadian doctors

This was published in 2003 by the Canadian Medical Association (CMA). This is a CMA guide to physician health and wellbeing.

Physician health matters: A mental health strategy for physicians in Canada

This was prepared for Canadian Medical Association and published in February 2010.

Provincial physician health programs

This website offers information about the directory of all the physician health programs available throughout Canada along with contact information. They support physician wellbeing and public safety by enforcing, when necessary, intensive programs of physician monitoring.

American College of Physicians: Physician burnout and wellness information and resources

This is a selection of resources targeting areas of burnout, wellness, and resiliency.

Federation of State Physician Health Program

This is a non-profit initiative directed at rehabilitation of physicians with mental health and/or substance use issues. The majority of states are members (California, Delaware, Nebraska, and Wisconsin are not involved).

Pacific Assistance Group: California Physician Support & Monitoring Services; California Physician Health Program

As California currently does not have a formalized physician health program, the Pacific Assistance Group is an organization that currently provides physicians in this state with private rehabilitation and support services, as well as monitoring.

Nebraska Licensee Assistant Program

This program is a benefit for Nebraska health and health-related service licensees, certificate holders and registrants.

Family physician

Establishing a relationship with an accessible family physician is not unique to residents, but should be accessed by all proactively in times of health matters as a primary prevention strategy. When possible, access to a primary care physician affiliated with a family health team, which would allow ready access to mental health clinicians on a more rapid basis, is essential. For example, this is a model of care practiced in Ontario that attempts to mitigate systemic roadblocks when accessing mental health or other specialized services.

The Doctor Paradox: ‘Rediscovering passion in healthcare’

This is a website and podcast brought to you by Dr. Paddy Barrett that aims to address “why despite having incredibly meaningful jobs, doctors are increasingly unhappy at work.”

Four Tools for Reducing Burnout by Finding Work-Life Balance

This is a toolkit consisting of four different exercises: “Scheduling a Life Calendar”, “Intentional Date Nights”, “The Big Bucket List and Weekly Bucket Lists” and “The Work-Life Boundary Ritual” aimed at reducing the risk of burnout.

Centre for Practitioner Renewal

This represents a research centre focused on “improving and understanding the nature and effects of risk and resilience factors in the healthcare workplace.”

HEARTS in Healthcare: The movement for human-centred healthcare

This consists of an initiative aimed at re-humanizing healthcare with a variety of information.

The Happy MD: Stop physician burnout

This program has trained over 27,000 physicians to understand and prevent burnout.

Doctor Burnout. White Coat Black Art

The CBC series White Coat Black Art, hosted by Dr. Brian Goldman, had its first episode airing on July 28, 2018, which discussed physician burnout.

Though medical training can be challenging and stressful in and of itself, how one perceives these stressors and copes with them, is also of importance. Though there are different forms of counselling or psychotherapy, they all generally provide an opportunity for an individual to openly express themselves and their distress, to explore their problems from a different lens, and to learn alternative and perhaps more constructive coping strategies and ways to problem solve (Dyrbye et al, 2016). As such, data supports counselling and psychotherapy as an intervention to address burnout (Ishak et al, 2009).

Most of the evidence for therapy in physician burnout has supported the use of cognitive behavioural therapy (CBT); however, there have also been positive findings with more general and even very brief counselling treatments:

  • In a study of 400 Canadian psychiatry residents, around half of those who were burned out reported to have engaged in “personal psychotherapy” during residency, citing that therapy had a significant positive impact on both their personal and professional lives (Kealy et al, 2016).
  • A study of 200 Norwegian physicians utilized either a one-day individual counselling session or one-week group course, which focused on reflection of their current situations, needs, and coping strategies/resources. Those who engaged in these short-term interventions experienced a significant decline in emotional exhaustion, as well as a reduction in full-time sick leave (Rø et al, 2008).
  • A study of a five-week group CBT program for Australian family physicians found that those who engaged in treatment, compared to controls, showed improvement with regards to general psychological distress, workplace stress, quality of work life and morale (Gardiner et al, 2004).

Resources to consider:

  • Counselling through Student Wellness Centres or Resident Affairs
  • Private counsellor or social worker
  • Books, such as Mind Over Mood
  • Apps, such as WhatsUp, Moodnotes

As with our case example, Amanda, burnout can be a very lonely experience, both due to the fact that we can find ourselves detached or withdrawn from others, but also likely due to the culture of medicine which tends to instill some sense of competition and leads us to hide our perceived weaknesses and difficulties for fear of negative repercussions and embarrassment.

Despite this, social support is crucial. In fact, in a study of medical residents with burnout, the top two coping strategies that were highlighted as the most essential for managing stress were talking to other residents and talking to one’s significant other or family (Shanafelt et al, 2002). This is not surprising as humans have an innate desire to connect with others, as it provides not only a sense of belonging and community (McKenna et al, 2016), but it can help reduce stress and anxiety (Ishak et al, 2009).

Resources to consider:

  • Formal:
    • Balint groups or Doctoring to Heal programs
      • In medicine, we often learn to go into survival mode, to keep calm and carry on; however, we also tend to learn, from the lack of communication about physician distress, that it may not be appropriate or in our best interests to voice our difficulties coping. The problem with this, however, is that it leads us to feel as if we are sitting on an island all alone, even though many physicians and learners experience similar challenges and negative emotions. One way to combat this has been the formation of Balint or Doctoring to Heal groups, where residents or practicing physicians come together in small groups to discuss and reflect on different topics, share experiences about the ups and downs of their work and difficult patient encounters, and to help each other cope with their stressors and process their emotions. To date, evidence has shown that Balint groups may help to prevent stress and burnout, in addition to increasing job satisfaction (Romani & Ashkar, 2014), while Doctoring to Heal programs may foster improved personal awareness and physicians’ ability to deal with stressors, and both improve physicians’ skills and patient care (Rabow et al, 2001).
    • Mentoring
      • Particularly when starting out as a new medical student or resident, the road ahead may feel daunting and overwhelming, especially if one encounters roadblocks along the way. Given this, further social connection and guidance offered through mentoring programs is thought to be quite beneficial for physicians in training (Ross et al, 2017). Specifically, peer mentoring with senior residents is thought to be quite effective, as this can help build collegiality, grow residents’ confidence, and offers an opportunity to provide educational and psychosocial support (McKenna et al, 2016; Ross et al, 2017).
      • For example, a study of working adults found that those who were engaged in mentoring, particularly through a formal program, not only better integrated into their working environment, but this lessened workers’ emotional exhaustion as well as the risk of absenteeism or turnover (Boutelle, 2015).
    • Debriefing after patient loss or difficult encounter
      • It is not uncommon for physicians, and particularly medical learners, to place blame on themselves or feel distressed following a difficult clinical situation, whether that be a violent or angry patient, a patient death, or a medical error. To address this, some institutions have encouraged more regular debriefing or “grief rounds” to discuss such difficult topics, which allow individuals to reflect, process their emotions, and receive support, which in turn helps to prevent internalizing these events as failures (Dyrbye et al, 2016; Ross et al, 2017; Wilde et al, 2016).
  • Informal:
    • Speaking with family, friends, peers, or faculty
      • Whether by discussing cases, venting, or laughing together, higher levels of these social supports have been found to be protective against burnout for physicians (Dyrbye et al, 2010; Dyrbye et al, 2016). One theory is that such support reduces loneliness, which itself is associated with stress and burnout (Rogers et al, 2016).

With burnout, not only do we lose sight of our purpose and what is important to us, but often the work-life scale becomes unbalanced as we devote more and more of our resources in an effort to stay afloat at work and keep up with our various duties as a resident. The problem, however, is this tends to exacerbate the problem, as our relationships outside of medicine, our leisure pursuits, and basic self-care practices fall to the wayside even though they are vital for our self-identity and in replenishing our reserves and maintaining our satisfaction with our lives.

As such, to foster resilience and combat burnout, we may need to return back to the basics, such as by trying to regain a healthier lifestyle and working to instill a more equitable semblance of balance in our lives. While the right “work-life balance” may be different for each of us, one way that we can work towards this is by reflection to assess what is missing, and setting goals to help get us back to where we want to be (Deb, 2017). Goals in particular help keep us accountable and committed to our action plans, and help us build self-efficacy and confidence by frequently checking-in to evaluate our progress (Turkay, 2014). In considering some of the resources or suggestions below to foster self-care, consider formulating some goals to bring about these changes in your own daily routine.

Resources to consider:

  • Separating oneself from work and taking time for you
    • Fostering one’s life outside of medicine and residency is crucial to resiliency and maintaining balance. As one study demonstrated, 90% of residents rated both engaging in social relationships, along with participating in their hobbies or sports, as the most paramount wellness strategies (Shanafelt et al, 2003). Whether by connecting with a friend or loved one, engaging in religious/spiritual practices, rediscovering our hobbies and interests, playing sports, or listening to music or getting into creative arts, these are all ways to help us ground ourselves and provide joy (Deb, 2017; Dyrbye et al, 2016; Shanafelt et al, 2003).
    • In order to set boundaries between work and home, Ross et al (2017) recommend strategies such as setting aside time each day or week free from work related activities, scheduling and prioritizing social engagements or leisure pursuits, and ensuring we take vacations that are work-free and focused instead on rest, relaxation and rejuvenation. Setting time, even post-call, to rest and relax, such as via meditation, yoga, massage, or getting out into nature, can also be quite therapeutic and help to reduce the burden of stress (Dyrbye et al, 2016; Ishak et al, 2009).
  • Engaging in exercise
    • When it comes to promoting our general physical and mental wellbeing, thought it may seem simple, regular exercise can be of great benefit. For instance, studies have shown that physical activity can be a useful treatment for depression and anxiety, and in improving one’s general mood, memory, and overall cognitive functioning (Shak et al, 2009; Shanafelt et al, 2017).
    • While yoga can be helpful to instill a sense of mindfulness and relaxation (Ishak et al, 2009), engaging in 150 minutes per week of moderate-intensity exercise or 75 minutes of more vigorous training is considered the most ideal (Shanafelt et al, 2017). However, do not let the amount of exercise recommended get you down! A study of just a 10-minute stretching exercise in the workplace was found to be associated with reduced levels of anxiety and exhaustion and was thought to improve workers’ overall physical and mental wellbeing (Romani & Ashkar, 2014).
  • Eating a healthy diet
    • Though it is easy when we are busy or on call to skip meals, snack on junk food, or turn to quick and easy (but not always the healthiest) options, eating regularly throughout the day and having balanced meals are important to maintain our energy and concentration (Shanafelt et al, 2017).
    • Some simple tips to aid with this include setting aside even just a 15-minute break during one’s shift to eat, preparing and packing meals and snacks from home, or utilizing food or grocery delivery services to save time (Shanafelt et al, 2017).
  • Ensuring adequate sleep
    • After a night on call, it does not come as a surprise to anyone that sleep deprivation and deficits can have a negative impact on one’s life, such as by eroding our ability to cope adaptively and to function optimally with regards to our cognition. Sleep deprivation can also lead to irritability, low mood, and impaired relationships, and put us at risk, including of motor vehicle accidents, errors, and unprofessionalism due to chronic fatigue (Baldwin et al, 2004; Mansukhani et al, 2012; Shanafelt et al, 2017; Whitehead et al, 1992).
    • While ensuring we are abiding by sleep hygiene practices and engaging in regular exercise can help to solidify a regular and restorative sleep regimen (Shanafelt et al, 2017; Whitehead et al, 1992), many residents tend to struggle more when faced with busy nights on call or with varying shiftwork, which throw their sleep patterns out of whack. In those cases, experts have suggested that “anchoring” one’s sleep can be one of the most helpful strategies (Shanafelt et al, 2017). Essentially how one does this is by considering your normal hours of sleep during weekdays and weekends and trying to designate 3-4 hours (essentially half of your normal sleep) after a night shift that is close to the beginning and/or end of your normal sleep period to maintain your regular circadian rhythm and to minimize disruptions (Shanafelt et al, 2017; Whitehead et al, 1992). Further, Shanafelt et al (2017) also reported that limiting our sleep after call to noon instead of all day can be beneficial.
  • Fostering a more positive mindset
    • Whether due to a combination of perfectionistic traits or working amidst the culture of medicine, which can often suggest that failure or mistakes are inadmissible, it is not uncommon for physicians and medical learners to be their own harshest critic. We tend to set unachievably high standards for ourselves, and can soon get in the habit of looking at ourselves and our work with a negative lens, leading to low sense of esteem and accomplishment, and ultimately driving the wheels of burnout forward. While it is not realistic to stop challenging situations from arising or to completely ignore negative feelings or events per se, taking time to actively consider the positives, or to positively reframe situations, can help provide boosts to our mood (Dyrbye et al, 2016; Shanafelt et al, 2017).
    • While the literature suggests that adopting a positive to negative emotion ratio of 3:1 is most optimal in fostering resiliency (Shanafelt et al, 2017), it may be hard to consider how one goes about making this shift in one’s emotions and thinking. To start, experts suggest replacing the time we often spend venting with a few minutes, even if it is just 1-2 minutes a day, reflecting on the day or shift with a more positive perspective (Shanafelt et al, 2017). Whether through considering what we are grateful for or appreciative of, or in considering our own skills or our valued role in a patient’s life, all of these actions have been shown to foster improved mood, team cohesiveness, and greater professional development and success (Shanafelt et al, 2017).

As resident physicians and practicing physicians, our work revolves around caring for others and treating the ill. Given our commitment to our careers and altruistic attitudes, however, it is easy to spend most of our time helping others and prioritizing the wellbeing of our patients over our own. However, physicians are humans too. None of us are immune to the common cold, cardiovascular disease, or even burnout and depression. We tend to forget this, however, and even in the face of illness or suffering, we can become the worst patients. For instance, we work even when we are ill (Penedo et al, 2005), we downplay our symptoms and avoid seeking help (Davidson et al, 2003), and we self-diagnose and medicate (Christie et al, 1998).

These behaviours can be harmful to both our patients and ourselves. Instead, to function optimally and provide the best care, we need to start caring for ourselves and prioritize our own wellbeing. This can be accomplished by building our own healthcare network, seeing our doctors/team regularly (Shanafelt et al, 2017), and knowing when it is time to ask for help (Dyrbye et al, 2016). By doing so, we build resilience by attending to and filling up our physical and emotional reserves.

Resources to consider:

  • Family physician – Visit them routinely!
  • Mental health and counselling services
  • Physician help lines
  • Your local emergency room – Visit if you are feeling unsafe and need immediate support. Also do not be afraid to ask for increased privacy to ensure confidentiality.

Did you know?

A study of internal medicine residents found that almost 50% had no primary care physician or considered themselves to be their own family doctor (Christie et al, 1998). Those that did not have a primary care physician were more likely to engage in self-treatment, of which over half reported self-prescribing a medication (Christie et al, 1998).

Another study of Australian physicians found that almost three in four physicians downplay their symptoms or feel embarrassed to seek out care from another physician, and 95% are likely to work when sick. Particularly when it comes to depression or other mental health issues, these numbers increase as 87% were reluctant to seek out appropriate consultation (Davidson et al, 2003).

Skill building exercise

Resource check

Now that we have had a chance to learn about some of the evidence-based strategies to combat burnout and some of the resources that may exist, it is time to explore what is available where you live. Whether for yourself or a colleague in need, having an understanding of the various tools, programs, and crisis supports that are available through your community or institution can be a good way to stay prepared and can help tackle burnout early on.

To assist with this, consider and explore each of the following areas to see what supports exist for medical learners and physicians in your area:

  1. Regional or national practicing physicians’ or resident physicians’ organizations
  2. Academic institution (including Resident Affairs office)
  3. Residency program
  4. Community
    • Family physicians
    • Counsellors or psychiatrists
    • Addiction services (e.g., Caduceus groups)
    • Crisis supports (e.g., distress lines)

Given the utility and importance of social support, it may also be worthwhile to consider those around you, whom you would feel comfortable sharing experiences with. Perhaps this may include trusted faculty members, co-residents, or former medical school classmates. Consider whether it may be possible to arrange regular meetings to discuss what is on your mind, any difficulties you are facing, and ways to address and cope with these challenges. You may be surprised who else has had similar experiences or feels the same as you!

Case conclusion

Though Amanda was struggling with feeling as though she was an imposter in her program, the one resident who was struggling to keep up and who had lost sight of the purpose and joy of her work, she was surprised one day to discover that she wasn’t alone. At a resident social, a more senior peer opened up to her about their difficulties with processing a patient’s death and struggling to find time for their own self-care, which was necessary for them to maintain their wellness. Through this interaction, Amanda not only felt relieved and reassured, but she felt closer to her peer group, particularly as she and her co-resident began meeting regularly for coffee to discuss their challenges.

Inspired by her peer’s own coping strategies, Amanda decided that in order to create some separation between work and home, she needed to go back to the basics. Though it felt a little silly at first, Amanda began scheduling in outings with her spouse and friends, as well as time to attend yoga and the gym, or go on a hike. She worked to try and limit the hours she spent studying and writing notes, and even picked a day or two a week where she focused only on relaxing or engaging in her hobbies or relationships. In doing so, her mood, self-esteem, and sleep improved, and she found that when working, she was more focused and productive, and she began to enjoy her clinical and academic work more.

Amanda also scheduled a day off to attend her own medical appointments, including with her family physician. After relaying her story and symptoms, her family physician worried that she may be experiencing a depressive episode. Though medications were discussed, Amanda opted to pursue psychotherapy instead. Through her family doctor, Amanda was connected to a social worker who began to engage her regularly in the evenings on both CBT and mindfulness work, which Amanda enjoyed and found helped her in managing her perfectionistic and anxious tendencies. In discussion with her family doctor, Amanda also began to cut down on drinking and began going for massages regularly, often on her post-call days.

While Amanda was slowly starting to feel better, one day she received tragic news that one of her young patients, who had recently had a miscarriage, had died by suicide. This was unexpected and greatly shook Amanda. She felt upset and deeply saddened, and as the news sunk in, guilt began to emerge as she felt that she had let the patient and their family down. She worried excessively that she could have done more. The loneliness and darkness returned with a vengeance; however, as she had been exploring options for resident support, she knew there were help lines for physicians. On one particularly difficult night, Amanda contacted the 24-hour helpline through her residents’ association, which allowed her to express her distress and receive some support and guidance. The next day, Amanda also sought out her supervisor and asked if they could discuss the suicide and debrief. Amanda learned that her supervisor had lost a few patients over the years himself and each time though he had struggled, he had ensured he had others to talk with, which helped him in processing the grief. Her supervisor also recommended that it may be helpful for her to write a story or a narrative to review her experience with that patient and the emotions that arose following the patient’s death. Though it was difficult, Amanda found this exercise to be cathartic and therapeutic, reminding her of what she had done for the patient and what she could learn from this experience moving forward.

Though it took some time and there continued to be ups and downs, by the time fourth year rolled around, Amanda felt stronger, and more capable of handling all that was still to come.

1. To recap, what are the core features of burnout?

A Emotional exhaustion
You are partially correct. Although this is one of the main manifestations, burnout is defined by three core features including emotional exhaustion, depersonalization, and a reduced sense of accomplishment.
B Depersonalization
You are partially correct. Although this is one of the main manifestations, burnout is defined by three core features including emotional exhaustion, depersonalization, and a reduced sense of accomplishment.
C Reduced sense of accomplishment
You are partially correct. Although this is one of the main manifestations, burnout is defined by three core features including emotional exhaustion, depersonalization, and a reduced sense of accomplishment.
D A and B
You are partially correct. Although both emotional exhaustion and depersonalization are prominent symptoms of burnout, particularly which are used in the literature to define individuals experiencing this syndrome, a reduced sense of accomplishment is also considered a core feature.
E A, B and C
Well done! Though in the literature, individuals may only need to experience symptoms of one of the three core features to be considered “burned out”, exhaustion, depersonalization, and a reduced sense of accomplishment are all manifestations of the condition.

2. Which of the following have been associated with untreated burnout?

A Riskier use of alcohol
You are partially correct. This certainly is a problem associated with physician burnout; however, some other options presented in this exercise are also challenges that can arise among physicians struggling with burnout.
B Depression and suicidal ideation
You are partially correct. These are problems associated with physician burnout; however, some other options presented in this exercise are also challenges that can arise among physicians struggling with burnout.
C Dissatisfaction with one’s career
You are partially correct. This is one of the problems associated with physician burnout; however, some other options presented in this exercise are also challenges that can arise among physicians struggling with burnout.
D Reduced empathy and altruism
You are partially correct. This is certainly a problem associated with physician burnout; however, some other options presented in this exercise are also challenges that can arise among physicians struggling with burnout.
E All of the above
You’re right! Studies have shown that the problems of physician burnout can be widespread, as it is associated with substance abuse, mental health concerns such as depression and suicide, job dissatisfaction and turnover, and reduced empathy and altruism, which can also negatively impact patient care.

3. Which of the following learners is experiencing symptoms concerning not just for burnout, but for depression?

A Jade is in her last year of residency in diagnostic radiology. Her board exams are quickly approaching, leading her to feel quite anxious, as due to a busy interventional radiology elective, she feels that she has not been able to devote as much time to studying. She feels overwhelmed, stressed, and worries that she may not pass.
By the sounds of it, Jade is certainly facing a significant stressor as she nears writing her final exams to become a radiologist, which are no doubt anxiety provoking. Based on what we know, it appears that she is stressed and overwhelmed; however, at this point there does not seem to be any signs of burnout or depression.
B Grant is a fourth year resident specializing in geriatric medicine. Over the last few weeks to months, he has been finding that the various demands between his clinical work, call shifts, and studying have been adding up, such that he feels he is never able to accomplish everything he needs to. Over time, when at work, he finds the patients he is dealing with to be increasingly challenging, such that he is not sure how to help them, leading to feelings of incompetence and doubt. He also finds that he feels quite irritated, leading him to be more aggressive and abrupt with patients, and has a hard time focusing when conducting an interview. Every day he feels more and more exhausted, and cannot wait to get home to relax with his family.
It seems as though Grant has been under increasing stress for some time and is having difficulty keeping up with all the various demands and work pressures. As a result of this, he displays all three signs of burnout including exhaustion, depersonalization, and reduced sense of personal accomplishment. He may be at risk of depression; however, given what we know presently, it does not seem that this is interfering in other parts of his life nor does he endorse current symptoms of depression.
C Melanie is nearing the end of her first year of emergency medicine. She has always struggled with perfectionism and often pushed herself to the limits to succeed even in medical school. As residency began, Melanie felt excited and motivated, but over the last several months, her positivity and passion has seemingly evaporated. Not only has Melanie been feeling exhausted, having regular troubles sleeping, but she has become increasingly negative and withdrawn from her colleagues. She often feels like the imposter of the group, who probably should not have made it this far. She feels down and has found herself crying frequently, even at work. She has been having increasing difficulty getting out of bed and has called in sick twice now as a result. On top of that she has lost her appetite, and has lost around 5 lbs. Melanie is no longer interested in spending time with her friends and family, and isolates further. Most recently, she has also had fleeting thoughts that perhaps everything would be better if she just was not around.
You got it! While Melanie certainly demonstrates some of the core features of burnout, it appears that these symptoms have begun interfering not just with work, but with her life outside medicine as well, particularly as she becomes increasingly withdrawn. Her reports of anhedonia, poor appetite and weight loss, and suicidal ideation, are also quite concerning, and suggestive of depression.
D A & B
Both options A and B are on the spectrum we described earlier, with A being more representative of stress and B of burnout; however, neither suggest depression, although this is a future risk should these issues persist.
E All of the above
Not quite. While Melanie in option C certainly sounds as though she is depressed, neither Jade nor Grant currently exhibit symptoms of depression. Jade is likely experiencing significant stress, while Grant appears burned out. You are right however, in having some concern about all three individuals, as certainly depression and suicidal ideation are associated with prolonged stress and burnout.

4. What are some effective strategies to increase one’s social connectedness and support?

A Spending time with one’s spouse, family, or friends
You are partially correct. Although this is one way to engage with others and receive social support, some other options presented in this exercise are also strategies to help us find support and avoid feeling isolated and alone.
B Debriefing with an allied staff or preceptor following a difficult encounter
You are partially correct. Although this is one way to engage with others and receive social support, some other options presented in this exercise are also strategies to help us find support and avoid feeling isolated and alone.
C Receiving mentoring from a senior colleague
You are partially correct. Although this is one way to engage with others and receive social support, some other options presented in this exercise are also strategies to help us find support and avoid feeling isolated and alone.
D Engaging in a Doctoring to Heal/Balint group with other residents or faculty
You are partially correct. Although this is one way to engage with others and receive social support, some other options presented in this exercise are also strategies to help us find support and avoid feeling isolated and alone.
E All of the above
Good job! It is known that social and peer support is crucial to resiliency and maintaining wellness. All of these options, which highlight both informal and formal approaches to building social support and connectedness have been found to be helpful in this regard.

5. If you were becoming increasingly distressed or were in crisis, where could you turn for help?

A Local emergency room
You are partially correct. This is definitely one resource to utilize if you’re feeling overwhelmed, distressed, or in need of more formalized and intensive support. Though what we might need and where we feel comfortable asking for help can vary, it’s important to know that some other options listed in this exercise are also resources for physicians in need.
B Family physician
You are partially correct. This is definitely one resource to utilize if you’re feeling overwhelmed, distressed, or in need of more formalized and intensive support; however, some other options listed in this exercise are also resources for physicians in need.
C Practicing physician/Resident physician crisis line
You are partially correct. This is definitely one resource to utilize if you’re feeling overwhelmed, distressed, or in need of more formalized and intensive support; however,some other options listed in this exercise are also resources for physicians in need.
D Physician Health Program or Employee Assistance Program
You are partially correct. This is definitely one resource to utilize if you’re feeling overwhelmed, distressed, or in need of more formalized and intensive support. Though what we might need and where we feel comfortable asking for help can vary, it’s important to know that some other options listed in this exercise are also resources for physicians in need.
E All of the above
Way to go! When crisis occurs or burnout persists such that one begins to experience mental health challenges, it is important to know the resources that exist for physicians to obtain help. As you have identified, all of the options above are safe places and programs for physicians.

  • Baldwin DC, Daugherty SR. Sleep deprivation and fatigue in residency training: Results of a National survey of first- and second-year residents. Sleep. 2004;27(2):217-23.
  • Boutelle C. Mentors who mitigate. November 18, 2015. Accessed 18 Nov, 2018.
  • Christie JD, Rosen IM, Bellini LM, et al. Prescription drug use and self-prescription among resident physicians. JAMA. 1998;280:1253-5.
  • Davidson SK, Schattner PL. Doctors’ health-seeking behaviour: a questionnaire study. Med J Aust. 2003;179(6):302-5.
  • Deb A. Practical considerations in addressing physician burnout. Continuum (Minneap Minn). 2017;23(2):557-62.
  • Dyrbye LN, Power DV, Massie FS, et al. Factors associated with resilience to and recovery from burnout: a prospective, multi-institutional study of US medical students. Med Educ. 2010;44(10):1016-26.
  • Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ. 2016;50(1):132-49.
  • Gardner M, Lovell G, Williamson P. Physicians you can heal yourself! Cognitive behavioural training reduces stress in GPs. Fam Pract. 2004;21(5):545-51.
  • Ishak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;1(2):236-42.
  • Kealy D, Halli P, Ogrodniczuk JS, Hadkipavlou G. Burnout among Canadian psychiatry residents: A national survey. Can J Psychiatry. 2016;61(11):732-6.
  • Mansukhani MP, Kolla BP, Surani S, Varon J, Ramar K. Sleep deprivation in resident physicians, work hour limitations, and related outcomes: A systematic review of the literature. Postgrad Med. 2012;124(4):241-9.
  • McKenna KM, Hashimoto DA, Maguire MS, Bynum WE 4th. The missing link: connection is the key to resilience in medical education. Acad Med. 2016;91(9):1197-9.
  • Penedo FJ, Dahn JR. Exercise and well-being: A review of mental and physical health benefits associated with physical activity. Curr Opin Psychiatry. 2005;18:189-93.
  • Rabow MW, McPhee SJ. Doctoring to heal. West J Med. 2001;174(1):66-9.
  • Rø KE, Gude T, Tyssen R, Aasland OG. Counselling for burnout in Norwegian doctors: one year cohort study. BMJ. 2008;337:a2004.
  • Rogers E, Polonijo AN, Carpiano RM. Getting by with a little help from friends and colleagues: Testing how residents’ social support networks affect loneliness and burnout. Can Fam Physician. 2016;62(11):e677-e683.
  • Romani M, Ashkar K. Burnout among physicians. Libyan J Med. 2014;9:23556. doi: 10.3402/ljm.v9.23556.
  • Ross S, Liu EL, Rose C, Chou , Battaglioli N. Strategies to enhance wellness in emergency medicine residency training programs. Ann Emerg Med. 2017;70(6):891-7.
  • Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):358-67.
  • Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114(6):513-9.
  • Turkay S. Setting goals: Who, why, how? Manuscript. 2014.
  • Whitehead DC, Thomas H Jr, Slapper DR. A rational approach to shift work in emergency medicine. Ann Emerg Med. 1992;21(10):1250-8.
  • Wiederhold BK, Cipresso P, Pizzioli D, Widerhold M, Riva G. Intervention for physician burnout: a systematic review. Open Med. 2018;13:253-63.
  • Wilde L, Worster B, Oxman D. Monthly “grief rounds” to improve residents’ experience and decrease burnout in medical intensive care unit rotation. Am J Med Qual. 2016;31(4):379.