Well-Being in Residency: A Systematic Review

Well-Being in Residency: A Systematic Review

Kristin S. Raj, MD

Citation: Kristin S. Raj (2016) Well-Being in Residency: A Systematic Review. Journal of Graduate Medical Education: December 2016, Vol. 8, No. 5, pp. 674-684.

Journal Club entry by: Karyn King, TUSM-MMC, M18


The rates of physician burnout in the United States have been observed to be higher than those of the general population, in one study by Shanafelt et al (2012) burnout values were determined to be as high as 60% in certain specialties.1 Over the recent years, with increased concern for resident burnout, interventions to address resident wellness have been increasingly incorporated into graduate medical education curriculums across the United States. The objective of this well-being systematic review by Raj (2016) was to review the current literature on resident well-being and identify factors associated with well-being, identify interventions being used to address resident well-being, and provide goals for future resident well-being research. After a review of 26 articles that met inclusion criteria, the author found that several important well-being themes emerged including: sleep, coping mechanisms, resident autonomy, building of competence, and enhanced social relatedness. However, due to the fact that research on resident well-being is in its infancy and that there isn’t one widely accepted and validated tool for measuring resident wellbeing it is difficult to assess the efficacy of current interventions. The author believes that future work in the realm of resident well-being should focus on formation of a validated assessment tool so as to evaluate the broad array of interventions currently being implemented in residencies across the United States.

Discussion questions:

  • What is it about graduate medical education as it stands currently that makes residency such a difficult and stressful time for residents?
  • Did your residency have any interventions to promote well-being and if so, were they effective?
  • Do you feel it is appropriate to put so much effort and funding into resident well-being if for many years residents have progressed through residency and into life as an attending physician without such interventions?
  • If you were building a well-being assessment tool to evaluate resident well-being and the efficacy of well-being interventions what would this tool look like?
  • Do you think it is fair to allocate well-being interventions differently across different residencies based on their generally reported levels of resident burnout?
    1. For example, psychiatry physicians report burnout rates of about 41% while emergency medicine physicians report burnout rates of >60%. Would it be fair to provide more interventions for emergency medicine physicians than their psychiatry colleagues?

For information on a virtual discussion of this article, please see: JGME-ALiEM Hot Topics in Medical Education: An Analysis of a Virtual Discussion on Resident Well-Being

Additional references:

Results of a Flipped Classroom Teaching Approach in Anesthesiology Residents

Results of a Flipped Classroom Teaching Approach in Anesthesiology Residents

By John Gilboy, MS4 Tufts- Maine Track

Given the competing responsibilities of residents to patient care and professional growth, program directors must critically contemplate the most effective means of providing formal learning opportunities. Sparked by Educating Physicians: A Call for Reform of Medical School and Residency1 and fanned by increased student motivation, task value, and engagement, the UGME curriculum has transitioned from the traditional passive transfer of content-centered knowledge to a flipped classroom model emphasizing self-paced asynchronous learning and learner-center activities.2 Despite this fundamental shift, passive lectures still dominate formal education opportunities in weekly resident conferences.

Aiming to optimize knowledge and skill transference to residents, modern researchers are applying flipped classroom principles to graduate medical education.  In a prospective controlled multicenter educational research study of anesthesiology residents, educational content was delivered by either flipped classroom or traditional lecture for a given topic. Residents were assed for knowledge transfer via 40 item multiple choice test, including benchmark (pretest), acquisition (posttest), and retention (4-month retention) tests. Residents’ attitudes towards the flipped classroom were measured with a survey before and after the intervention. Results indicated that the teaching style did not impact knowledge acquisition (posttest adjusted mean = 5%, P= .06; d= 0.48), but that the flipped classroom demonstrated improved retention compared to traditional lectures (retention adjusted mean =6%, P= .014, d= 0.56). In addition to knowledge retention, residents preferred the flipped classroom modality (pre= 46%; post =82%, P< .0001).3

Questions for Discussion

  • Does implementing a flipped classroom model for resident didactics present unique logistical barriers to the residents, teaching attending, and program directors?
  • What aspects of the flipped classroom correspond to increased resident preference? Could similar elements be introduced our current lecture-based of resident curriculum?
  • Does the flipped classroom model present additional opportunities for attending to assess and provide feedback on clinical reasoning, professionalism, and/or teamwork?
  • Does the pre-assignment present a barrier to implementation and resident engagement?

To review article: <Link >


  1. Dooley-Hash S. Educating Physicians: A Call for Reform of Medical School and Residency. 2010;304(11):1240–1241. doi:10.1001/jama.2010.1351
  2. Chen, Fei, Angela M. Lui, and Susan M. Martinelli. “A systematic review of the effectiveness of flipped classrooms in medical education.” Medical Education 51.6 (2017): 585-597.
  3. Martinelli, Chen, Dilorenzo, Mayer, Fairbanks, Moran, . . . Schell. (2017). Results of a Flipped Classroom Teaching Approach in Anesthesiology Residents. Journal of Graduate Medical Education,9(4), 485-490.

Empathy training in medical students – a randomized controlled trial

Empathy training in medical students – a randomized controlled trial

M. Wündrich, C. Schwartz, B. Feige, D. Lemper, C. Nissen & U. Voderholzer

Journal Club Entry by Anne Sprogell, TUSM-Maine Track Program, M18

It is well established that empathy is an important part of the doctor-patient relationship, ultimately leading to better patient satisfaction and outcomes. Given its positive impact on the patient experience, it seems logical that it should be a part of undergraduate medical education. But is empathy something that can be taught? Or is it an innate quality that you either have or you don’t? If it can be taught, what is the best strategy? In this randomized controlled trial of 158 third year medical students at a German university, Wündrich et al. attempt to answer these questions.

Discussion Questions

  1. How do you define empathy? How do you convey empathy in your own everyday practice?
  2. Do you make a delibrate effort to convey empathy to patients, or do you think it is an innate quality that you naturally portray? Is empathy a skill that you learned and that you continue to practice and develop?
  3. When giving feedback to medical students, how often do you include feedback on empathy? What concrete recommendations do you provide?

Nighthawk: Making Night Float Education and Patient Safety Soar

Nighthawk Making Night Float Education and Patient Safety Soar.

Brett W. Sadowski, Hector A. Medina, Joshua D. Hartzell, and William T. Shimeall

Journal of Graduate Medical Education: December 2017, Vol. 9, No. 6, pp. 755-758.

Journal Club Entry by Kimberly Dao, TUSM-Maine Track Program, M18

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) adopted an 80-hour-workweek restriction for residents. In response, many residency programs have implemented night float rotations for patient coverage despite the numerous reports of its negative impacts on patient care and safety, education, and resident satisfaction. To address the educational void created by overnight training, the authors explored a pilot supervision program that sought to optimize patient safety and improve education.The authors found that establishing enhanced supervision, increased teaching, a must-call list, and reduced conflicting resident roles improved education and increased resident satisfaction.


Discussion questions:

  1. What is the night float culture like at Maine Medical Center (MMC)?
  2. What are the measures implemented by the MMC residency programs, if any, addressing patient safety and resident education? Which ones work and which ones don’t?
  3. Where is there an opportunity for improvement? Can MMC benefit from piloting a nighthawk system?
  4. What is the value in night float rotations? Does it still have a place in residency training?

Preparing Fourth-Year Medical Students to Teach During Internship by Haber, Bardach, Vedanthan, et al.

Preparing Fourth-Year Medical Students to Teach During Internship by Haber, Bardach, Vedanthan, et al.

Andy Biedlingmaier, Tufts M18 Student on Medical Education Elective

An important responsibility of the medical intern is to teach medical students, however new interns are not always prepared to assume the role of teacher.  There is a lack of training in teaching techniques at the medical school level, and courses in education are usually elective (i.e., not mandatory) for students. 

The medical school in this article sought to fill this knowledge gap by creating a mandatory course at the end of fourth year composed of four, one-hour classroom sessions over two separate afternoons.  The sessions were as follows:

Session 1:  Promoting understanding and retention in the clinical setting

Format:  Lecture with modeled behavior by speaker

Content: Understand that clinical teaching occurs through small, incremental   transfer of knowledge over many “teachable moments” throughout the day

Session 2:  Evaluating students fairly and giving feedback

Format:  Lecture with modeled behavior by speaker and role-play in pairs

Content:  Identifying educational goals, methods of evaluation, and criteria for effective formative and summative feedback

Session 3:  Q&A panel with residents identified as excellent teachers

Format:  Resident panel answers anonymous questions raised by students

Content:  Specific to the students’ questions

Session 4:  Small group discussions and role-playing

Format:  Discussion and role-play in groups of 6-8 students with 1-2 resident leaders per group

Content:  Clinical scenarios provide opportunity to practice teaching skills

The course was elective from 2000-2002 and mandatory from 2003-2005.  Overall course ratings from 2000-2005 had a mean of 4.4 out of 5 (5= excellent, 1=poor) from 224 completed student questionnaires (62% response rate).  The 2004 class was surveyed at the end of their intern year, and 84% of students agreed that the course helped them prepare for their role as teacher (n=45, response rate 60%). 

Questions for discussion:

1) Should a “teaching to teach” course be mandatory in undergraduate medical education? If so, when should the course occur and for how many classroom hours?

2) Do you agree with the overall content of the sessions? Are there any topics that should be omitted, added, or modified?

3) Other than as mentioned in the discussion, how could future research seek to objectively measure whether or not the course produces improved teaching in medical interns?


Haber, RJ, Bardach, NS, Vedantha, R, et al. Preparing fourth-year medical students to teach during internship.  J Gen Intern Med.  2006; 21: 518-520.

Damned If You Do, Damned If You Don’t: Bias in Evaluations of Female Resident Physicians

“Damned If You Do, Damned If You Don’t: Bias in Evaluations of Female Resident Physicians”-Esther K. Choo, MD, MPH

Journal Club Entry by Sarah Couser, TUSM-Maine Track Program, M18

For 20 years, medical schools have been accepting almost the same number of male and female students. Despite this important achievement, there remains significant gender bias when it comes to training female students and future physicians. The author of this paper discusses a recent study that identified gender bias in the evaluation of male and female third-year emergency residents. The study concludes that female residents receive “discordant feedback” regarding issues of autonomy and assertiveness, characteristically male traits. Esther Choo reflects on how this conflicting information may prevent female residents them from improving clinically.

To reference the study, please refer to this link:

“Gender Differences in Attending Physicians’ Feedback to Residents: A Qualitative Analysis”

Anna S. Mueller, Tania M. Jenkins, Melissa Osborne, Arjun Dayal, Daniel M. O’Connor, and Vineet M. Arora

Discussion questions:

1. Mueller et al. note that women only represent 38% of EM residents across the country. At Maine

Medical Center, women represent approximately ~36% of EM residents (10/28). Do you notice any

distinct differences regarding gender in your own department?

2. Can you think of any instances of gender bias in your workplace? Can you think of a situation in which

you might have been susceptible to bias?

3. What can you do to try and counteract implicit gender bias in the workplace? What can we be more

mindful of?

Are you interesting in learning if you have any implicit biases?

Take the quiz here:


Making the Case for History of Medical Education

Making the Case for History of Medical Education David Jones, Jeremy Greene, Jacalyn, Duffin, John Harley Warnert Journal of the History of Medicine and Allied Sciences. Vol 70, No.4 (2014).

Journal Club Entry by Michael P.H. Stanley, TUSM-Maine Track Program, M18

The history of history in medical education has waxed and waned since as far back as the 18th century. At its zenith in the 1950s and 1960s nearly half of all medical schools had some formal historical teaching, if not full-professorships and sometimes entire history of medicine departments.  In 2001, over 100 of 174 medical schools surveyed had no history offerings or were unsure if they did.  The authors of this paper diverge from more traditional arguments that history of medicine should be considered as one of a number of medical humanities offerings primarily in service of the core domain of Professionalism. Instead they propound that history of medicine is “an essential component of medical knowledge, reasoning, and practice.” The authors assert that by demonstrating how the history of medicine readily engages our competency-based educational objectives, the field can gain acceptance as a regular feature in medical educational curricula.

Discussion questions:

  1. If history of medicine has continued to thrive, why has its introduction and maintenance in medical school curricula waxed and waned so considerably over time?
  2. How is history of medicine different from and similar to other medical humanities (such as narrative medicine, medical ethics, medical aesthetics, etc?). How is it different from and similar to reductionist or natural science medical subjects (such as pathophysiology, biochemistry, etc?).
  3. Is trying to justify history of medicine’s inclusion in medical school curricula through competency-based education inappropriately ascribing reductive measurements to an unmeasurable field? How might programs measure competency or otherwise assess medical students in history of medicine?
  4. Where do you find opportunities for inclusion of history of medicine in your own experience of medical education?

Just Fun or a Predjudice? Physician Stereotypes in Common Jokes and their Attribution to Medical Specialties by Undergraduate Medical Students

This month’s Journal Club post was written by Emily Zarookian, MD based on the article: Just fun or a prejudice? – physician stereotypes in common jokes and their attribution to medical specialties by undergraduate medical students by Sigrid Harendza and Martin Pyra.  

“Have you heard this one?”, the surgical resident asks myself and fellow medical students during our third year general surgery rotation. “How do you hide a $100 dollar bill from an orthopedic surgeon? Put it in a textbook! How do you hide a $100 dollar bill from an internist? Put it under a dressing! How do you hide a $100 dollar bill from a general surgeon? Tape it to his wife’s forehead!”

Most medical students are exposed to jokes regarding stereotypical attributes of various specialties during medical school. In this paper, Harendza and Pyra, attempt to analyze what degree of stereotypes exists among medical students at various stages of training by extracting characteristics from common “doctor jokes” and analyzing how medical students assign these to various specialties over time.

Discussion Questions

  1. Reflecting back on your medical school experience, do you think it is possible your specialty selection was influenced by exposure to commonly held stereotypes regarding what type of personality belongs in which specialty?
  2. Do you think the demonstrated increase in congruent assignments of stereotypical characteristics to specialties over the course of medical school is actually due to stereotypical doctor jokes? Or is there any underlying truth within these jokes which medical students discover with exposure to various specialties?
  3. Is it surprising that the most stereotypes seemed to exist regarding general surgeons and psychiatrists? Why would this be?


Seeking Consistency and Fairness in the Assessment of Professionalism

This month’s Journal Club post was written by Alex Fiorentino, MD, Maine Track ’17, based on the following article:  Basing the Evaluation of Professionalism on Observable Behavior: A Cautionary Tale by Ginsburg, Regehr, and Lingard1.

Though an estimated 90% of U.S. medical schools offer some type of formal instruction in professionalism2, it is difficult for medical educators to agree upon what constitutes professionalism, much less apply a consistent standard of professionalism to trainees3.  In the setting of increasing efforts to evaluate trainees via direct observation of competencies, the authors of the above study set out to assess whether observation of student behaviors can serve as the basis for consistent and legitimate evaluation of professionalism.

Discussion Questions:

  1. How would you define professional behavior – and unprofessional behavior – among medical trainees?
  2. Which is more useful for determining whether a lapse in professionalism has occurred: an account of exactly what a trainee did, or an explanation of why they did it?
  3. Are there situations in medicine in which truthfulness represents an unprofessional course of action, or is lying always unprofessional?
  4. Can professionalism be taught? If so, what would be your ideal method for teaching it?



  1. Ginsburg S, Regehr G, Lingard L. Basing the evaluation of professionalism on observable behaviors: a cautionary tale. Academic Medicine, 2004 Oct;79(10 Suppl):S1-4.
  1. Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in undergraduate medical education. JAMA, 1999 Sep 1;282(9):830-2.
  1. DeAngelis CD. Medical professionalism. JAMA, 2015 May 12;313(18):1837-8. doi: 10.1001/jama.2015.3597.


How Do Residents Spend Their Shift Time? A Time and Motion Study with a Particular Focus on the Use of Computers

How Do Residents Spend Their Shift Time? A Time and Motion Study with a Particular Focus on the Use of Computers

This month’s journal club was written by Benjamin Levin, MD, Maine Track ’16, with reference to the following article: How do residents spend their shift time? A time and motion study with a particular focus on the use of computers, Lena Mamykina, PhD, David Vawdrey, PhD, George Hripcsak, MD, MS, Academic Medicine, Published online March 29, 2016. 

Medicine is constantly evolving; we live in an era where copious amounts of medical information are at our fingertips. With a mandate on EHR usage, residents are spending more time on the computer documenting and looking up patient information.   This access to information and creation of information has altered the practice of medicine and changed resident education.

A recent study published in Academic Medicine recorded and analyzed how residents on a general medicine service used their time with a focus on how they utilize computers. I’ll leave it up to the reader to decide if the results are surprising or not and to think about the following questions.

-Does the distribution of documentation and clinical activity correspond with your own experience?

-Are we experiencing documentation and information overload?

-Is resident education suffering due to the burden of documentation?

-Should there be concerns about quality after examining the results of this study?