Summary thesis

Medical residency is a demanding and challenging period, and burnout is highly prevalent in medical residents. In the Netherlands, approximately one fifth of medical residents have moderate to severe burnout symptoms. Although burnout has significant effects on the health of the individual and on his or her job performance, research on interventions to prevent or reduce burnout in medical residents is limited. Over the last few years, mindfulness-based interventions (MBIs), such as Mindfulness-Based Stress Reduction (MBSR) have been reported to be helpful in decreasing burnout and promoting wellbeing in healthcare professionals. However, hardly any evidence is available on the effectiveness of MBSR in medical residents. The primary aim of this thesis was to examine the effectiveness of MBSR in reducing burnout in medical residents. The following four research questions were addressed:

1)      What are potential contributing factors of burnout and work engagement in medical residents?

In chapter 2 we focused on the potential predictors of burnout in medical residents. We examined the associations of job demands and resources, home demands and resources, and work–home interferences with burnout in male and female medical residents. The study population consisted of a nation-wide sample of medical residents. Path analysis was used to examine the associations between job and home characteristics and work–home interference and burnout in both males and females. In total, 2115 (41.1%) residents completed the questionnaire. In both sexes emotional demands at work and the interference between work and home were important contributing factors of burnout. Opportunities for job development appeared to be an important protective factor. Other contributing and protective factors were different for male and female residents. In females, social support from family or partner seemed protective against burnout. In males, social support from colleagues and participation in decision-making at work seemed important. This study implied that effectively handling emotional demands at work, dealing with the interference between work and home, and having opportunities for job development are essential factors that should be addressed when developing interventions to prevent or reduce burnout in medical residents. However, it is important to take gender differences into consideration when implementing preventive or therapeutic interventions for burnout in medical residents.

While chapter 2 focused on burnout, chapter 3 focused on work engagement in medical residents. In this chapter, the results of a study on the potential predictors of work engagement in the same cross-sectional sample are described. Path analysis was used to examine the associations between the potential predictors and work engagement. Important positive contributing factors of work engagement were opportunities for job development, mental demands at work, positive work[1]home interference and positive home-work interference. Emotional demands at work and negative home-work interference were negatively associated with work engagement and seem to hinder work engagement. The influence of these factors on work engagement was similar in male and female residents. This study implied that opportunities for job development, having challenging work, dealing effectively with emotional demands and home-work interference are of high relevance in enhancing work engagement.

2)      What is the feasibility and effectiveness of MBSR in physicians?

Chapter 4 described the results of a mixed methods pilot study of MBSR in general practitioners (GPs). MBSR is an 8-week group-based intervention, including mindfulness practices and teachings on stress. This study was conducted in order to gain insight into the feasibility and effects of MBSR on burnout, empathy, and (work-related) wellbeing in GPs. A waiting list-controlled pre-/post-study and a qualitative study were conducted. Fifty Dutch GPs participated in this study. The MBSR group reported greater improvements in depersonalization (burnout), dedication (work engagement) and mindfulness skills compared with the control group. There was no change in empathy. The qualitative data indicated that the MBSR course increased their wellbeing and compassion towards themselves and others, including their patients. The study indicated that MBSR for GPs is feasible and might result in fewer burnout symptoms and increased work engagement and wellbeing. However, an adequately powered randomized controlled trial is needed to confirm these findings. 128

3)      What is the effectiveness of MBSR in reducing burnout in medical residents?

In Chapter 5 the outcomes of the randomized controlled trial (RCT) of Mindfulness-Based Stress Reduction (MBSR) in medical residents are reported. In total, 148 medical residents participated in the RCT comparing MBSR with a waitlist-control group. In contrast to our expectations, no significant difference was found between the two groups on the primary outcome, emotional exhaustion (burnout). However, exploratory moderation analysis showed that the intervention outcome was moderated by baseline severity of emotional exhaustion; those with more emotional exhaustion at baseline did seem to benefit. Furthermore, the MBSR group did report significantly greater improvements compared to the control group in reduced personal accomplishment, worry, mindfulness skills, self-compassion and perspective taking (empathy). To conclude, this RCT suggested that although MBSR did not result in a significant reduction of emotional exhaustion in the whole group, residents with high baseline levels of emotional exhaustion seemed to benefit from the intervention. This indicates the potential of MBSR as a burnout intervention for residents. Our findings also indicate that MBSR might be beneficial for medical residents in terms of wellbeing more generally and therefore could have a valuable place in medical residency programs. However, our findings are preliminary and should be interpreted with care. More research is needed in order to confirm these findings. 4) How does MBSR influence the professional development of medical residents?

Chapter 6 described the results of a qualitative study in which we explored how MBSR influences medical residents’ professional development. In-depth, face-to-face interviews were conducted with 19 medical residents. The constant comparison method was used to analyze the data. The analysis of the data resulted in five themes: (1) awareness of thoughts, emotions, bodily sensations and behavior; (2) increased self-reflection; (3) acceptance and non-judgment; (4) increased resilience; and (5) relating to others. Medical residents indicated that the MBSR training increased their awareness and self-reflection at work and that they were more accepting towards themselves and towards their limitations. Furthermore, they mentioned that they were more resilient (the competence to cope and adapt in the face of adversity and to bounce back when stressors become overwhelming) and better at setting priorities and limits. They improved their self-care and work-life balance. In addition, residents indicated that the training made them more aware of how they communicated. They asked for help more often and they seemed to be more open towards feedback. Finally, they indicated an increased sense of compassion for others. This study indicated that mindfulness training can serve as a tool to cultivate important professional competencies for medical residents.