Functional Neuroimaging Correlates of Burnout among Internal Medicine Residents and Faculty Members.

Steven J Durning,Rebecca S Lipner,Anthony R Artino,Michelle Costanzo,Eric Holmboe,Cees Van Der Vleuten,Lambert Schuwirth,Thomas J Beckman,Liselotte N Dyrbye,Christopher M Wittich,Michael J Roy

doi:10.3389/fpsyt.2013.00131

Abstract

Burnout is prevalent in residency training and practice and is linked to medical error and suboptimal patient care. However, little is known about how burnout affects clinical reasoning, which is essential to safe and effective care. The aim of this study was to examine how burnout modulates brain activity during clinical reasoning in physicians. Using functional Magnetic Resonance Imaging (fMRI), brain activity was assessed in internal medicine residents (n = 10) and board-certified internists (faculty, n = 17) from the Uniformed Services University (USUHS) while they answered and reflected upon United States Medical Licensing Examination and American Board of Internal Medicine multiple-choice questions. Participants also completed a validated two-item burnout scale, which includes an item assessing emotional exhaustion and an item assessing depersonalization. Whole brain covariate analysis was used to examine blood-oxygen-level-dependent (BOLD) signal during answering and reflecting upon clinical problems with respect to burnout scores. Higher depersonalization scores were associated with less BOLD signal in the right dorsolateral prefrontal cortex and middle frontal gyrus during reflecting on clinical problems and less BOLD signal in the bilateral precuneus while answering clinical problems in residents. Higher emotional exhaustion scores were associated with more right posterior cingulate cortex and middle frontal gyrus BOLD signal in residents. Examination of faculty revealed no significant influence of burnout on brain activity. Residents appear to be more susceptible to burnout effects on clinical reasoning, which may indicate that residents may need both cognitive and emotional support to improve quality of life and to optimize performance and learning. These results inform our understanding of mental stress, cognitive control as well as cognitive load theory.

Highlights

Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and a low sense of personal accomplishment [1]
We found that depersonalization scores are associated with reduced BOLD signal in the DLPFC, precuneus, and middle frontal gyrus, and that emotional exhaustion scores are associated with increased BOLD signal in the posterior cingulate cortex and middle frontal gyrus among resident physicians
Our results revealed that emotional exhaustion was associated with significant increase in BOLD signal of the middle frontal gyrus and the posterior cingulate cortex during the task of answering clinical reasoning items

Summary

Introduction

Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and a low sense of personal accomplishment [1]. It is believed that recurrent stressful interactions with patients lead to high emotional exhaustion and depersonalization (e.g., burnout). Longitudinal studies involving medical residents further suggests that burnout predicts subsequent selfreported medical error [8, 10]. These findings coupled with a recent national study of most U.S medical residents that demonstrated substantially worse performance on a standardized medical knowledge assessment among learners with high emotional exhaustion [4] and suggested that burnout may impede cognitive performance

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