Investigating Burnout Among Fellows

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Burnout is a condition all physicians are vulnerable to. By working long hours, in often stressful conditions, with lives on the line can make stress hormones go into overdrive and push even the most capable and adaptable at risk of burnout. While there is a wealth of peer-reviewed literature about burnout in residents and attending physicians, studies often overlook one important physician group: fellows.

“Fellows are in a unique period of their career where they’re being supervised but are also looking for more autonomy. They don’t fit in either of the buckets [residents and attending physicians] that most of the literature looks at,” says Colleen E. Bennett, MD, MSHP, a first-year General Pediatrics attending physician at Children’s Hospital of Philadelphia. She and Marissa Kilberg, MD, MSEd, a first-year Endocrinology attending physician, have been leading the charge around burnout as it relates to fellows.

Colleen E. Bennett, MD, MSHP and Marissa Kilberg, MD, MSEd (L) Colleen E. Bennett, MD, MSHP and (R) Marissa Kilberg, MD, MSEd Both physicians completed their residency and fellowship programs at CHOP before pursuing their masters’ degrees – Dr. Bennett in health policy research and Dr. Kilberg in medical education. Both physicians are interested in medical education. As Director of Education for the Division of Endocrinology and Diabetes, Dr. Kilberg regularly interacts with rotating residents and fellows. The two doctors served as co-chairs of the Fellows Association Steering Committee in 2018-2019, making them uniquely positioned to examine the effects of burnout on the very population they’re interested in supporting.

Why study burnout?

Drs. Kilberg and Bennett’s work on burnout was conceived after previous research on the topic by Anna K. Weiss, MD, MSEd, an attending physician in the Emergency Department, and Jay Mehta, MD, MS, an attending physician in the Division of Rheumatology and Program Director of CHOP’s Pediatric Residency Program.

Drs. Weiss and Mehta created a quantitative survey on burnout, featuring a burnout inventory list, burnout symptoms, and examining the stigma about receiving care for mental health issues relates to burnout. The pair presented their work to the Fellows Association Steering Committee, where Drs. Kilberg and Bennett reviewed their work and decided to follow up with research of their own.

Drs. Kilberg and Bennett conducted nine focus groups with CHOP fellows – first in-person gatherings, then virtually due to COVID-19 restrictions. The pair used qualitative interviewing methods to analyze the relationship between fellows and burnout.

“We wanted to create a space for constructive conversations,” shares Dr. Bennett. Having recently been fellows themselves, this encouraged the focus groups to be “open and honest,” Dr. Kilberg added.

Many common themes and stressors emerged, including:

  • Differences in levels of autonomy, often impacted by specific staff members, patient load and other stressors
  • Opportunities and missed opportunities for more autonomy/self-direction
  • Transparency in scheduling
  • Challenges related to work-life balance.

Using the data they collected, a recent publication from the National Academy of Sciences, and following a conceptual framework, Drs. Bennett and Kilberg created a “fellows-specific” model for program directors to use.

Dr. Kilberg says their primary goal in creating the fellow-specific model was to “help fellows at CHOP,” but if successful, the model could be used to “help other institutions going forward.”

In addition, the pair met with Mackenzie Frost, MD, MedEd, Director of Fellowship Education in the Department of Pediatrics, to discuss their data and how it might impact the fellowship program in general – such as fellows orientation – and asked to present their work at national meetings such as the Association of Pediatric Program Directors (APPD), Pediatric Academic Societies (PAS) and the Association of American Medical College’s (AAMC) Group on Educational Affairs (GEA) conference. They also plan to share their data in the form of a peer-reviewed manuscript at some point.

Combatting burnout with camaraderie

Another aspect of fellow burnout the doctors are researching includes finding new ways to improve their work and build camaraderie among groups of fellows across the institution.

“There’s a lot of expression of the fellowship experience feeling very siloed,” Dr. Bennett explains. “Each fellowship has its own curriculum and way of functioning; whereas in residency, all the residents are part of the same program.”

Because each fellowship program is unique, Drs. Kilberg and Bennett are researching ways they can better connect fellows with their peers -- particularly as the COVID-19 pandemic remains a public health threat.

Planning for the future

In presenting their work at national meetings, Drs. Bennett and Kilberg have connected with CHOP colleagues and faculty at other institutions who are also pursuing scholarship on burnout. For example, Lilly Buchhalter, MD, a second-year Pediatric Emergency Medicine fellow has been investigating the impact of childcare insecurity on burnout in fellows and presented at the same session as Dr. Kilberg at a recent AAMC GEA meeting. Even through the virtual platform, they were able to connect. Both look forward to future opportunities to collaborate.

Drs. Kilberg and Bennett are also hoping to present at an upcoming Program Directors’ meeting and develop appropriate mental health support for fellows. They’d like to create a resource for fellows like what exists for residents.

For now, however, the physicians want fellows to know that many aspects of burnout are more modifiable than people might realize.

“We sorted things into more modifiable and less modifiable that way we could direct our efforts and make change. And we learned throughout our experience that a lot more than what we’d imagined is modifiable,” says Dr. Kilberg. “Based on what resources program directors have available, they can create a plan of attack and easily address what things to tackle and what things fellows are really looking for.”

Adds Dr. Bennett, “It’s about getting creative and having fellows be a part of the conversation, so you know the best way to address it.”

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