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. 2018 Sep 18;320(11):1114–1130. doi: 10.1001/jama.2018.12615

Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians

Liselotte N Dyrbye 1,✉, Sara E Burke 2, Rachel R Hardeman 3, Jeph Herrin 4, Natalie M Wittlin 5, Mark Yeazel 6, John F Dovidio 5, Brooke Cunningham 6, Richard O White 7, Sean M Phelan 8, Daniel V Satele 9, Tait D Shanafelt 10, Michelle van Ryn 11
PMCID: PMC6233627  PMID: 30422299

Key Points

Question

Do rates of burnout and career choice regret among resident physicians vary by clinical specialty?

Findings

In this prospective cohort study of 3588 second-year resident physicians with follow-up since medical school, reported symptoms of burnout occurred in 45.2% of participants and career choice regret in 14.1%. However, there were wide ranges of prevalence by clinical specialty (29.6%-63.8% for burnout symptoms and 7.4%-32.7% for career choice regret).

Meaning

Symptoms of burnout and career choice regret were prevalent among US resident physicians.

Abstract

Importance

Burnout among physicians is common and has been associated with medical errors and lapses in professionalism. It is unknown whether rates for symptoms of burnout among resident physicians vary by clinical specialty and if individual factors measured during medical school relate to the risk of burnout and career choice regret during residency.

Objective

To explore factors associated with symptoms of burnout and career choice regret during residency.

Design, Setting, and Participants

Prospective cohort study of 4732 US resident physicians. First-year medical students were enrolled between October 2010 and January 2011 and completed the baseline questionnaire. Participants were invited to respond to 2 questionnaires; one during year 4 of medical school (January-March 2014) and the other during the second year of residency (spring of 2016). The last follow-up was on July 31, 2016.

Exposures

Clinical specialty, demographic characteristics, educational debt, US Medical Licensing Examination Step 1 score, and reported levels of anxiety, empathy, and social support during medical school.

Main Outcomes and Measures

Prevalence during second year of residency of reported symptoms of burnout measured by 2 single-item measures (adapted from the Maslach Burnout Inventory) and an additional item that evaluated career choice regret (defined as whether, if able to revisit career choice, the resident would choose to become a physician again).

Results

Among 4696 resident physicians, 3588 (76.4%) completed the questionnaire during the second year of residency (median age, 29 [interquartile range, 28.0-31.0] years in 2016; 1822 [50.9%] were women). Symptoms of burnout were reported by 1615 of 3574 resident physicians (45.2%; 95% CI, 43.6% to 46.8%). Career choice regret was reported by 502 of 3571 resident physicians (14.1%; 95% CI, 12.9% to 15.2%). In a multivariable analysis, training in urology, neurology, emergency medicine, and general surgery were associated with higher relative risks (RRs) of reported symptoms of burnout (range of RRs, 1.24 to 1.48) relative to training in internal medicine. Characteristics associated with higher risk of reported symptoms of burnout included female sex (RR, 1.17 [95% CI, 1.07 to 1.28]; risk difference [RD], 7.2% [95% CI, 3.1% to 11.3%]) and higher reported levels of anxiety during medical school (RR, 1.08 per 1-point increase [95% CI, 1.06 to 1.11]; RD, 1.8% per 1-point increase [95% CI, 1.6% to 2.0%]). A higher reported level of empathy during medical school was associated with a lower risk of reported symptoms of burnout during residency (RR, 0.99 per 1-point increase [95% CI, 0.99 to 0.99]; RD, −0.5% per 1-point increase [95% CI, −0.6% to −0.3%]). Reported symptoms of burnout (RR, 3.20 [95% CI, 2.58 to 3.82]; RD, 15.0% [95% CI, 12.8% to 17.3%]) and clinical specialty (range of RRs, 1.66 to 2.60) were both significantly associated with career choice regret.

Conclusions and Relevance

Among US resident physicians, symptoms of burnout and career choice regret were prevalent, but varied substantially by clinical specialty. Further research is needed to better understand these differences and to address these issues.

This survey study investigates risk factors for symptoms of burnout and career choice regret among US physicians during their second year of residency.

Introduction

Burnout, a syndrome that is driven by work-related stressors and characterized by emotional exhaustion, depersonalization, and low sense of personal accomplishment,1 has been associated with a higher frequency of medical errors, lapses in professionalism, impeded learning, problematic alcohol use, and suicidal ideation.2,3,4,5,6 Physicians who report symptoms of burnout are more likely to have career dissatisfaction6,7 and to leave their current practice, retire early, or reduce their clinical hours.8

Studies of US physicians have found substantial differences in the prevalence of symptoms of burnout and career satisfaction by clinical specialty.7,9 For example, in a 2014 study of 6880 US physicians, 46.3% of general pediatricians and 71.6% of emergency medicine physicians reported symptoms of burnout. In a 2008 study of 7905 US surgeons, ophthalmologists and orthopedic surgeons were twice as likely to be satisfied with their career choice as general surgeons.9

To our knowledge, no similar national study has been conducted for resident physicians. Most studies were cross-sectional, conducted in a single institution, and measured factors associated with graduate medical education.2,10,11,12,13,14

Personal factors known to buffer or exacerbate the effects of stress on mental health may also affect burnout and career satisfaction.11,15 These factors include positive coping resources, such as social support, and factors such as anxiety that may compound the effects of stress. Attitudes such as empathy also may buffer the effects of stress.

This longitudinal study assessed symptoms of burnout in a US sample of second-year resident physicians who had been followed up since their first year of medical school. The aims were to (1) explore rates of reported symptoms of burnout and regret of career and specialty choice based on clinical specialty and (2) identify factors measured during medical school that may increase the risk of symptoms of burnout and regret of career and specialty choice by the second year of residency.

Methods

This analysis is derived from a prospective observational study (Cognitive Habits and Growth Evaluation Study) designed to examine changes in medical trainees’ well-being, experiences, and attitudes from medical school through residency. Self-reported data from repeated questionnaires by the same respondents were used to assess the 2 study aims.

Study Sample

The methods used in this study have been reported.16 Briefly, first-year medical students attending a stratified random sample of 49 allopathic US medical schools were invited to participate in the study between October 2010 and January 2011 (Figure). Four years later, during the spring of 2014 (January-March), those who had provided written informed consent and completed the baseline questionnaire (ie, baseline responders) were invited to complete the year 4 medical school questionnaire (MS4 questionnaire). During the spring of 2016, baseline responders were invited to complete the second-year resident questionnaire (postgraduate year 2 [PGY-2] questionnaire).

Figure. Flow of Participants in the Cognitive Habits and Growth Evaluation Study.

Figure.

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aOf the 4732 medical students who responded to the baseline questionnaire, 34 quit pursuing a doctor of medicine (MD) degree and 2 died, leaving 4696 resident physicians invited to respond to the PGY-2 questionnaire.

Participants received financial incentives for each questionnaire they completed. The institutional review boards at the University of Minnesota, Oregon Health & Science University, and the Mayo Clinic approved the study. Participants who gave consent and completed both the MS4 and the PGY-2 questionnaires were included in this study.

Exposure

The PGY-2 questionnaire asked participants to indicate the clinical specialty of their current residency training program. Similar training programs were combined as follows: diagnostic radiology, nuclear medicine, and radiology oncology were combined into radiology and child neurology, neurology, and neurodevelopmental disabilities were combined into neurology.

The baseline questionnaire included standard questions to measure demographic characteristics (year of birth, sex, race, ethnicity, country of birth). Race and ethnicity were included in the analysis because previous studies have suggested a relationship between race and ethnicity and the mental health of medical students and resident physicians.17,18,19

The MS4 questionnaire asked participants to report their US Medical Licensing Examination (USMLE) Step 1 score and educational debt. The PGY-2 questionnaire included questions to update demographic characteristics (relationship status, parental status, whether had children <5 years of age, and household income during residency). Fixed-response options to items were provided.

The MS4 questionnaire included the Patient-Reported Outcome Measurement Information System anxiety short form,20,21 8 items from the Jefferson Scale of Physician Empathy (JSPE),22,23,24 and the Tangible Support and Emotional Support subscales from the Medical Outcomes Study Social Support Measure.25 The Patient-Reported Outcome Measurement Information System anxiety short form was developed and validated by the National Institutes of Health.20,21 For this instrument, respondents indicated the frequency of experiencing various emotions on a 5-point scale. Response options ranged from “never” to “very often” (score range, 4-20) and a higher score indicated greater anxiety.

The JSPE measures attitudes toward the value of physician empathy in clinical encounters and has well-established psychometric properties.22,23,24 At baseline, 2 of the 3 JSPE subscales (Perspective Taking and Standing in the Patient’s Shoes subscales) were administered.23,24 Using data from the baseline responders, factor analysis indicated that 4 items did not translate meaningfully, and those 4 items were subsequently excluded from the MS4 questionnaire. Respondents indicated their level of agreement on a 7-point scale for the JSPE. Response options ranged from “strongly disagree” to “strongly agree” (score range, 7-56) and a higher score indicated greater empathic orientation.

For the Tangible Support and Emotional Support subscales from the Medical Outcomes Study Social Support Measure, respondents rated how often various types of support were available to them on a 5-point scale. Response options ranged from “none of the time” to “all of the time” (score range, 1-5) and a higher score indicated better social support.25 Although the minimal clinically important differences for these scale measures have not been established for this population, a magnitude of change between 0.25 and 0.50 SD from the mean for the studied population is likely to indicate that an important change has occurred.26,27

Main Outcomes and Measures

Symptoms of Burnout

Although the full Maslach Burnout Inventory (MBI) is the reference standard for measuring symptoms of burnout,1 its length limits its utility in large questionnaires. Therefore, symptoms of burnout were measured at the PGY-2 time point using 2 single-item measures adapted from the full MBI and previously demonstrated in multiple samples including more than 10 000 physicians and medical students to stratify the risk of burnout.28,29 Compared with the full MBI domain scores, the areas under the receiver operating characteristic curve in these studies28,29 were 0.94 for the single item of emotional exhaustion and 0.93 for the single item of depersonalization and the positive likelihood ratios were 14.9 and 23.4, respectively.

In the same studies,28,29 a 1-point increase in the score for the single item of emotional exhaustion was associated with an increase of 3% to 4% in suicidal ideation and an increase of 3% in perceived major medical error. Similarly, a 1-point increase in the score for the single item of depersonalization was associated with an increase of 5% to 6% in suicidal ideation and an increase of 5% in perceived major medical error.20,21 Respondents in the current study indicated the frequency of experiencing burnout-related feelings or emotions (“I feel burned out from my work” and “I’ve become more callous toward people since I started this job”) on a 7-point scale. Response options ranged from “never” to “every day.” Those with a high score (frequency ≥once per week) on the emotional exhaustion or depersonalization items were considered to have symptoms of burnout.28,29 This approach has been used previously in national studies of US physicians.4,7

Career and Specialty Choice Regret

Regret regarding career and specialty choice were assessed at the PGY-2 time point with questions based on similar items from prior physician questionnaires.9,30 Resident physicians were asked, “If you could revisit your career choice, would you choose to become a physician again?” and “If you could revisit your specialty choice, would you choose the same specialty again?” Response options were “definitely not,” “probably not,” “maybe,” “probably,” and “definitely yes.” Responses of “probably not” or “definitely not” indicated career and specialty choice regret.

Statistical Analyses

Standard summary statistics were used to characterize the sample. Respondents were initially sampled by medical school, therefore, an assumption was not made that the outcomes were independent of the school from which they graduated. Instead, we assessed the intraschool correlation for each outcome to assess for such autocorrelation within school. All intraclass correlation coefficients were less than 1% and model convergence proved problematic when including school as a random effect, therefore, fixed-effects logistic regression models were used for all analyses with robust standard errors adjusted for clustering by school. The outcome rate was not close to 0 or 1, making interpretation of odds ratios difficult, therefore, all effects were transformed from the logistic models into relative risks (RRs) using marginal probabilities.

In addition to specialty, each model included the following fixed set of covariates, which were identified as potential confounders or effect modifiers of the association between specialty and the dependent variables: demographics, educational debt, USMLE Step 1 score, and scores for anxiety, empathy, and social support measured during year 4 of medical school. An overall symptom of burnout variable was added to the models for career and specialty choice regret.

In all models, internal medicine was the reference specialty because it was the most common among the resident physicians studied. P values from the Wald test are reported for categorical variables. All bivariable and multivariable models used multiple imputation with 20 imputations to account for missing values.

All tests were 2-sided and significance was defined as P < .05. All comparisons were performed using SAS version 9 (SAS Institute Inc) and Stata version 15.1 (StataCorp).

Results

Between October 2010 and January 2011, 4732 (81.2%) of 5823 first-year medical students completed the baseline questionnaire (Figure). Of 4732 baseline responders, 3994 (84%) completed the MS4 questionnaire from January to March 2014. There were 204 baseline responders who were ineligible to participate for the MS4 questionnaire (the reasons for ineligibility appear in the Figure).

In 2016, we were unable to contact 775 of the 4732 baseline responders to invite them to complete the PGY-2 questionnaire. In addition to the 775, there were 34 baseline responders who were no longer pursuing medicine (and not invited to complete the PGY-2 questionnaire) and 2 who had died. Of the 3921 baseline responders we were able to contact, 244 were not eligible for the PGY-2 questionnaire due to not being a second-year resident. Overall, 3588 (90% of 3994 MS4 responders, 76% of 4732 baseline completers, and 42% of all 8594 first-year students) responded to the PGY-2 questionnaire. The last day of follow-up was July 31, 2016.

The characteristics of the study participants appear in Table 1. The demographic characteristics were generally similar to all US resident physicians.32,33 With respect to parental and marital status, the demographic characteristics of those who responded to both the baseline questionnaire and the PGY-2 questionnaire were similar to those who did not respond to the PGY-2 questionnaire (eTable in Supplement 1). Those who responded to both questionnaires were slightly more likely to be female (50.8% vs 47.1%), younger than 24 years of age (74.0% vs 70.6%), white (65.8% vs 59.2%), and be born in the United States (85.6% vs 80.3%) and less likely to be Hispanic (5.4% vs 8.2%) (P < .05 for all comparisons).

Table 1. Characteristics of US Resident Physicians.

US Resident Physicians
(N = 3588)
Specialty, No. (%)a
Internal medicine 815 (22.7)
Dermatology 71 (2.0)
Radiologyb 198 (5.5)
Emergency medicine 301 (8.4)
Family medicine 306 (8.5)
Anesthesiology 255 (7.1)
Neurologyc 87 (2.4)
Obstetrics and gynecology 234 (6.5)
Pathology 49 (1.4)
Pediatrics 412 (11.5)
Physical medicine and rehabilitation 30 (0.8)
Psychiatry 148 (4.1)
Surgery (general) 199 (5.5)
Other surgeryd 56 (1.6)
Ophthalmology 95 (2.6)
Orthopedic surgery 153 (4.3)
Otolaryngology 67 (1.9)
Plastic surgery 27 (0.8)
Neurological surgery 26 (0.7)
Urology 59 (1.6)
Symptoms of burnout, No./total No. (%)e 1615/3574 (45.2)
Measured during year 4 of medical school, mean (SD)
Anxietyf 10.7 (3.7)
Empathyg 50.2 (5.5)
Emotional social supporth 4.3 (0.8)
Tangible social supporth 3.9 (1.1)
Age in 2016, median (interquartile range), yi,j 29.0 (28.0-31.0)
Sex, No. (%)i (n = 3579)
Male 1750 (48.9)
Female 1822 (50.9)
Other 7 (0.2)
Race/ethnicity, No. (%)i (n = 3550)
White 2354 (66.3)
Black 142 (4.0)
East Asian 444 (12.5)
South Asian 307 (8.6)
American Indian or Alaskan Native 1 (0.03)
Native Hawaiian or Pacific Islander 10 (0.3)
Multiracial 183 (5.2)
Unknownk 109 (3.1)
Not Hispanic or Latino, No./total No. (%)i 3347/3527 (94.9)
Single relationship status, No./total No. (%)a 1852/3532 (52.4)
Parental status, No. (%) (n = 3540)
No childrena 3067 (86.6)
No children <5 y of age 3120 (88.1)
Born in United States, No./total No. (%)i 2760/3213 (85.9)
Household income during residency, No. (%)a (n = 3528)
<$49 000 376 (10.7)
$50 000-$74 999 1802 (51.1)
$75 000-$99 999 497 (14.1)
$100 000-$249 999 806 (22.8)
≥$250 000 47 (1.3)
Educational debt quartile, No. (%)a (n = 2970)
Highest (≥$210 000) 748 (25.2)
Second highest ($150 000-$209 999) 833 (28.0)
Second lowest ($60 000-$149 999) 650 (21.9)
Lowest ($<60 000) 739 (24.9)
US Medical Licensing Examination Step 1 score, No. (%)l (n = 3214)
≤200 154 (4.8)
201-210 259 (8.1)
211-220 378 (11.8)
221-230 593 (18.5)
231-240 634 (19.7)
241-250 619 (19.3)
251-260 443 (13.8)
≥261 134 (4.2)
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a

Data derived from the questionnaire during the second year of residency.

b

Includes diagnostic radiology, nuclear medicine, and radiology oncology.

c

Includes child neurology, neurology, and neurodevelopmental disabilities.

d

Includes integrated thoracic surgery and integrated vascular surgery, among others.

e

Positive for symptoms of burnout if had a score of 5 (≥once per week) or higher (range, 1-7) on either of 2 questions. Taken from the Maslach Burnout Inventory, one question was on “emotional exhaustion” and the other was on “depersonalization.”

f

The score range is 4-20; higher scores indicate greater anxiety. The Patient-Reported Outcome Measurement Information System anxiety short form was used. A raw score of 10 converts to a t score of 59.5 (SE, 2.6), which is approximately 1 SD above the US general population mean.

g

The score range is 7-56; higher scores indicate greater empathic orientation. Eight items from the Jefferson Scale of Physician Empathy were used.

h

The score range is 1-5; higher scores indicate better social support. The Tangible Support and Emotional Support subscales from the Medical Outcomes Study Social Support Measure were used. An Emotional Support subscale score of 4.3 transforms on a 0-100 scale to 82.5, which is higher than the population norm of 69.9. A Tangible Support subscale score of 3.9 transforms on a 0-100 scale to 72.5, which is higher than the population norm of 69.8.31

i

Data derived from baseline medical school questionnaire.

j

Age calculated from year of birth to 2016.

k

Respondent indicated unknown race. Response was considered missing if the respondent did not answer the question.

l

Self-reported on the questionnaire during year 4 of medical school. The score range is 1-300; higher scores indicate better performance. Most examinees score in the range of 140-260.

Symptoms of emotional exhaustion at least weekly were reported by 1272 of 3574 resident physicians (35.6% [99% CI, 34.0%-37.2%]) and 1246 of 3574 resident physicians (34.9% [99% CI, 33.3%-36.5%]) reported symptoms of depersonalization at least weekly. Both high emotional exhaustion and high depersonalization were reported by 903 of 3574 resident physicians (25.3% [95% CI, 23.9%-26.7%]). Overall, 1615 of 3574 resident physicians (45.2% [95% CI, 43.6%-46.8%]) reported at least 1 symptom of burnout at least weekly.

In terms of career and specialty choice regret, 502 of 3571 resident physicians (14.1% [95% CI, 12.9%-15.2%]) reported that they would “definitely not” or “probably not” choose to become a physician again and 253 of 3570 resident physicians (7.1% [95% CI, 6.3%-8.0%]) indicated they would “definitely not” or “probably not” choose the same specialty if given the chance to revisit their career and specialty choice.

Reported symptoms of burnout during the second year of residency appear in Table 2 by demographic characteristics; specialty; reported levels of anxiety, social support, and empathy during year 4 of medical school; and USMLE Step 1 score. Substantial variation in reported symptoms of burnout among second-year resident physicians was observed by clinical specialty (Wald P < .001). In multivariable models, after controlling for demographics, educational debt, USMLE Step 1 score, and levels of anxiety, empathy, and social support during year 4 of medical school, training in urology, neurology, emergency medicine, and general surgery were significantly associated with higher RRs of reported symptoms of burnout during the second year of residency (range of RRs, 1.24-1.48) relative to training in internal medicine. In contrast, training in dermatology (RR, 0.62 [95% CI, 0.37 to 0.87]; risk difference [RD], −16.4% [95% CI, −27.1% to −5.7%]) and pathology (RR, 0.63 [95% CI, 0.34 to 0.93]; RD, −15.8% [95% CI, −29.3% to −2.4%]) was associated with lower RRs for reported symptoms of burnout during the second year of residency relative to training in internal medicine (Table 2).

Table 2. Association of Resident Specialty and Characteristics With Symptoms of Burnout.

Burnout Status Burnout
Prevalence, %		 Bivariable Analysis Multivariable Analysis
No.
With
Burnouta 		No.
Without
Burnout		 Absolute Risk Difference,
% (95% CI)b 		Relative Risk
(95% CI)b 		Wald P Value Absolute Risk Difference,
% (95% CI)b 		Relative Risk
(95% CI)b 		Wald P Value
Specialtyc
Internal medicine 346 466 42.6 1 [Reference] 1 [Reference] <.001 1 [Reference] 1 [Reference] <.001
Dermatology 21 50 29.6 −13.0 (−24.2 to −1.9) 0.69 (0.44 to 0.95) −16.4 (−27.1 to −5.7) 0.62 (0.37 to 0.87)
Radiology 70 128 35.4 −7.3 (−14.7 to 0.2) 0.83 (0.66 to 1.00) −7.8 (−16.1 to 0.4) 0.82 (0.64 to 1.00)
Emergency medicine 161 138 53.8 11.2 (4.6 to 17.8) 1.26 (1.10 to 1.43) 14.6 (8.8 to 20.5) 1.34 (1.18 to 1.50)
Family medicine 113 191 37.2 −5.4 (−11.8 to 1.0) 0.87 (0.73 to 1.02) −3.0 (−10.6 to 4.5) 0.93 (0.76 to 1.10)
Anesthesiology 107 145 42.5 −0.2 (−7.1 to 6.8) 1.00 (0.83 to 1.16) 0.2 (−7.6 to 8.0) 1.00 (0.82 to 1.19)
Neurology 53 33 61.6 19.0 (8.2 to 29.8) 1.45 (1.18 to 1.71) 20.8 (8.8 to 32.9) 1.48 (1.18 to 1.79)
Obstetrics and gynecology 114 119 48.9 6.3 (−0.9 to 13.6) 1.15 (0.97 to 1.32) 3.2 (−4.4 to 10.8) 1.07 (0.89 to 1.26)
Pathology 17 32 34.7 −7.9 (−21.7 to 5.8) 0.81 (0.49 to 1.13) −15.8 (−29.3 to −2.4) 0.63 (0.34 to 0.93)
Pediatrics 178 234 43.2 0.6 (−5.3 to 6.5) 1.01 (0.88 to 1.15) −0.8 (−8.0 to 6.4) 0.98 (0.82 to 1.15)
Physical medicine and rehabilitation 15 15 50.0 7.4 (−10.8 to 25.6) 1.17 (0.74 to 1.60) 10.1 (−13.6 to 33.8) 1.23 (0.67 to 1.80)
Psychiatry 65 83 43.9 1.3 (−7.4 to 10.0) 1.03 (0.83 to 1.24) 0.7 (−10.2 to 11.7) 1.02 (0.76 to 1.27)
Surgery (general) 107 92 53.8 11.2 (3.4 to 18.9) 1.26 (1.07 to 1.45) 10.2 (1.6 to 18.8) 1.24 (1.02 to 1.45)
Other surgery 27 29 48.2 5.6 (−7.9 to 19.1) 1.13 (0.81 to 1.45) 7.2 (−8.9 to 23.4) 1.17 (0.79 to 1.54)
Ophthalmology 53 42 55.8 13.2 (2.6 to 23.7) 1.31 (1.05 to 1.57) 6.9 (−3.4 to 17.2) 1.16 (0.91 to 1.41)
Orthopedic surgery 76 77 49.7 7.1 (−1.6 to 15.7) 1.17 (0.96 to 1.37) 8.7 (−1.9 to 19.3) 1.20 (0.95 to 1.46)
Otolaryngology 30 37 44.8 2.2 (−10.2 to 14.5) 1.05 (0.76 to 1.34) −1.2 (−15.8 to 13.4) 0.97 (0.63 to 1.31)
Plastic surgery 12 15 44.4 1.8 (−17.2 to 20.9) 1.04 (0.60 to 1.49) 2.2 (−17.5 to 21.9) 1.05 (0.59 to 1.51)
Neurological surgery 13 12 52.0 9.4 (−10.5 to 29.3) 1.22 (0.75 to 1.69) 8.7 (−14.6 to 32.0) 1.20 (0.65 to 1.75)
Urology 37 21 63.8 21.2 (8.4 to 34.0) 1.50 (1.18 to 1.81) 19.4 (5.6 to 33.1) 1.45 (1.11 to 1.79)
Measured during year 4 of medical school, mean (SD)
Anxietyd 11.5 (3.7) 10.1 (3.6) 1.8 (1.6 to 1.9) 1.08 (1.06 to 1.10) <.001 1.8 (1.6 to 2.0) 1.08 (1.06 to 1.11) <.001
Empathye 49.8 (5.8) 50.6 (5.2) −0.5 (−0.6 to −0.4) 0.99 (0.99 to 0.99) <.001 −0.5 (−0.6 to −0.3) 0.99 (0.99 to 0.99) <.001
Emotional supportf 4.2 (0.8) 4.4 (0.8) −4.6 (−6.2 to −3.0) 0.93 (0.92 to 0.95) <.001 −1.2 (−4.7 to 2.2) 0.98 (0.91 to 1.04) .49
Tangible supportf 3.8 (1.1) 4.0 (1.0) −3.4 (−4.9 to −1.9) 0.94 (0.92 to 0.96) .001 −1.70 (−3.98 to 0.60) 0.97 (0.93 to 1.00) .14
Age in 2016, mean (SD), yg,h 29.8 (2.3) 29.8 (2.5) −0.1 (−0.8 to 0.6) 1.00 (0.98 to 1.01) .27 0.1 (−0.6 to 0.8) 1.00 (0.99 to 1.02) .81
Sexg
Male 726 1022 41.5 1 [Reference] 1 [Reference] .002 1 [Reference] 1 [Reference] .003
Female 885 930 48.8 7.2 (4.0 to 10.5) 1.17 (1.09 to 1.26) 7.2 (3.1 to 11.3) 1.17 (1.07 to 1.28)
Other 2 5 28.6 −13.0 (−46.5 to 20.6) 0.69 (−0.12 to 1.49) −8.9 (−42.6 to 24.9) 0.79 (−0.02 to 1.60)
Raceg
White 1036 1257 45.2 1 [Reference] 1 [Reference] .89 1 [Reference] 1 [Reference] .46
Nonwhite 536 646 45.3 0.2 (−3.3 to 3.6) 1.00 (0.93 to 1.08) −1.4 (−5.0 to 2.3) 0.97 (0.89 to 1.05)
Ethnicityg
Hispanic or Latino 95 85 52.8 1 [Reference] 1 [Reference] .09 1 [Reference] 1 [Reference] .09
Not Hispanic or Latino 1486 1852 44.5 −8.1 (−15.6 to −0.6) 0.85 (0.73 to 0.97) −7.1 (−15.1 to 1.0) 0.86 (0.73 to 1.00)
Relationship statusc
Single 856 996 46.2 1 [Reference] 1 [Reference] .31 1 [Reference] 1 [Reference] .22
Married or domestic partner 738 942 43.9 −2.3 (−5.6 to 1.0) 0.95 (0.88 to 1.02) 3.4 (−2.1 to 8.9) 1.08 (0.95 to 1.21)
Parental statusc
No children 1422 1644 46.4 1 [Reference] 1 [Reference] <.001 1 [Reference] 1 [Reference] .10
≥1 Child 176 297 37.2 −9.1 (−13.8 to −4.4) 0.80 (0.70 to 0.90) −12.7 (−26.9 to 1.6) 0.73 (0.44 to 1.02)
Have children <5 y of age
No 1441 1678 46.2 1 [Reference] 1 [Reference] .003 1 [Reference] 1 [Reference] .25
Yes 157 263 37.4 −8.8 (−13.7 to −3.8) 0.81 (0.71 to 0.92) 8.9 (−6.0 to 23.7) 1.20 (0.86 to 1.54)
Birth locationg
Other country 190 261 42.1 1 [Reference] 1 [Reference] .13 1 [Reference] 1 [Reference] .07
United States 1260 1492 45.8 3.6 (−1.3 to 8.5) 1.09 (0.96 to 1.21) 4.4 (−0.3 to 9.1) 1.11 (0.98 to 1.23)
Household income during residency, $c
<49 000 173 203 46.0 1 [Reference] 1 [Reference] .14 1 [Reference] 1 [Reference] .13
50 000-74 999 830 972 46.1 0.1 (−5.5 to 5.7) 1.00 (0.88 to 1.12) 1.2 (−4.3 to 6.7) 1.03 (0.90 to 1.15)
75 000-99 999 200 297 40.2 −5.5 (−12.1 to 1.1) 0.88 (0.75 to 1.01) −4.1 (−11.6 to 3.4) 0.91 (0.75 to 1.07)
100 000-249 999 365 440 45.3 −0.6 (−6.7 to 5.5) 0.99 (0.85 to 1.12) 0.2 (−7.2 to 7.5) 1.00 (0.84 to 1.17)
≥250 000 25 22 53.2 7.4 (−7.8 to 22.5) 1.16 (0.82 to 1.50) 5.6 (−7.9 to 19.0) 1.12 (0.82 to 1.43)
Educational debt >$1000c
Yes 1281 1567 45.0 1 [Reference] 1 [Reference] .57 1 [Reference] 1 [Reference] .99
No 180 208 46.4 1.4 (−3.8 to 6.5) 1.03 (0.91 to 1.15) 0 (−5.0 to 5.0) 1.00 (0.89 to 1.11)
US Medical Licensing Examination Step 1 scorei
≤200 66 88 42.9 1 [Reference] 1 [Reference] .13 1 [Reference] 1 [Reference] .18
201-210 102 157 39.4 −2.5 (−12.3 to 7.2) 0.94 (0.72 to 1.16) −2.1 (−10.6 to 6.3) 0.95 (0.76 to 1.14)
211-220 167 210 44.3 1.6 (−7.7 to 10.9) 1.04 (0.81 to 1.26) 1.5 (−6.5 to 9.6) 1.04 (0.84 to 1.23)
221-230 283 308 47.9 4.9 (−3.9 to 13.7) 1.12 (0.89 to 1.34) 4.0 (−3.2 to 11.2) 1.09 (0.91 to 1.27)
231-240 301 332 47.6 4.4 (−4.3 to 13.2) 1.10 (0.88 to 1.33) 4.3 (−3.6 to 12.3) 1.10 (0.90 to 1.30)
241-250 260 356 42.2 −0.5 (−9.3 to 8.3) 0.99 (0.78 to 1.19) −0.6 (−8.3 to 7.1) 0.99 (0.81 to 1.16)
251-260 211 231 47.7 4.7 (−4.6 to 14.0) 1.11 (0.88 to 1.35) 5.0 (−3.2 to 13.3) 1.12 (0.91 to 1.33)
≥261 63 71 47.0 4.3 (−7.4 to 16.0) 1.10 (0.81 to 1.39) 5.0 (−4.1 to 14.0) 1.12 (0.89 to 1.34)
Open in a new tab
a

Positive for symptoms of burnout if had a score of 5 (≥once per week) or higher (range, 1-7) on either of 2 questions. Taken from the Maslach Burnout Inventory, one question was on “emotional exhaustion” and the other was on “depersonalization.” The C statistic for the model was 0.66 (pseudo R2 = 0.06).

b

A higher relative risk is less desirable. Relative risk represents risk of reported symptoms of burnout in the categorical group relative to the reference group. Risk difference or absolute risk reduction is the change in risk of burnout relative to the reference group. For age, anxiety, empathy, emotional support, and tangible support, the relative risk and risk difference indicate the incremental increase in the relative risk of symptoms of burnout associated with each 1-unit increase in age or scores. All models used multiple imputation with 20 imputations to account for missing values.

c

Data derived from the questionnaire during the second year of residency.

d

The score range is 4-20; higher scores indicate greater anxiety. The Patient-Reported Outcome Measurement Information System anxiety short form was used. A raw score of 10 converts to a t score of 59.5 (SE, 2.6), which is approximately 1 SD above the US general population mean.

e

The score range is 7-56; higher scores indicate greater empathic orientation. Eight items from the Jefferson Scale of Physician Empathy were used.

f

The score range is 1-5; higher scores indicate better social support. The Tangible Support and Emotional Support subscales from the Medical Outcomes Study Social Support Measure were used. An Emotional Support subscale score of 4.3 transforms on a 0-100 scale to 82.5, which is higher than the population norm of 69.9. A Tangible Support subscale score of 3.9 transforms on a 0-100 scale to 72.5, which is higher than the population norm of 69.8.31

g

Data derived from baseline medical school questionnaire.

h

Age calculated from year of birth to 2016.

i

Self-reported on the questionnaire during year 4 of medical school. The score range is 1-300; higher scores indicate better performance. Most examinees score in the range of 140-260.

Female sex was associated with a higher RR of reported symptoms of burnout (RR, 1.17 [95% CI, 1.07 to 1.28]; RD, 7.2% [95% CI, 3.1% to 11.3%]). A higher anxiety score during year 4 of medical school was associated with a higher RR for reported symptoms of burnout during the second year of residency (RR, 1.08 per 1-point increase [95% CI, 1.06 to 1.11]; RD, 1.8% [95% CI, 1.6% to 2.0%]). In contrast, a higher empathy score during year 4 of medical school (RR, 0.99 per 1-point increase [95% CI, 0.99 to 0.99]; RD, −0.5% [95% CI, −0.6% to −0.3%) was associated with a lower RR for reported symptoms of burnout during the second year of residency. The C statistic for the model was 0.66 (pseudo R2 = 0.06).

Career and Specialty Choice Regret

During the second year of residency, data on reported regret for career choice appear in Table 3 and regret for specialty choice appear in Table 4; both tables contain demographic characteristics, specialty, reported symptoms of burnout during the second year of residency (on the PGY-2 questionnaire), levels of anxiety, social support, empathy during year 4 of medical school, and USMLE Step 1 score. After controlling for other factors, symptoms of burnout were associated with a higher RR for career choice regret (RR, 3.20 [95% CI, 2.58 to 3.82]; RD, 15.0% [95% CI, 12.8% to 17.3%]; Table 3).

Table 3. Association of Resident Specialty and Characteristics With Career Choice Regret.

Career Choice Regret Status Career Choice Regret Prevalence, % Bivariable Analysis Multivariable Analysis
No.
With
Career Choice Regreta 		No.
Without
Career Choice Regret		 Absolute Risk Difference,
% (95% CI)b 		Relative Risk
(95% CI)b 		Wald P Value Absolute Risk Difference,
% (95% CI)b 		Relative Risk
(95% CI)b 		Wald P Value
Specialtyc
Internal medicine 99 713 12.2 1 [Reference] 1 [Reference] <.001 1 [Reference] 1 [Reference] .002
Dermatology 11 60 15.5 3.3 (−5.4 to 12.0) 1.27 (0.54 to 2.00) 7.0 (−1.7 to 15.7) 1.54 (0.85 to 2.24)
Radiology 33 165 16.7 4.5 (−1.2 to 10.1) 1.37 (0.87 to 1.86) 7.1 (−0.5 to 14.7) 1.55 (0.91 to 2.18)
Emergency medicine 34 264 11.4 −0.8 (−5.0 to 3.5) 0.94 (0.59 to 1.28) −3.0 (−6.7 to 0.8) 0.77 (0.49 to 1.05)
Family medicine 27 275 8.9 −3.3 (−7.2 to 0.7) 0.73 (0.44 to 1.03) −4.0 (−8.0 to 0.1) 0.69 (0.40 to 0.99)
Anesthesiology 52 200 20.6 8.4 (3.0 to 13.9) 1.69 (1.18 to 2.21) 8.5 (2.8 to 14.2) 1.66 (1.19 to 2.13)
Neurology 15 71 17.4 5.2 (−3.1 to 13.6) 1.43 (0.72 to 2.14) 3.1 (−4.4 to 10.7) 1.24 (0.65 to 1.83)
Obstetrics and gynecology 28 205 12.0 −0.2 (−4.9 to 4.6) 0.99 (0.60 to 1.37) −2.9 (−7.8 to 2.0) 0.78 (0.41 to 1.14)
Pathology 16 33 32.7 20.5 (7.1 to 33.8) 2.68 (1.49 to 3.86) 20.7 (5.2 to 36.1) 2.60 (1.30 to 3.89)
Pediatrics 56 356 13.6 1.4 (−2.6 to 5.4) 1.11 (0.77 to 1.46) −0.1 (−3.7 to 3.6) 1.00 (0.71 to 1.28)
Physical medicine and rehabilitation 5 25 16.7 4.5 (−9.0 to 18.0) 1.37 (0.24 to 2.49) 8.2 (−7.0 to 23.3) 1.63 (0.44 to 2.82)
Psychiatry 25 123 16.9 4.7 (−1.7 to 11.1) 1.39 (0.83 to 1.94) 4.0 (−2.3 to 10.4) 1.31 (0.80 to 1.82)
Surgery (general) 38 161 19.1 6.9 (1.0 to 12.8) 1.57 (1.03 to 2.10) 2.7 (−1.4 to 6.9) 1.21 (0.87 to 1.55)
Other surgery 8 48 14.3 2.1 (−7.3 to 11.5) 1.17 (0.39 to 1.95) −2.0 (−8.8 to 4.8) 0.85 (0.33 to 1.36)
Ophthalmology 15 80 15.8 3.6 (−4.1 to 11.3) 1.30 (0.65 to 1.94) 2.8 (−5.6 to 11.1) 1.21 (0.55 to 1.88)
Orthopedic surgery 19 134 12.4 0.2 (−5.5 to 5.9) 1.02 (0.55 to 1.49) −0.8 (−6.5 to 4.8) 0.94 (0.50 to 1.37)
Otolaryngology 6 61 9.0 −3.2 (−10.4 to 4.0) 0.73 (0.16 to 1.31) −2.7 (−13.3 to 7.9) 0.79 (−0.02 to 1.60)
Plastic surgery 2 25 7.4 −4.8 (−14.9 to 5.3) 0.61 (−0.21 to 1.43) −8.5 (−17.0 to 0.1) 0.35 (−0.30 to 0.99)
Neurological surgery 4 21 16.0 3.8 (−10.7 to 18.4) 1.31 (0.11 to 2.52) 2.0 (−11.0 to 15.0) 1.15 (0.14 to 2.16)
Urology 9 49 15.5 3.3 (−6.3 to 12.9) 1.27 (0.47 to 2.07) −2.3 (−10.3 to 5.7) 0.82 (0.20 to 1.44)
Symptoms of burnoutc,d
No 130 1827 6.6 1 [Reference] 1 [Reference] <.001 1 [Reference] 1 [Reference] <.001
Yes 372 1242 23.0 16.4 (14.1 to 18.7) 3.47 (2.82 to 4.12) 15.0 (12.8 to 17.3) 3.20 (2.58 to 3.82)
Measured during year 4 of medical school, mean (SD)
Anxietye 11.8 (4.1) 10.6 (3.6) 0.5 (0.4 to 0.5) 1.08 (1.05 to 1.11) <.001 0.4 (0.2 to 0.5) 1.04 (1.01 to 1.08) .002
Empathyf 49.1 (6.5) 50.4 (5.2) −0.9 (−1.3 to −0.4) 0.98 (0.98 to 0.98) <.001 −0.3 (−0.8 to 0.2) 0.99 (0.98 to 1.00) .11
Emotional supportg 4.1 (0.9) 4.4 (0.8) −6.9 (−10.4 to −3.4) 0.82 (0.78 to 0.86) <.001 −2.4 (−5.8 to 0.9) 0.89 (0.80 to 0.99) .07
Tangible supportg 3.7 (1.2) 4.0 (1.1) −2.8 (−4.8 to −0.8) 0.88 (0.83 to 0.94) .002 −0.2 (−1.6 to 1.2) 0.99 (0.90 to 1.08) .78
Age in 2016, mean (SD), yh,i 29.9 (2.3) 29.8 (2.5) 0.1 (−0.2 to 0.4) 1.01 (0.97 to 1.05) .77 0 (−0.4 to 0.5) 1.00 (0.97 to 1.04) .87
Sexh
Male 240 1507 13.7 1 [Reference] 1 [Reference] .92 1 [Reference] 1 [Reference] .77
Female 260 1553 14.3 0.6 (−1.7 to 2.9) 1.04 (0.87 to 1.21) −0.5 (−2.5 to 1.6) 0.97 (0.83 to 1.11)
Other 2 5 28.6 14.8 (−18.7 to 48.4) 2.08 (−0.37 to 4.53) 6.0 (−25.4 to 37.4) 1.43 (−0.81 to 3.66)
Raceh
White 297 1995 13.0 1 [Reference] 1 [Reference] .01 1 [Reference] 1 [Reference] .14
Nonwhite 193 988 16.3 3.3 (0.8 to 5.8) 1.26 (1.05 to 1.47) 2.1 (−0.8 to 4.9) 1.16 (0.93 to 1.38)
Ethnicityh
Hispanic or Latino 40 140 22.2 1 [Reference] 1 [Reference] .01 1 [Reference] 1 [Reference] .07
Not Hispanic or Latino 450 2885 13.5 −8.7 (−14.8 to −2.5) 0.61 (0.44 to 0.79) −4.8 (−10.4 to 0.8) 0.74 (0.51 to 0.97)
Relationship statusc
Single 270 1581 14.6 1 [Reference] 1 [Reference] .43 1 [Reference] 1 [Reference] .81
Married or domestic partner 227 1452 13.5 −1.0 (−3.3 to 1.3) 0.93 (0.78 to 1.08) 0.4 (−2.7 to 3.4) 1.03 (0.80 to 1.25)
Parental statusc
No children 434 2630 14.2 1 [Reference] 1 [Reference] .39 1 [Reference] 1 [Reference] .51
≥1 Child 64 409 13.5 −0.6 (−3.9 to 2.7) 0.96 (0.72 to 1.19) −3.4 (−12.8 to 6.0) 0.76 (0.14 to 1.39)
Have children <5 y of age
No 442 2675 14.2 1 [Reference] 1 [Reference] .53 1 [Reference] 1 [Reference] .35
Yes 56 364 13.3 −0.9 (−4.4 to 2.6) 0.94 (0.69 to 1.18) 6.1 (−8.0 to 20.2) 1.46 (0.37 to 2.54)
Birth locationh
Other country 66 384 14.7 1 [Reference] 1 [Reference] .61 1 [Reference] 1 [Reference] .45
United States 383 2367 13.9 −0.8 (−4.3 to 2.7) 0.94 (0.72 to 1.17) 1.1 (−1.6 to 3.8) 1.08 (0.86 to 1.31)
Household income during residency, $c
<49 000 57 318 15.2 1 [Reference] 1 [Reference] .81 1 [Reference] 1 [Reference] .92
50 000 to 74 999 257 1544 14.3 −1.0 (−5.0 to 3.0) 0.93 (0.69 to 1.18) 0.6 (−2.2 to 3.3) 1.04 (0.82 to 1.26)
75 000 to 99 999 62 435 12.5 −2.8 (−7.4 to 1.8) 0.82 (0.54 to 1.09) 1.3 (−3.0 to 5.6) 1.10 (0.75 to 1.44)
100 000 to 249 999 111 694 13.8 −1.5 (−5.8 to 2.9) 0.90 (0.64 to 1.17) 0.6 (−3.4 to 4.7) 1.05 (0.74 to 1.36)
≥250 000 11 36 23.4 8.2 (−4.4 to 20.7) 1.54 (0.66 to 2.41) 5.5 (−9.9 to 20.8) 1.41 (0.23 to 2.60)
Educational debt >$1000c
Yes 402 2444 14.1 1 [Reference] 1 [Reference] .30 1 [Reference] 1 [Reference] .23
No 47 340 12.1 −1.8 (−5.3 to 1.7) 0.87 (0.63 to 1.12) −2.0 (−5.2 to 1.1) 0.86 (0.64 to 1.07)
US Medical Licensing Examination Step 1 scorej
≤200 25 128 16.3 1 [Reference] 1 [Reference] .29 1 [Reference] 1 [Reference] .24
201-210 38 221 14.7 −1.1 (−8.2 to 6.0) 0.93 (0.50 to 1.36) −0.8 (−9.5 to 7.8) 0.95 (0.46 to 1.44)
211-220 58 318 15.4 −0.4 (−7.1 to 6.3) 0.98 (0.56 to 1.39) −0.9 (−8.5 to 6.7) 0.95 (0.52 to 1.37)
221-230 92 498 15.6 −0.2 (−6.5 to 6.2) 0.99 (0.59 to 1.39) −2.0 (−10.0 to 6.1) 0.88 (0.46 to 1.31)
231-240 92 541 14.5 −1.1 (−7.4 to 5.2) 0.93 (0.56 to 1.31) −3.1 (−10.8 to 4.6) 0.82 (0.44 to 1.19)
241-250 70 546 11.4 −4.3 (−10.4 to 1.9) 0.73 (0.43 to 1.03) −5.3 (−12.8 to 2.2) 0.69 (0.37 to 1.01)
251-260 58 384 13.1 −2.4 (−8.9 to 4.2) 0.85 (0.48 to 1.22) −4.9 (−12.5 to 2.7) 0.71 (0.38 to 1.05)
≥261 13 121 9.7 −5.5 (−13.4 to 2.3) 0.65 (0.24 to 1.06) −8.1 (−17.2 to 1.0) 0.53 (0.16 to 0.89)
Open in a new tab
a

Responded with “probably not” or “definitely not” to the following question: “If you could revisit your career choice, would you choose to become a physician again?” The C statistic for the model was 0.74 (pseudo R2 = 0.11).

b

A higher relative risk is less desirable. Relative risk represents risk of career choice regret in the categorical group relative to the reference group. Risk difference or absolute risk reduction is the change in risk of career choice regret relative to the reference group. For age, anxiety, empathy, emotional support, and tangible support, the relative risk and risk difference indicate the incremental increase in the relative risk of career choice regret associated with each 1-unit increase in age or scores. All models used multiple imputation with 20 imputations to account for missing values.

c

Data derived from the questionnaire during the second year of residency.

d

Positive for symptoms of burnout if had a score of 5 (≥once per week) or higher (range, 1-7) on either of 2 questions. Taken from the Maslach Burnout Inventory, one question was on “emotional exhaustion” and the other was on “depersonalization.”

e

The score range is 4-20; higher scores indicate greater anxiety. The Patient-Reported Outcome Measurement Information System anxiety short form was used. A raw score of 10 converts to a t score of 59.5 (SE, 2.6), which is approximately 1 SD above the US general population mean.

f

The score range is 7-56; higher scores indicate greater empathic orientation. Eight items from the Jefferson Scale of Physician Empathy were used.

g

The score range is 1-5; higher scores indicate better social support. The Tangible Support and Emotional Support subscales from the Medical Outcomes Study Social Support Measure were used. An Emotional Support subscale score of 4.3 transforms on a 0-100 scale to 82.5, which is higher than the population norm of 69.9. A Tangible Support subscale score of 3.9 transforms on a 0-100 scale to 72.5, which is higher than the population norm of 69.8.31

h

Data derived from baseline medical school questionnaire.

i

Age calculated from year of birth to 2016.

j

Self-reported on the questionnaire during year 4 of medical school. The score range is 1-300; higher scores indicate better performance. Most examinees score in the range of 140-260.

Table 4. Association of Resident Specialty and Characteristics With Specialty Choice Regret.

Specialty Choice Regret Status Specialty Choice Regret Prevalence, % Bivariable Analysis Multivariable Analysis
No. With
Specialty Choice Regreta 		No. Without Specialty Choice Regret Absolute Risk Difference,
% (95% CI)b 		Relative Risk
(95% CI)b 		Wald P Value Absolute Risk Difference,
% (95% CI)b 		Relative Risk
(95% Ci)b 		Wald P Value
Specialtyc
Internal medicine 86 723 10.6 1 [Reference] 1 [Reference] <.001 1 [Reference] 1 [Reference] <.001
Dermatology 1 70 1.4 −9.2 (−12.7 to −5.8) 0.13 (−0.13 to 0.39) −8.2 (−12.6 to −3.8) 0.21 (−0.16 to 0.58)
Radiology 12 186 6.1 −4.6 (−8.5 to −0.6) 0.57 (0.24 to 0.90) −3.8 (−8.4 to 0.8) 0.63 (0.23 to 1.04)
Emergency medicine 10 289 3.3 −7.3 (−10.2 to −4.3) 0.31 (0.11 to 0.52) −7.4 (−10.0 to −4.9) 0.29 (0.12 to 0.46)
Family medicine 15 288 5.0 −5.7 (−8.9 to −2.4) 0.47 (0.22 to 0.71) −5.0 (−8.4 to −1.6) 0.52 (0.24 to 0.81)
Anesthesiology 15 237 6.0 −4.7 (−8.3 to −1.1) 0.56 (0.26 to 0.86) −5.5 (−9.2 to −1.8) 0.47 (0.18 to 0.77)
Neurology 6 80 7.0 −3.7 (−9.4 to 2.1) 0.66 (0.13 to 1.18) −4.6 (−9.1 to −0.0) 0.56 (0.13 to 0.99)
Obstetrics and gynecology 18 215 7.7 −2.9 (−6.9 to 1.1) 0.73 (0.37 to 1.08) −1.7 (−6.0 to 2.5) 0.83 (0.45 to 1.22)
Pathology 6 43 12.2 1.6 (−7.8 to 11.0) 1.15 (0.26 to 2.05) 0 (−8.1 to 8.1) 1.00 (0.23 to 1.78)
Pediatrics 22 390 5.3 −5.3 (−8.3 to −2.3) 0.50 (0.27 to 0.73) −4.4 (−8.1 to −0.7) 0.58 (0.27 to 0.89)
Physical medicine and rehabilitation 1 29 3.3 −7.3 (−14.1 to −0.5) 0.31 (−0.29 to 0.92) −5.8 (−14.8 to 3.2) 0.44 (−0.40 to 1.29)
Psychiatry 5 143 3.4 −7.3 (−10.9 to −3.6) 0.32 (0.04 to 0.60) −7.0 (−11.1 to −2.9) 0.32 (0.01 to 0.64)
Surgery (general) 34 165 17.1 6.5 (0.8 to 12.1) 1.61 (1.02 to 2.19) 3.1 (−2.6 to 8.8) 1.30 (0.72 to 1.88)
Other surgery 3 53 5.4 −5.3 (−11.5 to 1.0) 0.50 (−0.06 to 1.07) −6.4 (−11.2 to −1.5) 0.39 (−0.03 to 0.81)
Ophthalmology 4 91 4.2 −6.4 (−11.0 to −1.9) 0.40 (0.01 to 0.78) −8.3 (−12.0 to −4.6) 0.20 (−0.08 to 0.49)
Orthopedic surgery 5 148 3.3 −7.4 (−10.9 to −3.8) 0.31 (0.04 to 0.58) −6.9 (−10.6 to −3.3) 0.33 (0.03 to 0.64)
Otolaryngology 3 64 4.5 −6.2 (−11.5 to −0.8) 0.42 (−0.05 to 0.89) −6.4 (−12.2 to −0.6) 0.38 (−0.13 to 0.89)
Plastic surgery 2 25 7.4 −3.2 (−13.3 to 6.9) 0.70 (−0.24 to 1.64) −6.3 (−13.5 to 0.9) 0.39 (−0.28 to 1.06)
Neurological surgery 0 25 0 0 1.00 (1.00 to 1.00) 0 1.00 (1.00 to 1.00)
Urology 5 53 8.6 −2.0 (−9.5 to 5.5) 0.81 (0.11 to 1.51) −3.8 (−10.7 to 3.1) 0.63 (−0.02 to 1.28)
Symptoms of burnoutc,d
No 60 1898 3.1 1 [Reference] 1 [Reference] <.001 1 [Reference] 1 [Reference] <.001
Yes 193 1419 12.0 8.9 (7.1 to 10.7) 3.91 (2.80 to 5.01) 7.6 (6.0 to 9.2) 3.29 (2.57 to 4.01)
Measured during year 4 of medical school, mean (SD)
Anxietye 12.0 (4.3) 10.6 (3.6) 0.2 (0.2 to 0.3) 1.08 (1.04 to 1.12) <.001 0.2 (0.05 to 0.3) 1.04 (0.99 to 1.09) .09
Empathyf 48.7 (7.1) 50.4 (5.3) −1.0 (−1.8 to −0.3) 0.97 (0.97 to 0.98) <.001 −0.4 (−0.9 to 0.2) 0.98 (0.97 to 0.99) .02
Emotional supportg 3.9 (1.0) 4.3 (0.8) −10.0 (−15.0 to −4.9) 0.72 (0.68 to 0.76) <.001 −2.7 (−6.5 to 1.1) 0.83 (0.71 to 0.95) .03
Tangible supportg 3.6 (1.2) 4.0 (1.1) −3.5 (−5.9 to −1.1) 0.80 (0.73 to 0.87) <.001 0 (−1.2 to 1.1) 0.99 (0.83 to 1.16) .94
Age in 2016, mean (SD), yh,i 30.0 (2.9) 29.8 (2.4) 0.1 (0.1 to 0.1) 1.03 (0.98 to 1.08) .14 0.1 (0.01 to 0.1) 1.08 (1.02 to 1.14) .003
Sexh
Male 129 1616 7.4 1 [Reference] 1 [Reference] .32 1 [Reference] 1 [Reference] .13
Female 123 1691 6.8 −0.6 (−2.3 to 1.1) 0.92 (0.70 to 1.14) −1.5 (−3.6 to 0.5) 0.80 (0.57 to 1.03)
Other 0 7 0 0 1.00 (1.00 to 1.00) 0 1.00 (1.00 to 1.00)
Raceh
White 125 2167 5.5 1 [Reference] 1 [Reference] <.001 1 [Reference] 1 [Reference] .06
Nonwhite 119 1061 10.1 4.5 (2.6 to 6.5) 1.82 (1.38 to 2.25) 2.2 (−0.2 to 4.6) 1.37 (0.92 to 1.81)
Ethnicityh
Hispanic or Latino 24 156 13.3 1 [Reference] 1 [Reference] <.001 1 [Reference] 1 [Reference] .02
Not Hispanic or Latino 220 3114 6.6 −6.7 (−11.7 to −1.6) 0.50 (0.31 to 0.70) −4.8 (−9.6 to 0) 0.58 (0.32 to 0.84)
Relationship statusc
Single 160 1690 8.6 1 [Reference] 1 [Reference] <.001 1 [Reference] 1 [Reference] .12
Married or domestic partner 90 1589 5.4 −3.2 (−4.9 to −1.6) 0.62 (0.47 to 0.78) −1.7 (−3.9 to 0.5) 0.77 (0.52 to 1.02)
Parental statusc
No children 230 2833 7.5 1 [Reference] 1 [Reference] .03 1 [Reference] 1 [Reference] .54
≥1 Child 20 453 4.2 −3.3 (−5.3 to −1.2) 0.57 (0.31 to 0.82) −2.6 (−10.1 to 4.9) 0.64 (−0.33 to 1.62)
Have children <5 y of age
No 232 2884 7.4 1 [Reference] 1 [Reference] .03 1 [Reference] 1 [Reference] .67
Yes 18 402 4.3 −3.2 (−5.3 to −1.0) 0.57 (0.31 to 0.84) 2.9 (−11.5 to 17.2) 1.42 (−0.73 to 3.58)
Location of birthh
Other country 46 403 10.2 1 [Reference] 1 [Reference] .01 1 [Reference] 1 [Reference] .43
United States 176 2574 6.4 −3.5 (−6.4 to −0.6) 0.65 (0.46 to 0.85) −1.1 (−3.8 to 1.6) 0.86 (0.55 to 1.17)
Household income during residency, $c
<49 000 37 338 9.9 1 [Reference] 1 [Reference] <.001 1 [Reference] 1 [Reference] .16
50 000 to 74 999 136 1664 7.6 −2.3 (−5.5 to 0.9) 0.76 (0.50 to 1.03) −1.2 (−4.3 to 1.8) 0.85 (0.52 to 1.18)
75 000 to 99 999 23 474 4.6 −5.2 (−8.7 to −1.7) 0.47 (0.23 to 0.71) −1.9 (−6.0 to 2.2) 0.76 (0.32 to 1.21)
100 000 to 249 999 46 759 5.7 −4.1 (−7.5 to −0.7) 0.58 (0.34 to 0.82) −1.3 (−5.1 to 2.6) 0.84 (0.40 to 1.28)
≥250 000 10 37 21.3 11.3 (−0.8 to 23.3) 2.15 (0.79 to 3.51) 9.9 (−3.3 to 23.1) 2.25 (0.44 to 4.07)
Educational debt >$1000c
Yes 193 2651 6.8 1 [Reference] 1 [Reference] .72 1 [Reference] 1 [Reference] .79
No 28 360 7.2 0.5 (−2.3 to 3.3) 1.07 (0.66 to 1.47) 0.3 (−2.2 to 2.8) 1.05 (0.68 to 1.41)
US Medical Licensing Examination Step 1 scorej
≤200 14 139 9.2 1 [Reference] 1 [Reference] .22 1 [Reference] 1 [Reference] .48
201-210 17 242 6.6 −2.2 (−7.6 to 3.3) 0.76 (0.25 to 1.27) −1.3 (−6.3 to 3.7) 0.83 (0.24 to 1.42)
211-220 24 352 6.4 −2.4 (−7.6 to 2.7) 0.73 (0.27 to 1.18) −1.3 (−5.9 to 3.3) 0.83 (0.29 to 1.37)
221-230 40 549 6.8 −1.8 (−6.8 to 3.1) 0.80 (0.34 to 1.25) −1.6 (−5.8 to 2.6) 0.79 (0.33 to 1.25)
231-240 51 582 8.1 −0.7 (−5.7 to 4.3) 0.92 (0.40 to 1.44) 0.5 (−3.9 to 4.9) 1.07 (0.46 to 1.67)
241-250 36 580 5.8 −2.8 (−7.7 to 2.0) 0.68 (0.28 to 1.08) −0.7 (−4.8 to 3.4) 0.91 (0.42 to 1.41)
251-260 31 411 7.0 −1.7 (−6.8 to 3.3) 0.81 (0.33 to 1.29) −0.2 (−4.7 to 4.2) 0.97 (0.40 to 1.53)
≥261 6 128 4.5 −3.7 (−9.8 to 2.4) 0.59 (0.04 to 1.13) −2.8 (−7.5 to 1.9) 0.63 (0.13 to 1.13)
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a

Responded with “probably not” or “definitely not” to the following question: “If you could revisit your specialty choice, would you choose the same specialty again?” The C statistic for the model was 0.79 (pseudo R2 = 0.15).

b

A higher relative risk is less desirable. Relative risk represents risk of specialty choice regret in the categorical group relative to the reference group. Risk difference or absolute risk reduction is the change in risk of specialty choice regret relative to the reference group. For age, anxiety, empathy, emotional support, and tangible support, the relative risk and risk difference indicate the incremental increase in the relative risk of specialty choice regret associated with each 1-unit increase in age or scores. All models used multiple imputation with 20 imputations to account for missing values.

c

Data derived from the questionnaire during the second year of residency.

d

Positive for symptoms of burnout if had a score of 5 (≥once per week) or higher (range, 1-7) on either of 2 questions. Taken from the Maslach Burnout Inventory, one question was on “emotional exhaustion” and the other was on “depersonalization.”

e

The score range is 4-20; higher scores indicate greater anxiety. The Patient-Reported Outcome Measurement Information System anxiety short form was used. A raw score of 10 converts to a t score of 59.5 (SE, 2.6), which is approximately 1 SD above the US general population mean.

f

The score range is 7-56; higher scores indicate greater empathic orientation. Eight items from the Jefferson Scale of Physician Empathy were used.

g

The score range is 1-5; higher scores indicate better social support. The Tangible Support and Emotional Support subscales from the Medical Outcomes Study Social Support Measure were used. An Emotional Support subscale score of 4.3 transforms on a 0-100 scale to 82.5, which is higher than the population norm of 69.9. A Tangible Support subscale score of 3.9 transforms on a 0-100 scale to 72.5, which is higher than the population norm of 69.8.31

h

Data derived from baseline medical school questionnaire.

i

Age calculated from year of birth to 2016.

j

Self-reported on the questionnaire during year 4 of medical school. The score range is 1-300; higher scores indicate better performance. Most examinees score in the range of 140-260.

Training in pathology (RR, 2.60 [95% CI, 1.30 to 3.89]; RD, 20.7% [95% CI, 5.2% to 36.1%]) and anesthesiology (RR, 1.66 [95% CI, 1.19 to 2.13]; RD, 8.5% [95% CI, 2.8% to 14.2%]) was associated with a higher RR for career choice regret during the second year of residency relative to training in internal medicine. A higher anxiety score during year 4 of medical school was associated with a higher RR for career choice regret during the second year of residency (RR, 1.04 per 1-point increase [95% CI, 1.01 to 1.08]; RD, 0.4% [95% CI, 0.2% to 0.5%]). The C statistic for the model was 0.74 (pseudo R2 = 0.11).

Symptoms of burnout reported on the PGY-2 questionnaire (3.29 [95% CI, 2.57 to 4.01]; RD, 7.6% [95% CI, 6.0% to 9.2%]) and age (RR, 1.08 per 1 year older [95% CI, 1.02 to 1.14]; RD, 0.1% [95% CI, 0.01% to 0.1%]) were associated with an elevated RR of specialty choice regret during the second year of residency after controlling for demographics, educational debt, USMLE Step 1 score, specialty, and levels of anxiety, empathy, and social support during year 4 of medical school (Table 4). Training in anesthesiology, emergency medicine, family medicine, pediatrics, psychiatry, ophthalmology, and orthopedic surgery (range of RRs, 0.20 to 0.58) was associated with a lower RR of specialty choice regret during the second year of residency relative to training in internal medicine.

Not being Hispanic or Latino was associated with a lower RR for specialty choice regret (RR, 0.58 [95% CI, 0.32 to 0.84]; RD, −4.8% [95% CI, −9.6% to 0%]). A higher empathy score during year 4 of medical school (RR, 0.98 per 1-point increase [95% CI, 0.97 to 0.99]; RD, −0.4% [95% CI, −0.9% to 0.2%]) and a higher emotional social support score (RR, 0.83 per 1-point increase [95% CI, 0.71 to 0.95]; RD, −2.7% [95% CI, −6.5% to 1.1%) were associated with a lower RR for specialty choice regret during the second year of residency. The C statistic for the model was 0.79 (pseudo R2 = 0.15).

Discussion

Among US resident physicians in this study, reported symptoms of burnout and career choice regret were prevalent. Training in the fields of urology, neurology, emergency medicine, or general surgery (relative to internal medicine) and being female were independently associated with a higher RR for reported symptoms of burnout. Higher anxiety and lower empathy during year 4 of medical school also were associated with higher RRs for reported symptoms of burnout during residency.

The findings suggest the prevalence of burnout symptoms among resident physicians may be similar to that of practicing physicians (48.8%) and higher than other US workers (28.4% as assessed in 2014 using the same single-item measures adapted from the MBI).7 National studies of practicing physicians also have found the frequency of burnout symptoms to be higher among female physicians.7 Difficulties with work-life balance and work-home conflicts, sexism, stereotype threat, and discrimination may play a part.7,34,35,36

The clinical specialty areas with the highest prevalence of resident physicians experiencing symptoms of burnout mirrored those of practicing physicians to a large extent.7 These findings suggest the increased burnout among physicians in these specialties may be attributable, in part, to unique characteristics of the work intrinsic to these specialties. Alternatively, the high prevalence of burnout symptoms among supervising physicians in these specialties may adversely affect the learning environment, or these supervising physicians may model burnout to resident physicians, placing the resident physicians who are training in these specialties at greater risk.

Similar to practicing physicians,7 most resident physicians were satisfied with their career and specialty choice. Symptoms of burnout among resident physicians were strongly associated with career and specialty choice regret. After controlling for symptoms of burnout, training in pathology or anesthesiology was significantly associated with a higher RR of career choice regret relative to training in internal medicine. These specialty areas (pathology and anesthesiology) had a relatively low prevalence of symptoms of burnout, and when career choice regret occurs, it may be due to factors other than symptoms of burnout.

Further studies are needed to explore why being Hispanic or Latino was associated with a higher RR of specialty choice regret independent of burnout symptoms. Workplace discrimination related to ethnicity or social isolation may play a role.37,38,39 Resident physicians from ethnic minority groups may feel obligated to pursue excellence in their field and leverage their professional stature to improve the well-being of their communities.40

In addition, residency programs and institutions often repeatedly invite ethnic minority resident physicians to participate in various diversity and disparity initiatives. The disproportionate demand on minority resident physicians’ time, along with their ethnic-conscious professionalism, may add stressors, resulting in overcommitted or overwhelmed minority resident physicians who ultimately become dissatisfied.

Reported levels of anxiety and empathy during year 4 of medical school were associated with reported symptoms of burnout by second-year resident physicians. Reported level of anxiety during year 4 of medical school also was associated with career choice regret by second-year resident physicians. Similarly, reported levels of empathy and social support during year 4 of medical school, but not anxiety, were associated with clinical specialty choice regret. These data suggest that high anxiety, lack of social support, and lower empathy during year 4 of medical school relate to risk of symptoms of burnout during residency or have an effect on career and specialty choice regret.

Limitations

This study has several limitations. First, the cohort may not be representative of all US resident physicians. Although the sample was drawn from 49 US medical schools and the demographic characteristics of the sample are similar to those of all students matriculating in US medicals schools in 2010,32,33 only 55% of students (4732 of 8594) from the sampled medical schools responded to the baseline questionnaire.

Second, cause and effect as well as the direction of the relationships observed cannot be determined from the study design because there were no baseline measurements of the outcome variables (eg, career choice regret).

Third, it is highly likely that there are other important dimensions related to burnout, as well career and specialty choice regret, that were not measured in this study.

Fourth, the limited number of participants in some specialties might have caused the study to be underpowered.

Fifth, there is no true reference standard definition of burnout and this study used a convenient proxy for the MBI, which is treated as a reference standard.

Conclusions

Among US resident physicians, symptoms of burnout and career choice regret were prevalent, but varied substantially by clinical specialty. Further research is needed to better understand these differences and to address these issues.

Supplement 1.

eTable. Demographic characteristics of the 3588 who responded to both the baseline and PGY2 questionnaires and the 1144 who did not respond to the PGY2 questionnaire

Click here for additional data file. (42.3KB, pdf)
Supplement 2.

Data Sharing Statement

Click here for additional data file. (43KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eTable. Demographic characteristics of the 3588 who responded to both the baseline and PGY2 questionnaires and the 1144 who did not respond to the PGY2 questionnaire

Click here for additional data file. (42.3KB, pdf)
Supplement 2.

Data Sharing Statement

Click here for additional data file. (43KB, pdf)

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