Effect of a Novel Mindfulness Curriculum on Burnout During Pediatric Internship: A Cluster Randomized Clinical Trial

Yarden S Fraiman; Christine C Cheston; Howard J Cabral; Celeste Allen; Andrea G Asnes; Jefferson T Barrett; Maneesh Batra; William Bernstein; Tammy Bleeker; Pam M Dietz; Joanna Lewis; Su-Ting T Li; T Marsha Ma; John D Mahan; Catherine D Michelson; Sue E Poynter; Mark A Vining; Katherine Watson; Colin M Sox

doi:10.1001/jamapediatrics.2021.5740

. 2022 Jan 24;176(4):365–372. doi: 10.1001/jamapediatrics.2021.5740

Effect of a Novel Mindfulness Curriculum on Burnout During Pediatric Internship

A Cluster Randomized Clinical Trial

Yarden S Fraiman ^1,^2,^3,^✉, Christine C Cheston ⁴, Howard J Cabral ⁵, Celeste Allen ⁶, Andrea G Asnes ⁷, Jefferson T Barrett ^8,^9,¹⁰, Maneesh Batra ¹¹, William Bernstein ¹², Tammy Bleeker ¹³, Pam M Dietz ¹⁴, Joanna Lewis ¹⁵, Su-Ting T Li ¹⁶, T Marsha Ma ¹⁷, John D Mahan ¹⁸, Catherine D Michelson ⁴, Sue E Poynter ¹⁹, Mark A Vining ²⁰, Katherine Watson ²¹, Colin M Sox ⁴

¹Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts

²Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts

³Department of Pediatrics, Harvard Medical School, Boston, Massachusetts

⁴Boston Medical Center, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts

⁵Deparment of Biostatistics, Boston University School of Public Health, Boston, Massachusetts

⁶University of California, San Francisco Benioff Children’s Hospital Oakland, Oakland

⁷Yale-New Haven Hospital, New Haven, Connecticut

⁸Floating Hospital for Children–Tufts Medical Center, Boston, Massachusetts

⁹Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts

¹⁰Department of Pediatrics, The Children’s Hospital at Montefiore, Bronx, New York

¹¹Division of Neonatology, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle

¹²Department of Pediatrics, Saint Peter’s University Hospital, New Brunswick, New Jersey

¹³Department of Pediatrics, University of Florida, Gainesville

¹⁴Department of Pediatrics, Maine Medical Center, Portland, Maine

¹⁵Department of Pediatrics, Advocate Children’s Hospital, Park Ridge, Illinois

¹⁶Department of Pediatrics, University of California, Davis, Sacramento

¹⁷Pediatric Cardiology, Loyola Medicine, Maywood, Illinois

¹⁸Division of Nephrology and Hypertension, Department of Pediatrics, Nationwide Children’s, Columbus, Ohio

¹⁹Division of Critical Care, Department of Pediatrics, Cincinnati Children’s Hospital, University of Cincinnati, Cincinnati, Ohio

²⁰Department of Pediatrics, University of Massachusetts Medical School, Worcester

²¹Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania

Accepted for Publication: October 4, 2021.

Published Online: January 24, 2022. doi:10.1001/jamapediatrics.2021.5740

^✉

Corresponding Author: Yarden S. Fraiman, MD, Department of Neonatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Rose 3, Boston, MA 02215 (yfraiman@bidmc.harvard.edu).

Author Contributions: Drs Cabral and Sox had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Fraiman, Cheston, Ma, Mahan, Michelson, Poynter, Watson, Sox.

Acquisition, analysis, or interpretation of data: Fraiman, Cheston, Cabral, Allen, Asnes, Barrett, Batra, Bernstein, Bleeker, Dietz, Lewis, Li, Mahan, Michelson, Poynter, Vining, Sox.

Drafting of the manuscript: Fraiman, Cheston, Cabral, Bleeker, Poynter, Sox.

Critical revision of the manuscript for important intellectual content: Cheston, Cabral, Allen, Asnes, Barrett, Batra, Bernstein, Dietz, Lewis, Li, Ma, Mahan, Michelson, Poynter, Vining, Watson, Sox.

Statistical analysis: Fraiman, Cabral, Sox.

Obtained funding: Fraiman, Sox.

Administrative, technical, or material support: Fraiman, Cheston, Allen, Asnes, Bernstein, Bleeker, Ma, Mahan, Michelson, Poynter, Vining, Watson, Sox.

Supervision: Cheston, Allen, Bernstein, Watson, Sox.

Other - implementation of the mindfulness course at 1 institution: Dietz.

Other - coordination and implementation of curriculum at 1 site: Barrett.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported in part by the Association of Pediatric Program Directors’ Special Projects Program (Drs Fraiman and Sox) and the Fred Lovejoy House-staff Research and Education Fund at Boston Children’s Hospital (Dr Fraiman). Dr Fraiman was supported by grant T32HS000063 from the Agency for Healthcare Research and Quality as part of the Harvard-wide Pediatric Health Services Research Fellowship Program.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We acknowledge the voluntary contributions made by faculty and administrators at each site who facilitated implementing the study activities.

^✉

Corresponding author.

PMCID: PMC8787682 PMID: 35072694

Key Points

Question

Can a novel mindfulness curriculum designed for implementation in residency that does not require facilitator training reduce burnout among pediatric interns?

Findings

This cluster randomized clinical trial found that the levels of emotional exhaustion, depersonalization, burnout, empathy, and mindfulness among pediatric interns who completed the 6-month mindfulness curriculum did not significantly differ from those assigned to social lunches both immediately after completing the training experience and 9 months later.

Meaning

A novel mindfulness curriculum did not affect pediatric interns’ levels of burnout, empathy, and mindfulness compared with social time only, suggesting that additional study is needed to develop evidence-based methods to reduce trainee burnout.

Abstract

Importance

Mindfulness curricula can improve physician burnout, but implementation during residency presents challenges.

Objective

To examine whether a novel mindfulness curriculum implemented in the first 6 months of internship reduces burnout.

Design, Setting, and Participants

This pragmatic, multicenter, stratified cluster randomized clinical trial of a mindfulness curriculum randomized 340 pediatric interns to the intervention or control arm within program pairs generated based on program size and region. Fifteen US pediatric training programs participated from June 14, 2017, to February 28, 2019.

Interventions

The intervention included 7 hour-long sessions of a monthly mindfulness curriculum (Mindfulness Intervention for New Interns) and a monthly mindfulness refresher implemented during internship. The active control arm included monthly 1-hour social lunches.

Main Outcomes and Measures

The primary outcome was emotional exhaustion (EE) as measured by the Maslach Burnout Inventory 9-question EE subscale (range, 7-63; higher scores correspond to greater perceived burnout). Secondary outcomes were depersonalization, personal accomplishment, and burnout. The study assessed mindfulness with the Five Facet Mindfulness Questionnaire and empathy with the Interpersonal Reactivity Index subscales of perspective taking and empathetic concern. Surveys were implemented at baseline, month 6, and month 15.

Results

Of the 365 interns invited to participate, 340 (93.2%; 255 [75.0%] female; 51 [15.0%] 30 years or older) completed surveys at baseline; 273 (74.8%) also participated at month 6 and 195 (53.4%) at month 15. Participants included 194 (57.1%) in the Mindfulness Intervention for New Interns and 146 (42.9%) in the control arm. Analyses were adjusted for baseline outcome measures. Both arms’ EE scores were higher at 6 and 15 months than at baseline, but EE did not significantly differ by arm in multivariable analyses (6 months: 35.4 vs 32.4; adjusted difference, 3.03; 95% CI, −0.14 to 6.21; 15 months: 33.8 vs 32.9; adjusted difference, 1.42; 95% CI, −2.42 to 5.27). None of the 6 secondary outcomes significantly differed by arm at month 6 or month 15.

Conclusions and Relevance

A novel mindfulness curriculum did not significantly affect EE, burnout, empathy, or mindfulness immediately or 9 months after curriculum implementation. These findings diverge from prior nonrandomized studies of mindfulness interventions, emphasizing the importance of rigorous study design and suggesting that additional study is needed to develop evidence-based methods to reduce trainee burnout.

Trial Registration

ClinicalTrials.gov Identifier: NCT03148626

This cluster randomized clinical trial of pediatric interns assesses whether a novel mindfulness training program reduces burnout.

Introduction

Burnout is a triad of emotional exhaustion (EE), depersonalization, and feelings of inefficacy.¹ Between 39% and 75% of pediatric trainees experience burnout, with a worsening trend in prevalence during the past few decades.^2,3,4,5 Burnout affects physicians’ well-being, performance during training, risk of suicide, and patient care. Physicians with burnout are more likely to make medical errors and be less empathetic, and the patients of physicians with burnout are less likely to adhere to medical plans.^{6,7,8,9,10,11} Physician burnout costs the US health care system approximately $4.6 billion per year related to physician turnover and reduced productivity.¹²

Mindfulness, a state of nonjudgmental awareness in the present moment, can prevent burnout. Mindfulness curricula can reduce burnout among physicians and other professionals.^{13,14,15,16,17,18} Mindfulness is the only evidence-based approach to reduce burnout included in an Accreditation Council for Graduate Medical Education and American Academy of Pediatrics call for systems-level change to address trainee burnout.¹⁹ Although mindfulness curricula are effective, potential barriers to implementing mindfulness curricula include time required by the trainees and availability of facilitators with content expertise. Small single-center trials^17,18,20,21 of mindfulness have found variable effects. We know of no published multicenter randomized clinical trials of mindfulness curricula that target trainee burnout. To assess the effectiveness of a novel mindfulness curriculum that does not require prior facilitator training, Mindfulness Intervention for New Interns (MINdI),²² on burnout among pediatric interns, we conducted a multicenter cluster randomized clinical trial. We hypothesized that interns training in programs randomized to the mindfulness curriculum would have less burnout than interns randomized to the control arm.

Methods

Study Sample and Randomization

We conducted a pragmatic, multicenter, stratified cluster randomized clinical trial of a mindfulness curriculum during pediatric internship. See Supplement 1 for full trial protocol. We recruited 15 US pediatric residency programs to participate in this study and sent surveys to 365 eligible interns (Figure 1). All sites’ institutional review boards approved the study. To be eligible for inclusion, each participating pediatric residency program agreed to be randomized to have their interns experience the MINdI curriculum or social lunches. From June 14 to September 29, 2017, pediatric and medicine-pediatric interns training in study programs gave implied written consent by returning the baseline survey. All data were deidentified. This study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline.

Figure 1. — MINdI indicates Mindfulness Intervention for New Interns.

After pairing programs by location and size, we used a random-number generator to assign, within a pair, each program’s cluster of interns to experience a novel 7-session MINdI curriculum or an active control experience of nondidactic social lunch. Because an odd number of programs participated, we created 1 dummy variable for paired randomization. Each program’s interns had the same arm-specific unblinded training experience.

Intervention Arm

A 6-step approach to curricular design informed the development of MINdI.^22,23 The MINdI curriculum easily integrates into existing 1-hour didactic time ubiquitous among training programs and requires no additional facilitator training.²² Intervention programs received the MINdI facilitator manual and all necessary curriculum implementation supplies. The intervention was delivered monthly, starting during the first quarter of the intern year and continuing for 6 months, for a total of 7 sessions; programs were encouraged to facilitate interns’ attendance at MINdI sessions, although attendance was not required.

The MINdI curriculum was developed by a multidisciplinary team of medical education experts, residency program leadership, a chief resident, mindfulness practitioners, and trainees. Briefly, each session begins with a social lunch, followed by a minute of silence, introductory remarks regarding the mindfulness exercise, a mindfulness exercise, and a debriefing period. The curriculum is designed to provide mindfulness exercises that can easily be integrated into a medical trainee’s day or highlight a unique aspect of mindfulness that can be beneficial to medical trainees. In addition to the monthly curriculum, intervention programs were encouraged to invite participants to conduct a short mindfulness refresher, a 10-minute prerecorded body scan exercise, 2 weeks after each MINdI session.

Control Arm

In the active control arm, participants were scheduled to attend 6 interns-only, 1-hour social lunches that involved no mindfulness activities, as other mindfulness curricula randomized clinical trials have done.¹⁸

Outcomes

Outcomes were measured through surveys at baseline, month 6, and month 15. The Maslach Burnout Inventory Human Services Survey was used under license with Mind Garden Inc. The primary outcome (EE) was measured using the Maslach Burnout Inventory 9-question EE subscale (range, 7-63; higher scores correspond to higher degrees of perceived burnout).¹ Prespecified secondary outcomes included dichotomized burnout and the Maslach Burnout Inventory 5-item depersonalization subscale (range, 7-35; higher scores correspond to higher degrees of perceived burnout) and 8-item personal accomplishment subscale (range, 7-56; higher scores correspond to lower degrees of perceived burnout), as well as mindfulness and empathy. We defined burnout as having an EE score of 27 or higher and/or a depersonalization score of 10 or higher.^1,24 We measured mindfulness using the 39-item Five Facet Mindfulness Questionnaire, on which higher scores on a scale of 39 to 195 are interpreted as increased mindfulness.^25,26 We assessed empathy using the Interpersonal Reactivity Index’s Perspective Taking and Empathic Concern subscales, on which higher scores are interpreted as increased empathy.^27,28

The baseline survey also collected demographic information and report of prior mindfulness behaviors; surveys at months 6 and 15 also collected self-report of mindfulness-related knowledge, attitudes, and behaviors. Surveys at baseline were implemented before participants completed the first study session, and those at month 6 were implemented after completing the final study session. Participants were offered a $5 coffee gift card after completing each survey.

Statistical Analysis

To examine whether subject characteristics varied by study arm while addressing hierarchical effects of cluster randomization, we conducted bivariate linear generalized estimating equations and logistic regressions clustered on center. To estimate the between-group difference in outcome between the randomized groups while addressing hierarchical effects of cluster randomization, we used multivariate generalized estimating equations and logistic regressions clustered on center. All regressions included study arm, independent measures that significantly differed by study arm, or measures that were of a priori clinical interest, including self-identified gender and age. Race and ethnicity data were not collected because we did not consider race or ethnicity to be significantly associated with burnout during the study design. To address the concern of including independent variables possibly in the causal pathway, we performed additional sensitivity analyses without these variables and that included only baseline variables.

In addition, analyses of data at month 6 and/or month 15 controlled for the outcome at baseline, baseline survey month, prior weekend off at month 6, inpatient or intensive care rotation at month 15, and an arm × survey period interaction term based on prior data.²⁹ If the arm × survey month interaction term was statistically significant, we conducted stratified analyses of the month 6 and month 15 data. If the interaction term was not significant, then we removed the interaction term and conducted longitudinal analyses comparing the pooled outcomes at month 6 and month 15 while controlling for baseline.

Because 29.8% of data was missing, we conducted all multivariable analyses on 20 imputed data sets created using individual-level data following standard imputation procedures using PROC MI and PROC MI ANALYZE in SAS software, version 9.4 (SAS Institute Inc). These imputations were performed in PROC MI via a multiple imputation with chained equations approach with fully conditional specification. Data were imputed when missing at baseline given variables with fully observed values. Then the baseline data and fully observed variables at 6 months were used to impute values for variables with missing data at 6 months. This process continued in a similar fashion, with prior data and variables fully observed at 15 months used to impute missing values at 15 months. We report effect sizes as linear regression coefficients quantifying differences in means or in logistic model odds ratios (ORs) with 95% CIs, as well as 2-sided P values for primary outcome analyses. A 2-sided P < .05 was considered statistically significant.

Setting 1 − β = 0.8 and 2-sided α = .05, our a priori power calculations determined that at least 139 participants per group were needed to determine a 0.29 difference in mean EE to be statistically significant, a threshold selected because a meta-analysis³⁰ found that burnout reduction interventions significantly lowered EE scores by 0.28. These calculations, however, did not account for possible clustering by site. Had this been done, applying a reasonable intraclass correlation of 0.01 would have yielded a required enrollment sample with an additional 256 participants to achieve 80% power with a 2-sided α = .05. This addition of participants to the sample would not have been feasible, however, given the planned study period. We note that our sample as implemented was larger than other randomized clinical trials of mindfulness curricula that have intended to address burnout. We have provided 95% CIs with all estimates of group differences so that readers can judge the precision, or lack thereof, of our findings in this sample, in particular with respect to prior research^14,15,16,17 with smaller samples.

Results

Study Participants

Of the 359 consenting interns, 340 (94.7%; 255 [75.0%] female; 51 [15.0%] 30 years or older) completed surveys at baseline, 273 at month 6 (76.0%), and 195 at month 15 (54.3%); the 19 interns who did not complete the baseline survey were excluded. Analyses included 194 intervention participants (57.1%) and 146 control participants (42.9%). The dropout rate was 19.7% at 6 months and 42.6% at 15 months. Characteristics between those who were lost to follow-up and those who completed the study were not markedly different (eTable in Supplement 2).

Table 1 presents the study population characteristics. Gender was the only personal or program characteristic that significantly differed by arm, with more female interns in the MINdI arm than in the control arm (female vs male: 255 [75.0%] vs 85 [25.0%] for all interns; 153 [78.9%] vs 41 [21.1%] for MINdI arm; and 102 [69.9%] vs 44 [30.1%] for the control arm; P = .002). The only outcome that significantly differed at baseline in bivariate analyses was personal accomplishment, with the MINdI arm’s mean (SD) personal accomplishment score being higher than that in the control group (41.5 [4.1] vs 36.3 [10.9]; P = .003). Although burnout and mean EE and depersonalization scores did not differ at baseline by arm, these measures significantly increased during the 78-day enrollment period for 4 months in both groups (Figure 2). At month 6, MINdI participants were significantly less likely to have had the prior weekend off than controls (54 [39.4%] vs 54 [46.6%]; P = .04). At month 15, MINdI participants were significantly less likely to be rotating on an inpatient or intensive care service than controls (44 [43.1%] vs 48 [58.5%]; P = .02). Table 2 and Table 3 present results of multivariable analyses of 20 imputed data sets conducted to determine the effect of arm on continuous and dichotomous outcomes, respectively.

Table 1. Study Sample Characteristics and Outcome at Baseline^a.

Characteristic or outcome	All (N = 340)	MINdI arm (n = 194)	Control arm (n = 146)
Personal characteristics
Gender
Female	255 (75.0)	153 (78.9)	102 (69.9)
Male	85 (25.0)	41 (21.1)	44 (30.1)
Age ≥30 y	51 (15.0)	32 (16.6)	19 (13.0)
No prior mindfulness training	103 (30.5)	61 (31.6)	42 (29.0)
No prior mindfulness practice	56 (16.5)	30 (15.5)	26 (17.8)
Program characteristics
Program with <20 interns	93 (27.4)	48 (24.7)	45 (30.8)
US region
Eastern	159 (44.3)	66 (34.0)	91 (62.3)
Central	118 (32.9)	59 (30.4)	42 (27.8)
Western	82 (22.8)	69 (35.6)	13 (8.9)
Medicine-pediatrics residents	16 (4.7)	11 (5.7)	5 (3.5)
Survey implementation
Baseline (survey during intern orientation)	213 (62.7)	118 (60.8)	95 (65.1)
Month 6
Vacation in prior month	77 (30.4)	43 (31.4)	34 (29.3)
Prior weekend off	108 (42.7)	54 (39.4)	54 (46.6)
Rotating on inpatient or intensive care service	184 (73.0)	104 (76.5)	80 (69.0)
Month 15
Vacation in prior month	61 (32.8)	29 (28.2)	32 (38.6)
Prior weekend off	98 (52.7)	58 (56.3)	40 (48.2)
Rotating on inpatient or intensive care service	92 (50.0)	44 (43.1)	48 (58.5)
Outcomes at baseline^b
Burnout	233 (68.5)	145 (74.7)	88 (60.3)
Emotional exhaustion, mean (SD)^c	27.2 (9.7)	28.2 (10.1)	25.9 (8.9)
Depersonalization, mean (SD)^d	11.5 (5.1)	11.9 (5.0)	11.0 (4.8)
Personal accomplishment, mean (SD)^e	39.3 (8.2)	41.5 (4.1)	36.3 (10.9)
Empathetic concerns, mean (SD)^f	17.9 (2.2)	18.0 (2.0)	17.9 (2.2)
Perspective taking, mean (SD)^f	19.3 (2.9)	19.4 (3.0)	19.2 (2.8)
Mindfulness, mean (SD)^g	127.7 (16.3)	126.7 (16.5)	126.7 (16.1)

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Abbreviation: MINdI, Mindfulness Intervention for New Interns.

^{^a}

Data are presented as number (percentage) of interns unless otherwise indicated.

^{^b}

On the basis of analyses of nonimputed responses from study participants measured at baseline.

^{^c}

Total scores on the 9-item emotional exhaustion subscale (range, 7-63; higher scores correspond to higher degrees of perceived burnout).

^{^d}

Total scores on the 5-item depersonalization subscale (range, 7-35; higher scores correspond to higher degrees of perceived burnout).

^{^e}

Total scores on the 8-item personal accomplishment subscale (range, 7-56; higher scores correspond to lower degrees of perceived burnout).

^{^f}

Total scores on the 7-item perspective taking subscale (range, 7-35; higher scores correspond to higher degrees of perceived empathy).

^{^g}

Total scores on the 39-item Five Facet Mindfulness scale (range, 39-195; higher scores correspond to higher degrees of perceived mindfulness).

Figure 2. — MINdI indicates Mindfulness Intervention for New Interns.

Table 2. Impact of the MINdI Curriculum on Continuous Measures of Burnout, Mindfulness, and Empathy at Baseline, Month 6, and Month 15^a.

Outcomes	Baseline, unadjusted mean	Month 6		Month 15		Pooled MINdI vs control
Outcomes	Baseline, unadjusted mean	Unadjusted mean	Adjusted difference (95% CI)^b	Unadjusted mean	Adjusted difference (95% CI)^c	Unadjusted mean	Adjusted difference (95% CI)^d
Emotional exhaustion
MINdI arm	28.3	35.4	3.03 (−0.14 to 6.21)	33.8	1.42 (−2.42 to 5.27)	NA	NA
Control arm	25.6	32.4	3.03 (−0.14 to 6.21)	32.9	1.42 (−2.42 to 5.27)	NA	NA
Depersonalization
MINdI arm	11.9	16.0	1.2 (−0.56 to 2.96)	15.0	−0.27 (−2.37 to 1.83)	NA	NA
Control arm	11.0	14.8	1.2 (−0.56 to 2.96)	15.5	−0.27 (−2.37 to 1.83)	NA	NA
Personal accomplishment
MINdI arm	41.5	41.6	0.06 (−1.80 to 7.91)	NA	NA	40.5	0.14 (−1.70 to 1.98)
Control arm	36.3	41.6	0.06 (−1.80 to 7.91)	NA	NA	39.5	0.14 (−1.70 to 1.98)
Mindfulness
MINdI arm	126.6	125.5	−0.91 (−5.67 to 3.85)	NA	NA	128.6	−1.07 (−5.27 to 3.13)
Control arm	126.5	126.4	−0.91 (−5.67 to 3.85)	NA	NA	127.1	−1.07 (−5.27 to 3.13)
Empathetic concerns
MINdI arm	18.0	17.2	0.24 (−0.71 to 1.18)	NA	NA	16.7	0.27 (−0.54 to 1.08)
Control arm	17.9	17.0	0.24 (−0.71 to 1.18)	NA	NA	17.0	0.27 (−0.54 to 1.08)
Perspective taking
MINdI arm	19.4	21.5	1.02 (−0.36 to 2.41)	NA	NA	20.7	0.74 (−0.53 to 2.02)
Control arm	19.2	20.4	1.02 (−0.36 to 2.41)	NA	NA	20.8	0.74 (−0.53 to 2.02)

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Abbreviations: MINdI, Mindfulness Intervention for New Interns; NA, not applicable (pooled analyses were not completed based on the interaction term).

^{^a}

Mean results are from multivariable analyses of 20 imputed data sets.

^{^b}

Results of multivariable generalized estimating equation regressions at month 6 clustered on site while controlling for gender, age, month at baseline, baseline personal accomplishment, prior weekend off, and the outcome of interest at baseline.

^{^c}

Results of multivariable generalized estimating equation regressions at month 15 clustered on site while controlling for gender, age, month at baseline, baseline personal accomplishment, current inpatient rotation, and the level of the outcome at month 6. The longitudinal data were stratified by assessment period (month 6 and month 15) because preliminary models that included a MINdI arm × period interaction term were statistically significant.

^{^d}

Results of multivariable longitudinal generalized estimating equation regressions comparing pooled month 6 and month 15 while controlling for gender, age, month at baseline, baseline personal accomplishment, current inpatient rotation, and the outcome at baseline.

Table 3. Impact of the MINdI Curriculum on Dichotomous Measure of Burnout and Mindfulness-Related Knowledge, Behavior, and Attitudes at Baseline, Month 6, and Month 15^a.

Outcomes	Baseline, unadjusted rate	Month 6		Month 15		Pooled MINdI vs control
Outcomes	Baseline, unadjusted rate	Unadjusted rate, %	AOR (95% CI)^b	Unadjusted rate, %	AOR (95% CI)^c	Unadjusted rate, %	AOR (95% CI)^d
Burnout ^e
MINdI arm	74.7	92.0	2.28 (0.77-6.71)	83.7	0.60 (0.17-2.20)	NA	NA
Control arm	60.3	80.5	2.28 (0.77-6.71)	88.3	0.60 (0.17-2.20)	NA	NA
Knows evidence supporting mindfulness
MINdI arm	NA	69.4	3.23 (1.63-6.39)	NA	NA	68.3	2.56 (1.46-4.47)
Control arm	NA	40.4	3.23 (1.63-6.39)	NA	NA	58.1	2.56 (1.46-4.47)
Knows how to apply mindfulness in own life
MINdI arm	NA	76.9	3.99 (3.25-4.90)	80.4	1.64 (0.66-4.10)	NA	NA
Control arm	NA	42.5	3.99 (3.25-4.90)	71.0	1.64 (0.66-4.10)	NA	NA
Believes mindfulness benefited their life
MINdI arm	NA	60.1	2.51 (1.03-6.11)	73.0	1.24 (0.44-3.49)	NA	NA
Control arm	NA	27.0	2.51 (1.03-6.11)	63.2	1.24 (0.44-3.49)	NA	NA
Holds positive attitude toward mindfulness
MINdI arm	NA	72.2	2.60 (1.67-4.07)	64.1	0.64 (0.24-1.74)	NA	NA
Control arm	NA	56.5	2.60 (1.67-4.07)	67.8	0.64 (0.24-1.74)	NA	NA
Uses mindfulness techniques more often
MINdI arm	NA	38.9	1.48 (0.72-3.02)	NA	NA	64.7	1.02 (0.57-1.82)
Control arm	NA	25.9	1.48 (0.72-3.02)	NA	NA	61.9	1.02 (0.57-1.82)

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Abbreviations: AOR, adjusted odds ratio; MINdI, Mindfulness Intervention for New Interns; NA, not applicable (pooled analyses were not completed based on the interaction term).

^{^a}

Mean results are from multivariable analyses of 20 imputed data sets.

^{^b}

Results of multivariable logistic regressions at month 6 clustered on site while controlling for gender, age, month at baseline, baseline personal accomplishment, prior weekend off, current inpatient rotation, and the outcome of interest at baseline.

^{^c}

Results of multivariable logistic regressions at month 15 clustered on site while controlling for gender, age, month at baseline, baseline personal accomplishment, prior weekend off, current inpatient rotation, and the level of the outcome at month 6. The longitudinal data were stratified by assessment period (month 6 and month 15) because preliminary models that included a MINdI arm × period interaction term were statistically significant.

^{^d}

Results of multivariable longitudinal logistic regressions comparing month 6 to month 15 while controlling for gender, age, month at baseline, baseline personal accomplishment, prior weekend off, current inpatient rotation, the outcome at baseline, assessment period, and a MINdI arm × period interaction term.

^{^e}

Because initial logistic regressions models analyzing burnout at month 6 that clustered on site did not converge, the final regression model for burnout at month 6 did not cluster on site.

Primary Outcomes

In multivariable analyses of imputed data, EE at baseline did not significantly differ between the MINdI and control arms (adjusted difference, −0.37; 95% CI, −3.03 to 3.77) (Table 2). The MINdI and control arms’ mean (SD) EE scores were higher at month 6 (35.4 vs 32.4) than baseline (28.3 vs 25.6); however, multivariable analyses controlling for baseline EE revealed that EE at month 6 did not significantly differ by study arm (adjusted difference, 3.03; 95% CI, −0.14 to 6.21). Both arms’ mean EE scores remained higher than baseline at month 15 (33.8 vs 32.9). In multivariable longitudinal analyses, the arm-period interaction term was statistically significant (P = .02); in stratified multivariable analyses, EE did not significantly differ by arm at month 15 (adjusted difference, 1.42; 95% CI, −2.42 to 5.27).

Secondary Outcomes

Most respondents had burnout at baseline (74.7% in the MINdI arm and 60.3% in the control arm, month 6 (92.0% in the MINdI arm and 80.5% in the control arm), and month 15 (83.7% in the MINdI arm and 88.3% in the control arm) (Table 3). At baseline, no differences by arm were found in burnout, depersonalization (mean [SD] scores, 11.9 [5.0] for the MINdI arm and 11.0 [4.8] for the control arm), mindfulness (mean [SD] scores, 126.6 [16.4] for the MINdI arm and 126.5 [16.1] for the control arm), empathetic concerns (mean [SD] scores, 18.0 [2.0] for the MINdI arm and 17.9 [2.2] for the control arm), or perspective taking (mean [SD] scores 19.4 [3.0] for the MINdI arm and 19.2 [2.8] for the control arm).

No significant differences by arm were found in prior mindfulness training (31.6% in the MINdI arm and 29.0% in the control arm) or practice (15.5% in the MINdI arm and 17.8% in the control arm) at baseline. Multivariable longitudinal analyses revealed that levels of mindfulness (adjusted difference, −1.07; 95% CI, −5.27 to 3.13), empathetic concerns (adjusted difference, 0.27; 95% CI, −0.54 to 1.08), perspective taking (adjusted difference, 0.74; 95% CI, −0.53 to 2.02), and personal accomplishment (adjusted difference, 0.14; 95% CI, −1.70 to 1.98) did not significantly differ by arm between month 6 and month 15. The arm × period interaction term was statistically significant in multivariable longitudinal analyses conducted to the effect of arm on depersonalization (P < .001) and burnout (P = .004); subsequent multivariable analyses stratified by period revealed that these outcomes did not significantly differ by arm at month 15.

At month 6, multivariable analyses identified significant increases in report of knowing the evidence to support mindfulness (adjusted OR, 3.23; 95% CI, 1.63-6.39), how to apply mindfulness (adjusted OR, 3.99; 95% CI, 3.25-4.90), the belief that mindfulness benefited their life (adjusted OR, 2.51; 95% CI, 1.03-6.11), and having a positive attitude toward mindfulness (adjusted OR, 2.60; 95% CI, 1.67-4.07). Most of these changes were not persistent over time. Self-reported frequency of mindfulness practice at baseline and month 6 did not significantly differ by arm (adjusted OR, 1.48; 95% CI, 0.72-3.02). The odds of using these techniques more after the curriculum did not significantly differ by arm between month 6 and month 15 (adjusted OR, 1.02; 95% CI, 0.57-1.82). The arm × period interaction term was statistically significant (P < .001) in multivariable longitudinal analyses conducted to test the effect of arm on reporting to know how to apply, belief in the benefit of, and having a positive attitude toward mindfulness; subsequent multivariable analyses stratified by period revealed that none of these outcomes significantly differed by arm at month 15.

In the sensitivity analyses in which time-dependent variables were removed, the results relating to intervention effects were similar to those described above and in the tables of our regression models.

Discussion

Our multicenter cluster randomized clinical trial of a novel mindfulness curriculum implemented early in pediatric internship found that the intervention did not significantly affect interns’ EE, depersonalization, burnout, personal accomplishment, mindfulness, or empathy immediately after curriculum implementation and 15 months later. After the 6-month curriculum was completed, MINdI participants were significantly more likely than controls to report knowing how to apply mindfulness techniques and their evidence, as well as having a positive attitude about mindfulness and believing it benefited their life. Fifteen months after curriculum implementation, the only measure with a statistically significant between-arm difference was in knowledge of the evidence supporting the use of mindfulness.

In contrast to prior studies^14,15,17,18 of mindfulness curriculum, our study found no changes in burnout rates or levels of EE, depersonalization, mindfulness, or empathy between intervention and control participants. Our study intervention differs from prior studies^14,15 in a number of important ways. First, our curriculum was not facilitated by an experienced mindfulness practitioner. Recognizing the limitation of facilitation by a local content expert on the feasibility of widespread dissemination of mindfulness curricula, our curriculum relied on a scripted curriculum that did not require a content expert to facilitate education. However, our results prompt us to question the potential effect of greater facilitator experience in mindfulness training on curriculum effectiveness.

Second, prior curricula have been more robust compared with MINdI.^{13,14,15,21,30,31} For example, the mindfulness-based stress reduction curriculum published by Krasner et al¹⁴ was composed of an 8-week intensive phase that included 2.5 hours per week and a 7-hour retreat followed by a 2.5-hour per month maintenance period for 10 months. In contrast, our 7-session monthly curriculum was specifically designed to integrate into preexisting residency didactic time. It is possible our curriculum may not have been robust enough to induce a change in behavior and objective metrics of burnout, mindfulness, or empathy, although changes in mindfulness-related knowledge and attitudes were apparent. Although programs were encouraged to take attendance, it was not required. Thus, we have no consistent data on how many training sessions each intern experienced. We wonder whether there could be a dose response in the mindfulness training that we are not able to assess in which more participation may have led to better outcomes among trainees.

In our study population, most participants in both arms had scores indicating burnout at baseline, and burnout worsened during the study period. Because most participants completed the baseline survey before internship began, efforts to reduce burnout among trainees should be integrated into undergraduate medical education. Despite reporting increased mindfulness-related knowledge and positive attitudes toward mindfulness after completing the curriculum, participants did not report corresponding increases in mindfulness practice or objective measures of mindfulness. Perhaps competing demands and priorities early in medical training, including a primary focus on increasing clinical competence, persistently outweighed prioritization of new self-care techniques to prevent burnout.

Finally, selection bias may have influenced prior cohort studies^13,14,15,16 conducted among physicians who chose to participate in the mindfulness training that found mindfulness to be associated with decreased burnout. Small studies and those among medical trainees have often failed to show large or statistically significant effects of mindfulness on objective measures of burnout, empathy, or mindfulness.^{13,16,17,20,21,30}

Limitations

This study has several limitations. First, cluster randomization resulted in an imbalance in gender and baseline personal accomplishment between study arms. Second, our study is limited by missing data, a common limitation that may introduce bias into the results; to address this, we estimated missing values by multiple imputation, which may have resulted in underestimation of SEs. Third, our sample size was based on power calculations that did not account for possible clustering by site. Thus, findings of clinical importance that were not statistically significant should be cautiously interpreted and their precision judged by the widths of their 95% CIs. Fourth, our pragmatic trial design allowed variation in month of the intervention and control experiences and survey implementation, so temporal trends in burnout during training may have influenced intervention efficacy and our findings.

The mixed results of our methodologically rigorous cluster randomized clinical trial of MINdI may indicate that trainees face unique challenges in integrating mindfulness knowledge into behavior change. The study demonstrated that improvements in mindfulness-related knowledge and attitudes failed to translate into effects on burnout, empathy, and mindfulness. Although we cannot be sure why the intervention did not have its intended effect, we hypothesize 2 explanations. First, although MINdI was robust enough to affect knowledge and attitudes, it was not strong enough to affect distal outcomes. Second, our study identified higher rates of burnout than previously reported in the literature of pediatric trainees. It is possible that the high levels of burnout we detected represent a meaningful temporal shift and the diminished efficacy of individual-level interventions, such as mindfulness, to address epidemic levels of burnout. Burnout in medical training may be driven more at a systems level than a personal one, and in the context of pediatric internship, efforts to reduce burnout should focus more on system reform than personal training.^21,30,32

Conclusions

This multicenter cluster randomized clinical trial of a novel mindfulness curriculum demonstrated that the intervention did not significantly affect measures of burnout, mindfulness, or empathy among pediatric interns training across the US. However, intervention participants reported improved mindfulness-related knowledge, behaviors, and attitudes. The mixed results of this large, multicenter randomized clinical trial suggest that there is a need for further study, mechanism elucidation for behavior change, and curriculum optimization.

Supplement 1.

Trial Protocol

Click here for additional data file.^{(339.5KB, pdf)}

Supplement 2.

eTable. Study Sample and Lost to Follow-up Baseline Characteristics

Click here for additional data file.^{(135.6KB, pdf)}

Supplement 3.

Data Sharing Statement

Click here for additional data file.^{(13KB, pdf)}

References

1.Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory: third edition. In: Evaluating Stress: A Book of Resources. Scarecrow Education; 1997:191-218. Accessed March 9, 2019. https://psycnet.apa.org/record/1997-09146-011
2.Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613. doi: 10.1016/j.mayocp.2015.08.023 [DOI] [PubMed] [Google Scholar]
3.Ishak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;1(2):236-242. doi: 10.4300/JGME-D-09-00054.1 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Baer TE, Feraco AM, Tuysuzoglu Sagalowsky S, Williams D, Litman HJ, Vinci RJ. Pediatric resident burnout and attitudes toward patients. Pediatrics. 2017;139(3):e20162163. doi: 10.1542/peds.2016-2163 [DOI] [PubMed] [Google Scholar]
5.Zhou AY, Panagioti M, Esmail A, Agius R, Van Tongeren M, Bower P. Factors associated with burnout and stress in trainee physicians: a systematic review and meta-analysis. JAMA Netw Open. 2020;3(8):e2013761. doi: 10.1001/jamanetworkopen.2020.13761 [DOI] [PMC free article] [PubMed] [Google Scholar]
6.West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-1078. doi: 10.1001/jama.296.9.1071 [DOI] [PubMed] [Google Scholar]
7.Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. doi: 10.1097/SLA.0b013e3181bfdab3 [DOI] [PubMed] [Google Scholar]
8.Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. doi: 10.1016/j.mayocp.2016.10.004 [DOI] [PubMed] [Google Scholar]
9.Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62. doi: 10.1001/archsurg.2010.292 [DOI] [PubMed] [Google Scholar]
10.Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-341. doi: 10.7326/0003-4819-149-5-200809020-00008 [DOI] [PubMed] [Google Scholar]
11.Staples BB, Burke AE, Batra M, et al. ; Pediatric Resident Burnout-Resilience Study Consortium . Burnout and association with resident performance as assessed by pediatric milestones: an exploratory study. Acad Pediatr. 2021;21(2):358-365. doi: 10.1016/j.acap.2020.08.006 [DOI] [PubMed] [Google Scholar]
12.Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170(11):784-790. doi: 10.7326/M18-1422 [DOI] [PubMed] [Google Scholar]
13.Lamothe M, Rondeau É, Malboeuf-Hurtubise C, Duval M, Sultan S. Outcomes of MBSR or MBSR-based interventions in health care providers: a systematic review with a focus on empathy and emotional competencies. Complement Ther Med. 2016;24:19-28. doi: 10.1016/j.ctim.2015.11.001 [DOI] [PubMed] [Google Scholar]
14.Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293. doi: 10.1001/jama.2009.1384 [DOI] [PubMed] [Google Scholar]
15.Goodman MJ, Schorling JB. A mindfulness course decreases burnout and improves well-being among healthcare providers. Int J Psychiatry Med. 2012;43(2):119-128. doi: 10.2190/PM.43.2.b [DOI] [PubMed] [Google Scholar]
16.Goldhagen BE, Kingsolver K, Stinnett SS, Rosdahl JA. Stress and burnout in residents: impact of mindfulness-based resilience training. Adv Med Educ Pract. 2015;6:525-532. doi: 10.2147/AMEP.S88580 [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Verweij H, van Ravesteijn H, van Hooff MLM, Lagro-Janssen ALM, Speckens AEM. Mindfulness-based stress reduction for residents: a randomized controlled trial. J Gen Intern Med. 2018;33(4):429-436. doi: 10.1007/s11606-017-4249-x [DOI] [PMC free article] [PubMed] [Google Scholar]
18.Ireland MJ, Clough B, Gill K, Langan F, O’Connor A, Spencer L. A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Med Teach. 2017;39(4):409-414. doi: 10.1080/0142159X.2017.1294749 [DOI] [PubMed] [Google Scholar]
19.McClafferty H, Brown OW; Section on Integrative Medicine; Committee on Practice And Ambulatory Medicine; Section on Integrative Medicine . Physician health and wellness. Pediatrics. 2014;134(4):830-835. doi: 10.1542/peds.2014-2278 [DOI] [PubMed] [Google Scholar]
20.Lebares CC, Guvva EV, Olaru M, et al. Efficacy of mindfulness-based cognitive training in surgery: additional analysis of the mindful surgeon pilot randomized clinical trial. JAMA Netw Open. 2019;2(5):e194108. doi: 10.1001/jamanetworkopen.2019.4108 [DOI] [PMC free article] [PubMed] [Google Scholar]
21.West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281. doi: 10.1016/S0140-6736(16)31279-X [DOI] [PubMed] [Google Scholar]
22.Cheston CC, Sox CM, Michelson CD, Fraiman YS. MINdI: Mindfulness Instruction for New Interns. MedEdPORTAL. 2020;16:10933. doi: 10.15766/mep_2374-8265.10933 [DOI] [PMC free article] [PubMed] [Google Scholar]
23.Kern DE, Thomas PA, Howard DM, Bass EB. Curriculum Development for Medical Education: A Six-Step Approach. Johns Hopkins University Press; 1998. [Google Scholar]
24.Eckleberry-Hunt J, Kirkpatrick H, Barbera T. The problems with burnout research. Acad Med. 2018;93(3):367-370. doi: 10.1097/ACM.0000000000001890 [DOI] [PubMed] [Google Scholar]
25.Baer RA, Smith GT, Lykins E, et al. Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment. 2008;15(3):329-342. doi: 10.1177/1073191107313003 [DOI] [PubMed] [Google Scholar]
26.Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006;13(1):27-45. doi: 10.1177/1073191105283504 [DOI] [PubMed] [Google Scholar]
27.Davis MH. Measuring individual differences in empathy: evidence for a multidimensional approach. J Pers Soc Psychol. 1983;44(1):113-126. doi: 10.1037/0022-3514.44.1.113 [DOI] [Google Scholar]
28.Davis MH. A multidimensional approach to individual differences in empathy. J Pers Soc Psychol. 1980;10:85. [Google Scholar]
29.Kemper KJ, Schwartz A, Wilson PM, et al. ; Pediatric Resident Burnout-Resilience Study Consortium . Burnout in pediatric residents: three years of national survey data. Pediatrics. 2020;145(1):e20191030. doi: 10.1542/peds.2019-1030 [DOI] [PubMed] [Google Scholar]
30.Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205. doi: 10.1001/jamainternmed.2016.7674 [DOI] [PubMed] [Google Scholar]
31.Beckman HB, Wendland M, Mooney C, et al. The impact of a program in mindful communication on primary care physicians. Acad Med. 2012;87(6):815-819. doi: 10.1097/ACM.0b013e318253d3b2 [DOI] [PubMed] [Google Scholar]
32.Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward. JAMA. 2017;317(9):901-902. doi: 10.1001/jama.2017.0076 [DOI] [PubMed] [Google Scholar]

Associated Data

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

Supplementary Materials

Supplement 1.

Trial Protocol

Click here for additional data file.^{(339.5KB, pdf)}

Supplement 2.

eTable. Study Sample and Lost to Follow-up Baseline Characteristics

Click here for additional data file.^{(135.6KB, pdf)}

Supplement 3.

Data Sharing Statement

Click here for additional data file.^{(13KB, pdf)}

[poi210085r1] 1.Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory: third edition. In: Evaluating Stress: A Book of Resources. Scarecrow Education; 1997:191-218. Accessed March 9, 2019. https://psycnet.apa.org/record/1997-09146-011

[poi210085r2] 2.Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613. doi: 10.1016/j.mayocp.2015.08.023 [DOI] [PubMed] [Google Scholar]

[poi210085r3] 3.Ishak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;1(2):236-242. doi: 10.4300/JGME-D-09-00054.1 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi210085r4] 4.Baer TE, Feraco AM, Tuysuzoglu Sagalowsky S, Williams D, Litman HJ, Vinci RJ. Pediatric resident burnout and attitudes toward patients. Pediatrics. 2017;139(3):e20162163. doi: 10.1542/peds.2016-2163 [DOI] [PubMed] [Google Scholar]

[poi210085r5] 5.Zhou AY, Panagioti M, Esmail A, Agius R, Van Tongeren M, Bower P. Factors associated with burnout and stress in trainee physicians: a systematic review and meta-analysis. JAMA Netw Open. 2020;3(8):e2013761. doi: 10.1001/jamanetworkopen.2020.13761 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi210085r6] 6.West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-1078. doi: 10.1001/jama.296.9.1071 [DOI] [PubMed] [Google Scholar]

[poi210085r7] 7.Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. doi: 10.1097/SLA.0b013e3181bfdab3 [DOI] [PubMed] [Google Scholar]

[poi210085r8] 8.Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. doi: 10.1016/j.mayocp.2016.10.004 [DOI] [PubMed] [Google Scholar]

[poi210085r9] 9.Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62. doi: 10.1001/archsurg.2010.292 [DOI] [PubMed] [Google Scholar]

[poi210085r10] 10.Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-341. doi: 10.7326/0003-4819-149-5-200809020-00008 [DOI] [PubMed] [Google Scholar]

[poi210085r11] 11.Staples BB, Burke AE, Batra M, et al. ; Pediatric Resident Burnout-Resilience Study Consortium . Burnout and association with resident performance as assessed by pediatric milestones: an exploratory study. Acad Pediatr. 2021;21(2):358-365. doi: 10.1016/j.acap.2020.08.006 [DOI] [PubMed] [Google Scholar]

[poi210085r12] 12.Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170(11):784-790. doi: 10.7326/M18-1422 [DOI] [PubMed] [Google Scholar]

[poi210085r13] 13.Lamothe M, Rondeau É, Malboeuf-Hurtubise C, Duval M, Sultan S. Outcomes of MBSR or MBSR-based interventions in health care providers: a systematic review with a focus on empathy and emotional competencies. Complement Ther Med. 2016;24:19-28. doi: 10.1016/j.ctim.2015.11.001 [DOI] [PubMed] [Google Scholar]

[poi210085r14] 14.Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293. doi: 10.1001/jama.2009.1384 [DOI] [PubMed] [Google Scholar]

[poi210085r15] 15.Goodman MJ, Schorling JB. A mindfulness course decreases burnout and improves well-being among healthcare providers. Int J Psychiatry Med. 2012;43(2):119-128. doi: 10.2190/PM.43.2.b [DOI] [PubMed] [Google Scholar]

[poi210085r16] 16.Goldhagen BE, Kingsolver K, Stinnett SS, Rosdahl JA. Stress and burnout in residents: impact of mindfulness-based resilience training. Adv Med Educ Pract. 2015;6:525-532. doi: 10.2147/AMEP.S88580 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi210085r17] 17.Verweij H, van Ravesteijn H, van Hooff MLM, Lagro-Janssen ALM, Speckens AEM. Mindfulness-based stress reduction for residents: a randomized controlled trial. J Gen Intern Med. 2018;33(4):429-436. doi: 10.1007/s11606-017-4249-x [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi210085r18] 18.Ireland MJ, Clough B, Gill K, Langan F, O’Connor A, Spencer L. A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Med Teach. 2017;39(4):409-414. doi: 10.1080/0142159X.2017.1294749 [DOI] [PubMed] [Google Scholar]

[poi210085r19] 19.McClafferty H, Brown OW; Section on Integrative Medicine; Committee on Practice And Ambulatory Medicine; Section on Integrative Medicine . Physician health and wellness. Pediatrics. 2014;134(4):830-835. doi: 10.1542/peds.2014-2278 [DOI] [PubMed] [Google Scholar]

[poi210085r20] 20.Lebares CC, Guvva EV, Olaru M, et al. Efficacy of mindfulness-based cognitive training in surgery: additional analysis of the mindful surgeon pilot randomized clinical trial. JAMA Netw Open. 2019;2(5):e194108. doi: 10.1001/jamanetworkopen.2019.4108 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi210085r21] 21.West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281. doi: 10.1016/S0140-6736(16)31279-X [DOI] [PubMed] [Google Scholar]

[poi210085r22] 22.Cheston CC, Sox CM, Michelson CD, Fraiman YS. MINdI: Mindfulness Instruction for New Interns. MedEdPORTAL. 2020;16:10933. doi: 10.15766/mep_2374-8265.10933 [DOI] [PMC free article] [PubMed] [Google Scholar]

[poi210085r23] 23.Kern DE, Thomas PA, Howard DM, Bass EB. Curriculum Development for Medical Education: A Six-Step Approach. Johns Hopkins University Press; 1998. [Google Scholar]

[poi210085r24] 24.Eckleberry-Hunt J, Kirkpatrick H, Barbera T. The problems with burnout research. Acad Med. 2018;93(3):367-370. doi: 10.1097/ACM.0000000000001890 [DOI] [PubMed] [Google Scholar]

[poi210085r25] 25.Baer RA, Smith GT, Lykins E, et al. Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment. 2008;15(3):329-342. doi: 10.1177/1073191107313003 [DOI] [PubMed] [Google Scholar]

[poi210085r26] 26.Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006;13(1):27-45. doi: 10.1177/1073191105283504 [DOI] [PubMed] [Google Scholar]

[poi210085r27] 27.Davis MH. Measuring individual differences in empathy: evidence for a multidimensional approach. J Pers Soc Psychol. 1983;44(1):113-126. doi: 10.1037/0022-3514.44.1.113 [DOI] [Google Scholar]

[poi210085r28] 28.Davis MH. A multidimensional approach to individual differences in empathy. J Pers Soc Psychol. 1980;10:85. [Google Scholar]

[poi210085r29] 29.Kemper KJ, Schwartz A, Wilson PM, et al. ; Pediatric Resident Burnout-Resilience Study Consortium . Burnout in pediatric residents: three years of national survey data. Pediatrics. 2020;145(1):e20191030. doi: 10.1542/peds.2019-1030 [DOI] [PubMed] [Google Scholar]

[poi210085r30] 30.Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205. doi: 10.1001/jamainternmed.2016.7674 [DOI] [PubMed] [Google Scholar]

[poi210085r31] 31.Beckman HB, Wendland M, Mooney C, et al. The impact of a program in mindful communication on primary care physicians. Acad Med. 2012;87(6):815-819. doi: 10.1097/ACM.0b013e318253d3b2 [DOI] [PubMed] [Google Scholar]

[poi210085r32] 32.Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward. JAMA. 2017;317(9):901-902. doi: 10.1001/jama.2017.0076 [DOI] [PubMed] [Google Scholar]

PERMALINK

Effect of a Novel Mindfulness Curriculum on Burnout During Pediatric Internship

Yarden S Fraiman, MD, MPH

Christine C Cheston, MD

Howard J Cabral, PhD, MPH

Celeste Allen, MD

Andrea G Asnes, MD, MSW

Jefferson T Barrett, MD, MPH

Maneesh Batra, MD, MPH

William Bernstein, MD

Tammy Bleeker, MEd

Pam M Dietz, MD

Joanna Lewis, MD

Su-Ting T Li, MD, MPH

T Marsha Ma, MD

John D Mahan, MD

Catherine D Michelson, MD, MMSc

Sue E Poynter, MD, MEd

Mark A Vining, MD

Katherine Watson, DO

Colin M Sox, MD, MS

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Design, Setting, and Participants

Interventions

Main Outcomes and Measures

Results

Conclusions and Relevance

Trial Registration

Introduction

Methods

Study Sample and Randomization

Figure 1. CONSORT Study Flow Diagram.

Intervention Arm

Control Arm

Outcomes

Statistical Analysis

Results

Study Participants

Table 1. Study Sample Characteristics and Outcome at Baselinea.

Figure 2. Burnout at Baseline Measurement.

Table 2. Impact of the MINdI Curriculum on Continuous Measures of Burnout, Mindfulness, and Empathy at Baseline, Month 6, and Month 15a.

Table 3. Impact of the MINdI Curriculum on Dichotomous Measure of Burnout and Mindfulness-Related Knowledge, Behavior, and Attitudes at Baseline, Month 6, and Month 15a.

Primary Outcomes

Secondary Outcomes

Discussion

Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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Table 1. Study Sample Characteristics and Outcome at Baseline^a.

Table 2. Impact of the MINdI Curriculum on Continuous Measures of Burnout, Mindfulness, and Empathy at Baseline, Month 6, and Month 15^a.

Table 3. Impact of the MINdI Curriculum on Dichotomous Measure of Burnout and Mindfulness-Related Knowledge, Behavior, and Attitudes at Baseline, Month 6, and Month 15^a.