Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents

Context: Physician distress is common and has been associated with negative effects on patient care. However, factors associated with resident distress and wellbeing have not been well described at a national level. Objectives: To measure well-being in a national sample of internal medicine residents and to evaluate relationships with demographics, educational debt, and medical knowledge. Design, Setting, and Participants: Study of internal medicine residents using data collected on 2008 and 2009 Internal Medicine In-Training Examination (IM-ITE) scores and the 2008 IM-ITE survey. Participants were 16 394 residents, representing 74.1% of all eligible US internal medicine residents in the 2008-2009 academic year. This total included 7743 US medical graduates and 8571 international medical graduates. Main Outcome Measures: Quality of life (QOL) and symptoms of burnout were assessed, as were year of training, sex, medical school location, educational debt, and IM-ITE score reported as percentage of correct responses. Results: Quality of life was rated "as bad as it can be" or "somewhat bad" by 2402 of 16 187 responding residents (14.8%). Overall burnout and high levels of emotional exhaustion and depersonalization were reported by 8343 of 16 192 (51.5%), 7394 of 16 154 (45.8%), and 4541 of 15 737 (28.9%) responding residents, respectively. In multivariable models, burnout was lesscommonamong international medical graduates than among US medical graduates (45.1% vs 58.7%; odds ratio, 0.70 [99% CI, 0.63-0.77]; P<.001). Greater educational debt was associated with the presence of at least 1 symptom of burnout (61.5% vs 43.7%; odds ratio, 1.72 [99% CI, 1.49-1.99]; P<.001 for debt >$200 000 relative to no debt). Residents reporting QOL "as bad as it can be" and emotional exhaustion symptoms daily had mean IM-ITE scores 2.7 points (99% CI, 1.2-4.3; P<.001) and 4.2 points (99% CI, 2.5-5.9; P<.001) lower than those with QOL "as good as it can be" and no emotional exhaustion symptoms, respectively. Residents reporting debt greater than $200 000 had mean IM-ITE scores 5.0 points (99% CI, 4.4-5.6; P<.001) lower than those with no debt. These differences were similar in magnitude to the 4.1-point (99% CI, 3.9-4.3) and 2.6-point (99% CI, 2.4-2.8) mean differences associated with progressing from first to second and second to third years of training, respectively. Conclusions: In this national study of internal medicine residents, suboptimal QOL and symptoms of burnout were common. Symptoms of burnout were associated with higher debt and were less frequent among international medical graduates. Low QOL, emotional exhaustion, and educational debt were associated with lower IM-ITE scores.