Residency is an arduous period marked by emotional, personal, and intellectual challenges experienced while contending with human suffering. Internship, in particular, is a uniquely challenging experience that can have a profound effect on stress and burnout, as a physician transitions from the role of student to autonomous provider. Several studies have evaluated the prevalence of burnout among resident physicians, finding correlations between burnout and depression [1], providing suboptimal care, and committing more medical errors [2]. Rosen et al. [3] showed that high-level burnout among interns increased from 4.3% at the beginning of the year to 55.3% at year-end (P<0.0001). Changes in duty hours, mandated by the Accreditation Council for Graduate Medical Education, were hoped to reduce the prevalence of exhaustion and improve patient safety. However, the impact of duty hour mandates has been equivocal to neutral [4]. Models for fostering a healthy work-life balance have been proposed, such as training students and residents in healthy adaptive coping strategies [5], addressing institutional culture [6], and seeking to balance professional and personal demands [7]. While these models have been proposed, several factors potentially impacting burnout have not been studied, especially emotional coping strategies and spirituality among interns. Many factors are outside the control of interns, including the call schedule, daily work demands, and team structure. A study that assessed spirituality among residents showed a protective effect of spirituality against depression and burnout [8]. Identifying constructive coping strategies that interns, in particular, employ to protect themselves against burnout may be helpful for reducing errors and improving intern satisfaction. This study aims to identify how specific coping strategies, behaviors, and spiritual attitudes affect burnout among interns in the internal medicine, primary care, and internal medicine/pediatrics residency programs at the Yale University School of Medicine and a Yale-affiliated community hospital internal medicine program at the beginning and middle of the intern year.

Our data reveal several intriguing findings about coping, burnout, and spirituality among physicians facing the difficult challenges of internship. First, upon arrival to internship, 30 (45%) met the criteria for high emotional exhaustion and 42 (64%) met the criteria for high depersonalization. These findings are quite different from those of Rosen et al., who reported a much lower prevalence of 4.3% [3]. Our data suggest a residual impact from the experience of medical school and raises several questions. What is it about the curriculum and culture of medical school that results in the high prevalence of intern burnout ‘even prior to starting residency?’ Is the high prevalence of depersonalization a coping strategy, a distancing, from the emotional stress of learning medicine? Must residency programs address burnout earlier in the training process? Although many interns started residency with symptoms of burnout, the prevalence increased during the winter months. However, our findings demonstrated heterogeneous manifestations of burnout. Emotional exhaustion (84.9%), depersonalization (84.9%), and personal accomplishment (75.5%) were observed to have a high prevalence. Despite the workload and the ensuing tendency for objectification, interns still have a sense that their work has meaning and purpose. This finding highlights the heterogeneous nature of burnout, where the three variables sometimes do not correlate tightly. An intern may experience not only some aspects of burnout, especially emotional exhaustion due to the demands of the job or depersonalization to distance oneself from the suffering of patients, but also a high degree of professional satisfaction about the impact made upon patients’ lives.

Second, we speculated that interns who engaged in activities outside the hospital or participated in extracurricular activities, such as research projects, would suffer less burnout. For example, participating in extracurricular activities would reflect an abiding interest, giving meaning and context to their role as interns and allowing them to incorporate varied experiences into their daily tasks. Moreover, extracurricular activities could reflect time management skills, mentorship seeking, and more interpersonal relationships. The data, however, did not support this hypothesis; although we speculated that extracurricular activities might be negatively correlated with burnout, no significant correlation was found (Table 2). While extracurricular involvement has not been studied among residents, a study among parish-based clergy demonstrated that varied activities, both within and outside one’s vocation, were associated with a lower prevalence of burnout [12].

Third, several emotional coping strategies had either a significantly helpful or harmful impact on emotional exhaustion and depersonalization. Acceptance and active coping were strongly associated with lower emotional exhaustion and depersonalization. Conversely, self-blame, denial, disengagement, and humor were associated with higher emotional exhaustion and depersonalization. Acceptance and active coping are proactive, self-reflective strategies that suggest a certain maturity. “I accept the reality of what has happened” and “I concentrate my efforts on doing something about it” are items that imply thoughtful introspection. Conversely, self-blame, denial, and disengagement are reactive, emotionally raw responses to stress. These findings are similar to those of the study of Sevencan et al. [13] dealing with burnout among interns and affirm the importance of emotional maturity and positive coping skills in mitigating burnout.

Fourth, spirituality also impacted burnout, most notably the internal/fluid and existential/meditative domains of the SIBS. The internal/fluid domain explores a person’s belief system, rather than their attendance or participation in formal religion. “My life has a purpose,” “My spiritual beliefs continue to evolve,” and “I can find meaning in times of hardship” are examples of internal belief items that suggest both flexibility and purpose in one’s belief system. The meditative/existential domain complements the internal/fluid system, with a focus on the belief in the utility of prayer and meditation. Interns with higher scores in the internal/fluid domain and the existential/meditative domain had a greater sense of personal accomplishment. However, those scores did not impact emotional exhaustion or depersonalization. The beliefs reflected in those items perhaps give support and meaning to the daily chores of patient care, thereby impacting personal accomplishment. However, these same beliefs are not enough to mitigate the intense physical demands and reflexive objectification that comes with the complicated nature of patient care. Other studies have evaluated correlations between spirituality and burnout among medical residents and students [1,2,13]. However, two of those studies did not distinguish which aspects of spirituality were relevant to the various burnout domains [2,13]. Among this intern population, where the prevalence of burnout was high, attendance at religious services or private religious practices was not found to be significantly associated with burnout. Instead, the internal and existential qualities of faith (items assessing ‘purpose’ and ‘meaning in times of hardship’) were found to be significant. The overt practice of religion was not found to have a statistically significant effect.

Some limitations of this study should be considered. First, with the exception of the community hospital program, all interns rotated within one training system. This shared experience opens the study to selection bias, because some unique features of the Yale experience may have promoted or protected against burnout. Nevertheless, the interns came from a multitude of different medical schools and personal backgrounds that should have influenced them as much, if not more, than their current training environment. Second, this study assessed correlations between data, but does not imply causation. Burnout, depression, and coping may reflect a continuum of varied responses to stress rather than separate variables that influence each other.

In conclusion, we found that interns who employed specific strategies of acceptance, active coping, and spiritual attitudes had lower levels of burnout. Despite this, behaviors such as reading outside the field of medicine, regular exercise, and taking time for family did not lessen any aspect of burnout. Recognizing the specific factors that may influence burnout may help program directors and interns mitigate the negative effects of training.