On the Topic of Academic Achievement, Professionalism, and Burnout in Family Medicine Residents

We greatly appreciate the thoughtful points raised in the response¹ to our paper² on the burnout and professionalism milestone attainment of family medicine resident physicians, and we appreciate the nuanced analysis of unique burnout contributors among physicians-in-training who identify as Black, Indigenous, or people of color (BIPOC).

In our findings, the statistically significant associations between burnout and race (where White respondents are more likely than Black or Asian respondents to report burnout) disappear in the multilevel model. This means that, put in the context of individual-, program-, and area-level characteristics, race does not have a significant independent ability to predict burnout. As you point out though, even this equivocal result is surprising given evidence that BIPOC residents are at risk of being denied the training opportunities, leadership roles, and sometimes even expected annual training promotion afforded their White colleagues.³

The interaction between psychological safety (or the lack thereof), discrimination, and equity in the graduate medical education arena is certainly an area of study that merits more in-depth inquiry and investment. Your explanation is a thought-provoking one and speaks to a larger need to study the role of psychological safety in the experience and reporting of burnout, particularly among people from traditionally marginalized backgrounds. Insofar as research identifies demographic factors that are protective against burnout (in our study, only international medical graduate status was robust to multilevel modeling), it is also worthwhile to identify learning opportunities to develop these protective factors, such as through increasing adaptive traits, like levels of resiliency and psychological flexibility.

We drew the data from survey responses by a group of graduating family medicine residents, as part of the process of initial specialty certification. Unfortunately, there is as of now no qualitative correlate to this quantitative data source. However, we agree that a mixed-methods approach, perhaps employing focus groups of recent family medicine diplomates, would be invaluable in delving deeper into the interaction between race and burnout in family medicine training. Looking forward, we are very interested in deconstructing contributors to burnout with an eye toward aiding in the development of strategies to mitigate their effects on the family medicine workforce and the patients we all serve.