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Comment on the Chaput et al Study, Professional Burnout Among Plastic Surgery Residents: Can it be Prevented? Outcomes of a National Survey.

C haput et al published an interesting study that provides additional data on the occurrence of burnout syndrome among plastic surgery residents and on protective/risk factors associated with the professional practice. However, in our opinion, it is important to highlight how burnout scores are constructed and the risk of misinterpretation. Maslach and Jackson described three core dimensions that characterize the burnout syndrome: (i) emotional exhaustion (EE), (ii) depersonalization (DP) and (iii) personal accomplishment (PA). These 3 dimensions are assessed as continuous variables. The total score for each dimension is categorized as low, average, or high, in accordance with cutoff values established by Maslach and coworkers, based on a sample of 1104 US physicians and nurses. These cutoffs were determined using the lower, middle, and upper thirds of the normative distribution of each score from this sample. It is important to remember that these cutoff values are statistically defined. Consequently, the expected prevalence of high EE, high DP, and low PA is 33.3%. In their article, Chaput et al reported that 25% and 13.5% of residents had high DP and EE scores. This is less than expected when compared to the normative distribution of scores inMaslach's sample. Moreover, the authors found low PA scores in 48.1% of residents (n = 25). This is significantly higher than 33.3% (P < 0.05). The lower rate of high EE and high DP and higher rate of low PA pattern have been already observed in previous survey that assessed themental health in radiologists and occupational physicians. Specifically, Ramirez et al reported that radiologists had the lowest scores concerning stress (feeling overloaded and its effect on home life, having managerial responsibilities and dealing with patients' suffering), but the highest rate of low PA scores (job satisfaction). The authors assumed that radiologists perform medical activities on request by a third party (treating physician) and therefore have little feedback from patients, do not have to deal with inappropriate requests and ongoing expectation of immediate responses. Obviously, this is not the case among surgery residents. Nevertheless, the high rate of low PA among plastic surgery residents is an interesting finding. Chaput et al. found that 28.8% of respondents exhibited signs of burnout. However, they chose to index burnout only to the high scores of the EE and DP subscales, whereas in the classical definition, burnout scores from all 3 subscales are required. This has a great influence on the burnout prevalence. For example, Shanafelt et al considered a high score on the DP or EE scales to be indicative of burnout syndrome and consequently reported a very high prevalence of burnout (76%) in a sample of 115 internal medicine residents. Conversely, a French study on 300 general practitioners using the classical definition reported a burnout prevalence of 5%. Moreover, almost 30% of residents had high scores in the EE or DP subscales, a lower prevalence compared to other studies on residents. However, to interpret this finding as ‘a third of residents experienced a burnout syndrome’ (or had poor mental ill-health) would represent a misunderstanding of the results. Indeed, the Maslach Burnout Inventory cutoffs are not clinically defined, but mathematically. This is not a diagnostic tool. Moreover, the criteria used (ie, high score in just 2 dimensions) overestimated the prevalence of “burnout,” and therefore caution is needed when comparing this result with other studies. Nevertheless, these considerations have no influence on the practice characteristics associated with high EE, high DP, and low PA, and the study provided interesting and rigorous results.