Burnout factors among residents in surgical and non-surgical specialties: a scoping review

Burnout factors among residents in surgical and non-surgical specialties: a scoping review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Burnout factors among residents in surgical and non-surgical specialties: a scoping review Wei Cen Wang, Abhirup Biswas, Amrit Kirpalani, Peter Zhan Tao Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4584396/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives Resident burnout is heterogeneous across specialties. This scoping review explores burnout factors within surgical and non-surgical specialties and how unique challenges within each discipline contribute to burnout. Methods A literature search was conducted on OVID Medline and 4 other databases with terms in: 1. residency, 2. burnout, 3. factors, and 4. burnout assessment measures. Original English articles published in North America were included. A frequency is calculated for each factor reported to have a statistically significant association with burnout within the surgical residency category and non-surgical residency category. Results There were 46, 50, and 1 study in surgical specialties, non-surgical specialties, and both, respectively. Sixty-five burnout factors were identified. The top personal factors were gender, mindset/mentality, and having a partner/children for both disciplines. The top program-related factors for both disciplines were training stage and workload, and mentorship for surgical specialties and work-life balance for non-surgical specialties. The top external factors for both disciplines were workplace relations, rotations, and co-resident support. The top two institutional factors were autonomy and administrative tasks for surgical specialties, and vice versa for non-surgical specialties. Conclusion Common burnout factors suggest ubiquitous challenges in residency. The differences in the burnout experience are driven by innate personal differences, medical culture, and hidden curriculum. Implementation of protective strategies would require thorough consideration of such similarities and differences and control for balancing factors to maintain the quality of education and patient care. residency burnout factors medical culture hidden curriculum Figures Figure 1 Introduction Burnout is widely regarded as a work-related stress syndrome with a disproportionally high prevalence among physicians compared to the general population (Shanafelt et al., 2012 ). This prevalence is higher among residents compared to practising physicians due to chronic stressors associated with residency, such as demanding work hours and responsibilities, steep learning curves, and poor work life balance ( Physician Wellness , 2022). Despite anti-burnout policies and guidelines such as national mandated work hour limitations (WHL) and requirements for all residency programs to establish policies to optimize resident wellbeing, the prevalence of burnout is still 41% and 58% among American and Canadian residents, respectively ( Creating a Culture of Wellness in Medicine , 2022; Insights from Exclusive AMA Report on Resident Well-Being with Mark Greenawald, MD , 2023). Furthermore, WHL has received varying degrees of backlash from both residents and faculties due to decreased satisfaction on quality of education and perceived patient care (Schwartz et al., 2013 ; Awan et al., 2021 ; Antiel et al., 2011 ). The complexity of burnout is further dissected by Dr. Mamta Gautham ( CJPL Turning Burnout into Joy , 2018), who categorizes its drivers into intrinsic factors, such as personality traits inherent to physicians, extrinsic factors tied to the practice environment, and the pervasive culture within medicine that often perpetuates these stressors. Notably, the manifestation and determinants of burnout vary significantly across specialties, with a distinct dichotomy between surgical and non-surgical fields. These domains differ not only in the technical nature of work but also in the cultural and lifestyle expectations placed on these residents (Bui et al., 2020 ; Woodside et al., 2008 ). The existing literature hints at these differences, with research in Italy revealing variance in work-related burnout factors between surgical and non-surgical residents (Serenari et al., 2019 ) and a large-scale American study observing comparable burnout rates but higher levels of depersonalization among surgical residents (Nituica et al., 2021 ). Such findings suggest that the underlying causes of burnout may not be uniformly addressed across specialties. Therefore, a nuanced understanding of these specialty-specific stressors is crucial for developing targeted, effective interventions. This scoping review aims to bridge this gap by examining the literature on resident burnout factors within surgical versus non-surgical specialties. By identifying and comparing the unique challenges faced by residents in these distinct fields, this study seeks to illuminate the specific factors contributing to burnout and inform the development of tailored strategies to enhance resident well-being and resilience. Methods The methods of this scoping review are designed according to the framework reported by Arksey and O’Malley (Arksey & O’Malley, 2005 ). We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist to guide the reporting of this scoping review (Tricco et al., 2018 ). A review protocol was not registered. Identifying the Research Question Given the distinct dichotomy in technical nature of work, culture, and lifestyle between surgical and non-surgical specialties, our central research objective is to identify factors contributing to burnout among surgical versus non-surgical specialties reported in literature. These factors will be analyzed to identify common and unique challenges within either medical discipline, which can serve to illuminate effective targeted strategies for residency reforms. Identifying Relevant Studies The literature search was conducted on the OVID Medline, ERIC, Embase Classic + Embase, APA PsychInfo, and SCOPUS databases from 1970 – June 2023. The search strategy was designed to capture original research reporting burnout factors within medical residency. Given that burnout is a subjective experience, we included “self-reporting qualitative burnout assessment” as one of the domains of the search strategy to focus on research that captured direct experiences of residents. The search strategy used both index terms and text words to identify articles that included terms in all 4 of the following domains: 1. medical residency, 2. burnout, 3. factors, 4. surveys, questionnaires, or other burnout assessment measures. The full search strategy used for the SCOPUS database is as follows, with a time filter of “1970 and onwards” manually applied to the results: ( ( TITLE-ABS-KEY ( ( surg* OR medic* OR physician* ) W/3 ( residen* OR intern* ) ) ) OR ( TITLE-ABS-KEY ( "internship and residency" ) ) ) AND ( TITLE-ABS-KEY ( "psychological burnout" OR "occupational burnout" OR exhaustion OR burnout OR "burn* out" ) ) AND ( TITLE-ABS-KEY ( "maslach burnout inventory" OR "maslach burnout index" OR "oldenburg burnout inventory" OR "single item burnout measure" OR "copenhagen burnout inventory" ) ) AND ( EXCLUDE ( DOCTYPE, "re" ) OR EXCLUDE ( DOCTYPE, "cp" ) OR EXCLUDE ( DOCTYPE, "le" ) OR EXCLUDE ( DOCTYPE, "no" ) OR EXCLUDE ( DOCTYPE, "ed" ) OR EXCLUDE ( DOCTYPE, "er" ) ). Search strategies used for the other databases are included in Online Resource 1. Inclusion and Exclusion Criteria Original manuscripts reporting factors of burnout among residents in surgical and non-surgical specialties within North America and written in English were included. Surgical specialties included: cardiothoracic surgery, general surgery, obstetrics and gynecologic, neurological surgery, ophthalmic surgery, oral and maxillofacial surgery, orthopaedic surgery, otorhinolaryngology, plastic surgery, urology, and vascular surgery. All other specialties were considered “non-surgical”, such as family medicine, internal medicine, radiology, pediatrics, etc . Articles that aggregated surgical and non-surgical residents as one sample, conducted on medical students/physicians/other healthcare workers, military residency programs, non-MD/non-DO programs, outside of North America, non-English, and solely within the context of Covid-19 were excluded. A time restriction was set to only include studies published after 1970 as the term “burnout” gained usage after being coined by Herbert Freudenberger in the 1970s (Freudenberger, 1974 ). Article Screening Studies extracted from the database were imported into Covidence for removal of duplicates and screening. Screening was performed by two independent reviewers based on the predetermined inclusion and exclusion criteria (WCW, PW). Both reviewers first conducted a title and abstract screen and proceeded to do a full text screen with the articles selected from the first screen. Screening conflicts were resolved via discussion and consensus between the two reviewers. Data Extraction and Reporting the Results Study characteristics including author, year of publication, residency specialty, burnout measure tool, sample size, and identified burnout factors were extracted and charted manually in Excel (by WCW, Online Resource 2). The articles are divided into either the surgical specialty or non-surgical specialty category. Within both categories, a frequency is calculated for each factor reported to have a statistically significant association with burnout by dividing the number of articles reporting the factor by the total number of surgical or non-surgical specialty articles and multiplied by 100 (by WCW and AB). The calculated frequencies are used to compare the prevalence and interpret the significance of burnout factors within either medical discipline. Results A total of 97 articles were included in the final analysis (Fig. 1 ). Eighty-nine studies were conducted in the United States and 8 studies were conducted in Canada. There were 87 observational studies and 10 interventional studies. There were 46 studies in surgical specialties (Table 1 . A) and 50 studies in non-surgical specialties (Table 1 . B), and 1 study including both surgical and non-surgical specialties (Online Resource 2, Supplementary Table 3). General surgery, orthopedics, otolaryngology, obstetrics and gynecology were the most common surgical specialties studied, whereas internal medicine, emergency medicine, family medicine, and radiology are the most common non-surgical specialties studied. Nighty-five percent of studies used the Maslach Burnout Inventory (MBI)-HSS or other MBI variations as the burnout assessment tool. Other burnout assessment tools included the Mini Z Survey, Personal Well-being Score (PWS), Professional Quality of Life Scale (PROQoL), Copenhagen Burnout Inventory (CBI), and a single-item measure of burnout (Table 1 ). Table 1 Study Characteristics A. Studies on surgical specialties Number of studies Total # of articles 46 Countries Canada 2 US 44 Burnout Assessment Tool MBI 46 Other* 2 Types of studies Observational studies 39 Interventional studies 7 Surgical Subspecialties General surgery 16 Orthopedics 7 Otolaryngology 6 Obstetrics and gynecology 6 Urology 3 Neurosurgery 2 Plastic surgery 2 Multiple specialties 4 *“Overall, based on your definition of burnout, how would you rate your level of burnout?”, MiniZ. B. Studies on non-surgical specialties Number of Studies Total # of articles 50 Countries Canada 6 US 44 Burnout Assessment Tool MBI 47 Other* 4 Types of studies Observational studies 47 Interventional studies 3 Non-surgical Subspecialties Internal Medicine 14 Family medicine 7 Pediatrics 7 Radiology 7 Emergency medicine 5 Dermatology 2 Anesthesiology 1 PM&R 1 Psychiatry 1 Multiple non-surgical specialties 5 *Personal well-being score (PWS), Professional Quality of Life Scale, Copenhagen Burnout Inventory), MiniZ work-life survey, Categories of burnout factors There was a total of 65 factors significantly associated with resident burnout, which can be divided into 4 categories: personal, external, institutional, and program-related (Table 2 ). Specific burnout factors reported in each study are summarized in Online Resource 2. Personal factors included one’s intrinsic characters, values, perceptions, and controllable personal situations. Program-related factors characterize the learning environment of residency programs. Institutional factors include those determined or greatly affected by medical administrative policies and regulations. Lastly, external factors are aspects of one’s social network, finances, and professional setting that aren’t particularly driven by the healthcare institution or specific residency program. Personal factors had the highest frequency, followed by program-related factors, external factors, and institutional factors. For the personal factor category, the top three factors were gender, mindset and mentality, and having a partner or children for both surgical and non-surgical residencies. Only the female gender was associated with higher EE and global burnout and only the male gender was associated with higher DP and lower PA among surgical residents. Meanwhile, an equal number of articles found either the male or female gender associated with higher global burnout among non-surgical residents. Among both surgical and non-surgical residents, lower grit and resilience were associated with higher EE, DP, and global burnout and lower PA. Having a partner or children was shown to be protective across all burnout components among surgical and non-surgical residents alike, except for 1 study, which reported male emergency medicine residents in a relationship had a higher prevalence of burnout compared to female residents in a relationship, and single female and male residents. For the program related factor category, the top two factors were stage of training and workload for both surgical and non-surgical residents, and the top third factor was faculty mentorship/support for surgical residents and work-life balance for non-surgical residents. Post graduate year 1–3 was associated with EE, DP, and global burnout for both surgical and non-surgical specialties. However, junior years were associated with lower PA in non-surgical specialties but higher PA in surgical specialties. Increased workload, such as > 80 hour work week and duty hour violations, was associated with increased EE, DP, global burnout and decreased PA, while WHL was protective of EE and global burnout for both surgical and non-surgical residents. However, more internal medicine residents reported WHL having a negative effect on their quality of education and patient care than they did a positive or neutral effect, despite the decrease in measured burnout. For surgical specialties, having strong faculty support and mentorship, such as adequate constructive feedback and strong role models, was protective of EE, DP, and global burnout. For non-surgical specialties, poor work-life balance was associated with global burnout and emotional exhaustion. For the external factor category, workplace relations, rotations, and co-resident support were the top 3 factors for both surgical and non-surgical residents. Toxic workplace relations, such as hostile co-workers, public humiliation, discrimination, was associated with EE, DP, and global burnout among surgical residents and global burnout for non-surgical residents. Meanwhile, the perception of staff and faculty working well together was protective against burnout in non-surgical residents. High acuity rotations were associated with higher prevalence of EE, DP, but protective of PA for both surgical and non-surgical specialties. Inpatient rotations were associated with burnout in non-surgical specialties. Feeling well supported by co-residents was protective against burnout in both surgical and non-surgical residents. For the institutional factor category, the top factor was autonomy and secondly administrative tasks for surgical residents, and vice versa for non-surgical residents. Lack of autonomy, including poor control over one’s work, lack of independence, and working under close supervision was commonly associated with increased EE, DP, and global burnout among surgical residents. Meanwhile, more papers reported administrative concerns, such as inappropriate clerical burden and time pressure with electronic medical records documentation, as factors of burnout than lack of autonomy for non-surgical residents. Inadequate vacation time, duty hour violations and lack of job resources were institutional factors of burnout among surgical residents only. Table 2 Frequency of statistically significant burnout factors Factor Categories Frequency in surgical specialty studies (n) Frequency in non-surgical specialty studies (n) Personal Gender 19% (9) 20% (10) Mindset/mentality 13% (6) 25% (13) Partner/children 17% (8) 16% (8) Mental health 10% (5) 14% (7) Career/program choice satisfaction 8% (4) 12% (6) Age 8% (4) 10% (5) Rest 8% (4) 8% (4) Self perception/expectations 2% (1) 12% (6) Emotional intelligence 10% (5) 4% (2) Exercise 10% (5) 2% (1) Racial background 2% (1) 8% (4) Perceived stress 4% (2) 4% (2) Mindfulness 4% (2) 4% (2) Perceived value of work 2% (1) 6% (3) Quality of life 0% 8% (4) Substance use 2% (1) 4% (2) Coping mechanism 0% 6% (3) Spirituality/faith 2% (1) 4% (2) Physical health 2% (1) 2% (1) Fear of making a Mistake 2% (1) 2% (1) Fatigue 0 4% (2) Responsibility to patient 0 4% (2) Other 11% (5) a 10% (5) b Program-related Stage of training 38% (18) 22% (11) Workload 29% (14) 20% (10) Faculty mentorship/support 27% (13) 8% (4) Work-life balance 10% (5) 12% (6) Program design 8% (4) 4% (2) Program size 4% (2) 2% (1) Wellness programs 4% (2) 4% (2) Nightshift/calls 4% (2) 4% (2) Program expectations/values (including hidden curriculum) 2% (1) 4% (2) Involvement in program decisions 2% (1) 2% (1) Other 4% (2) c 2% (1) d External Workplace Relations 21% (10) 6% (3) Rotations 6% (3) 8% (4) Coresident Support 6% (3) 6% (3) Other social support 2% (1) 6% (3) Finances 4% (2) 4% (2) Work location 4% (2) 0 Patient relations 4% (2) 0 Colleague burnout 0 4% (2) Other 9% (4) e 6% (3) f Institutional Autonomy 10% (5) 6% (3) Administrative tasks 6% (3) 8% (4) Vacation time 6% (3) 0 Duty hour violations 4% (2) 0 Job resources 2% (1) 0 a Hobbies, future career goal, work engagement, self-care, feeling appreciated. b Personality, breadth of knowledge, worrying, moral distress, test score. c Co-resident attrition, professional development opportunities. d Space for error discussion. e Mental health services, food access at work, personal reputation, family member in medicine. f Exams, confronting tragedy, other doctors’ value towards the specialty Interventional Studies There were 10 interventional studies included that reported interventions which had a statistically significant effect on burnout, with 7 in surgical specialties and 3 in non-surgical specialties (Table 3 ). The Accreditation Council for Graduate Medical Education (ACGME) mandated WHL, which came into effect in July 2003, was the most studied. One study showed a decrease in EE among surgical residents following WHL. Two articles showed decrease in EE and global burnout following WHL among non-surgical residents. As previously mentioned, more non-surgical residents in one study reported WHL having a negative effect on their education and patient care than a positive or neutral effect, despite decreasing burnout. Weekly protected non-clinical time, formal mentorship program, resident wellness programs, narrative medicine curriculum, and reflective writing workshop were all found to be protective against burnout among surgical residents. Resiliency workshop was found to effectively decrease EE and DP among non-surgical residents. Table 3 Interventional Studies Author, Year Country Specialty Intervention Sample Size Avecedo, 2021 US Otolaryngology Resident wellness program 20 Burnet, 2022 US General Surgery Resident wellness program 85 Hutter, 2006 US Department of Surgery Mandated work hour restrictions 58 Stevens, 2020 US Otolaryngology Weekly protected non-clinical time 19 Winkle, 2010 US Obstetrics and gynecology Reflective writing workshop 18 Winkle, 2016 US Obstetrics and gynecology Narrative medicine curriculum 43 Zhang, 2017 Canada Otolaryngology Formal mentorship program 8 Brennan, 2019 US Family Medicine Resiliency program 28 Goitein, 2005 US Internal Medicine Mandated work hour restrictions 118 Gopal, 2005 US Internal Medicine Mandated work hour restrictions 121 Discussion In our study, factors associated with burnout fell under 4 categories: personal, program related, external, and institutional. The top factors associated with burnout were very similar between surgical and non-surgical specialties. These include stage of training, workload, specific rotations, gender, mindset, and having a partner or children. Interventional studies also revealed WHL, formal mentorship programs and resident wellness programs to be protective against burnout among surgical residents and WHL and resiliency programs to be protective for non-surgical residents. These factors are consistently reported in literature in association with resident well-being and are focused areas of residency program improvements (Raj, 2016 ; Ahart et al., 2023 ; Safety et al., 2009). These also highlight ubiquitous fundamental principles of high-quality residency education shared across all medical specialties. Some factors were uniquely significant within surgical and non-surgical specialties. Burnout factors more frequently or uniquely associated with surgical residencies included faculty support and mentorship, workplace relations, coresident attrition, and autonomy. The first three factors highlight that burnout within surgical residencies largely stems from the particular working and learning environments shaped by those working in surgery (Mutabdzic et al., 2015 ). This is supported by well documented incidences of mistreatment such as bullying, discrimination, and undermining, with attendings and senior coresidents being the most common perpetrators (Gianakos et al., 2022 ; Zhang et al., 2020 ; Wild et al., 2015 ). Furthermore, the significance of coresident attrition reflects the heavily team-based nature of surgical care, as positive teamwork is associated with improved operative outcomes (Sun et al., 2018 ; Mazzocco et al., 2009 ). Autonomy highlights residents’ struggles with developing surgical independence from attendings and the lack of control and resulting moral injury regarding hospital administrative oversights over procedures (Geevarghese & Pomfret, 2021 ). Meanwhile, having a good perceived quality of life was uniquely protective among non-surgical residents. This could suggest that non-surgical residents place a greater value on personal life compared to surgical residents, which is consistent with non-surgical residents ranking medical lifestyle and social-orientation, especially family time, as more important influencers for career choice than surgical residents (Scott et al., 2008 ; West et al., 2009 ). Lastly, our study found that self-perception and expectations was far more frequently associated with burnout among non-surgical residents than surgical residents. Interestingly, intrapersonal traits such as imposter syndrome and self-efficacy are more studied in surgical residents, so there appears to be a gap in literature to explain this difference of effect on burnout (Chodoff et al., 2023 ; Bhama et al., 2021 ; Leach et al., 2019 ; Medline et al., 2022 ). Work hour limitations are implemented based on concerns for resident well-being and patient safety. Gotein et al (Goitein et al., 2005 ) interestingly found that more internal medicine residents reported WHL having a negative effect on their education and patient care than a positive or neutral effect, with reasons including increased crossovers resulting in less active patient management, cutting corners to comply with WHL, inadequate teaching time, and missing or cutting short specific learning activities. Furthermore, a crossover study conducted by Desai et al (Desai et al., 2013 ) found that shortened WHL and decreased frequency of overnight calls in internal medicine resulted in increased post-call sleep but reduced availability for teaching conferences and resident presence during daytime work hours. Meanwhile, the ACGME mandated WHL also resulted in decreased operative cases for junior surgical residents, reports of adverse effect on surgical junior residency education, and senior surgical residents becoming more fatigued due to shift of duties from PGY-1 trainees (Schwartz et al., 2013 ; Awan et al., 2021 ). Residency program directors overall believed that WHL will decrease residents' ability to develop core competencies, with surgery program directors more likely to believe that the WHL will decrease residents' competency in patient care, medical knowledge, and practice-based learning and improvement than internal medicine program directors (Antiel et al., 2011 ). Furthermore, Gelfand et al (Gelfand et al., 2004 ) reported no significant changes in burnout parameters following WHL among surgical residents. This highlights the importance of considering balancing factors to avoid a narrowed focus on strictly tackling burnout through decreasing clinical workload at the expense of other valuable residency outcomes, such as education quality, patient care, and resident satisfaction. Lastly, a hidden curriculum likely plays a role in shaping the burnout experience given that successful progression through residency requires the adoption of specific values, paradigms and work ethic perpetrated within each discipline. For example, a study by Hill et al (Hill et al., 2014 ) suggested that medical students had a clear sense of the surgical hidden curriculum and that successful negotiation of a surgical career involved uncovering and enacting such curriculum. Therefore, the differences in values between surgical and non-surgical residents is a combined product of self-selection and hidden curriculums. Furthermore, the dissonance between self-beliefs and expected norms can further perpetuate burnout, so the identification of hidden curriculums is a key consideration for residency program refinement (Billings et al., 2011 ; Bennett et al., 2004 ). Strengths and Limitations This scoping review is the first to present, in parallel, the burnout factors within surgical and non-surgical specialties reported in current literature. We presented an extensive compilation of burnout factors that effectively highlighted the ubiquitous and unique challenges faced by surgical and non-surgical residents. We’ve also categorized the extensive list of factors into the personal, external, program-related and institutional factor category to better illustrate the roles of fundamental sources of residency burnout. Such information can provide valuable references and insight for targeted wellness strategies across all residency programs. One limitation of this study is the broad categorization of all medical specialties as either surgical or non-surgical. Given the advent of interventional medicine, future studies should consider this as a third category that falls between the surgical versus non-surgical dichotomy. Social desirability bias also presents another possible limitation as burnout studies are based on subjective resident reports. This calls for employing strategies to detect and limit social desirability bias in future resident burnout studies, such as incorporating validated social desirability scales and obtaining secondary perspectives from staff, friends or family (Bispo, 2022 ; Bergen & Labonté, 2020 ; Althubaiti, 2016 ). Conclusion This scoping review serves to explore burnout factors within surgical versus non-surgical residencies and to identify unique challenges within each discipline. There were numerous common burnout factors suggesting ubiquitous fundamental principles in resident wellness but also differences between surgical and non-surgical specialties that reflected the specific nature, culture and characteristics of professionals within either discipline. Implementation of protective strategies would require thorough consideration of such similarities and differences in the context of a hidden curriculum, and control for balancing factors to maintain the quality of education and patient care. Overall, this scoping review captures the key overarching patterns of burnout factors within surgical and non-surgical residencies that can serve as critical guides for promoting medical education and resident wellness. Declarations Acknowledgement : We would like to thank Maren Goodman, Teaching and Learning Librarian at Western University for the support in the literature search strategy design. Conflict of interest : The authors report no conflict of interest. Funding : This manuscript did not receive any funding. Data accessibility: Search strategies and pre-analysed data are available to all in Online Resource 1 and 2. Ethics Approval Statement: This scoping review did not involve direct participants and did not require an approval by the ethics committee. Author contributions: Wei Cen Wang: conceptualization, methodology, data curation, analysis, writing - original draft preparation. Abhirup Biswas: Data curation, formal analysis. Amrit Kirpalani: conceptualization, methodology, writing - review and editing. Peter Zhan Tao Wang: conceptualization, methodology, data curation, writing - review and editing, supervision. References Ahart, E. R., Gilmer, L., Tenpenny, K., & Krase, K. (2023). Improving resident well-being: A narrative review of wellness curricula. Postgraduate Medical Journal , 99 (1173), 679–686. https://doi.org/10.1136/postgradmedj-2022-141541 Althubaiti, A. (2016). Information bias in health research: Definition, pitfalls, and adjustment methods. Journal of Multidisciplinary Healthcare , 9 , 211–217. https://doi.org/10.2147/JMDH.S104807 Antiel, R. M., Thompson, S. M., Hafferty, F. W., James, K. M., Tilburt, J. C., Bannon, M. P., Fischer, P. R., Farley, D. R., & Reed, D. A. (2011). Duty Hour Recommendations and Implications for Meeting the ACGME Core Competencies: Views of Residency Directors. Mayo Clinic Proceedings , 86 (3), 185–191. https://doi.org/10.4065/mcp.2010.0635 Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology . https://doi.org/10.1080/1364557032000119616 Awan, M., Zagales, I., McKenney, M., Kinslow, K., & Elkbuli, A. (2021). ACGME 2011 Duty Hours Restrictions and Their Effects on Surgical Residency Training and Patients Outcomes: A Systematic Review. Journal of Surgical Education , 78 (6), e35–e46. https://doi.org/10.1016/j.jsurg.2021.06.001 Bennett, N., Lockyer, J., Mann, K., Batty, H., LaForet, K., Rethans, J.-J., & Silver, I. (2004). Hidden curriculum in continuing medical education. The Journal of Continuing Education in the Health Professions , 24 (3), 145–152. https://doi.org/10.1002/chp.1340240305 Bergen, N., & Labonté, R. (2020). “Everything Is Perfect, and We Have No Problems”: Detecting and Limiting Social Desirability Bias in Qualitative Research. Qualitative Health Research , 30 (5), 783–792. https://doi.org/10.1177/1049732319889354 Bhama, A. R., Ritz, E. M., Anand, R. J., Auyang, E. D., Lipman, J., Greenberg, J. A., & Kapadia, M. R. (2021). Imposter Syndrome in Surgical Trainees: Clance Imposter Phenomenon Scale Assessment in General Surgery Residents. Journal of the American College of Surgeons , 233 (5), 633–638. https://doi.org/10.1016/j.jamcollsurg.2021.07.681 Billings, M. E., Lazarus, M. E., Wenrich, M., Curtis, J. R., & Engelberg, R. A. (2011). The effect of the hidden curriculum on resident burnout and cynicism. Journal of Graduate Medical Education , 3 (4), 503–510. https://doi.org/10.4300/JGME-D-11-00044.1 Bispo, J. P. (2022). Social desirability bias in qualitative health research. Revista de Saúde Pública , 56 , 101. https://doi.org/10.11606/s1518-8787.2022056004164 Bui, A. H., Ripp, J. A., Oh, K. Y., Basloe, F., Hassan, D., Akhtar, S., & Leitman, I. M. (2020). The impact of program-driven wellness initiatives on burnout and depression among surgical trainees. American Journal of Surgery , 219 (2), 316–321. https://doi.org/10.1016/j.amjsurg.2019.10.027 Chodoff, A., Conyers, L., Wright, S., & Levine, R. (2023). “I never should have been a doctor”: A qualitative study of imposter phenomenon among internal medicine residents. BMC Medical Education , 23 (1), 57. https://doi.org/10.1186/s12909-022-03982-8 CJPLTurning Burnout into Joy Mamta Gautam, MD . (n.d.). Retrieved March 25, 2024, from https://cjpl.ca/burnjoy.html Common Program Requirements . (n.d.). Retrieved December 28, 2023, from https://www.acgme.org/programs-and-institutions/programs/common-program-requirements/ Creating a Culture of Wellness in Medicine: Medical Education Recommendations from the Royal College Physician Wellness Task Force . (n.d.). Canadian Medical Association. Retrieved December 28, 2023, from https://www.cma.ca/physician-wellness-hub/content/creating-culture-wellness-medicine-medical-education-recommendations-royal-college-physician Desai, S. V., Feldman, L., Brown, L., Dezube, R., Yeh, H.-C., Punjabi, N., Afshar, K., Grunwald, M. R., Harrington, C., Naik, R., & Cofrancesco, J. (2013). Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: A randomized trial. JAMA Internal Medicine , 173 (8), 649–655. https://doi.org/10.1001/jamainternmed.2013.2973 Doolittle, B. R., Windish, D. M., & Seelig, C. B. (2013). Burnout, Coping, and Spirituality Among Internal Medicine Resident Physicians. Journal of Graduate Medical Education , 5 (2), 257–261. https://doi.org/10.4300/JGME-D-12-00136.1 Freudenberger, H. J. (1974). Staff Burn-Out. Journal of Social Issues , 30 (1), 159–165. https://doi.org/10.1111/j.1540-4560.1974.tb00706.x Geevarghese, S. K., & Pomfret, E. A. (2021). Peer support networks: A local approach to the global issue of moral injury in surgical training and practice. Canadian Urological Association Journal , 15 (6 Suppl 1), S33–S35. https://doi.org/10.5489/cuaj.7300 Gelfand, D. V., Podnos, Y. D., Carmichael, J. C., Saltzman, D. J., Wilson, S. E., & Williams, R. A. (2004). Effect of the 80-hour workweek on resident burnout. Archives of Surgery (Chicago, Ill.: 1960) , 139 (9), 933–938; discussion 938-940. https://doi.org/10.1001/archsurg.139.9.933 Gianakos, A. L., Freischlag, J. A., Mercurio, A. M., Haring, R. S., LaPorte, D. M., Mulcahey, M. K., Cannada, L. K., & Kennedy, J. G. (2022). Bullying, Discrimination, Harassment, Sexual Harassment, and the Fear of Retaliation During Surgical Residency Training: A Systematic Review. World Journal of Surgery , 46 (7), 1587–1599. https://doi.org/10.1007/s00268-021-06432-6 Goitein, L., Shanafelt, T. D., Wipf, J. E., Slatore, C. G., & Back, A. L. (2005). The Effects of Work-Hour Limitations on Resident Well-being, Patient Care, and Education in an Internal Medicine Residency Program. Archives of Internal Medicine , 165 (22), 2601–2606. https://doi.org/10.1001/archinte.165.22.2601 Hill, E., Bowman, K., Stalmeijer, R., & Hart, J. (2014). You’ve got to know the rules to play the game: How medical students negotiate the hidden curriculum of surgical careers. Medical Education , 48 (9), 884–894. https://doi.org/10.1111/medu.12488 Insights from exclusive AMA report on resident well-being with Mark Greenawald, MD . (2023, September 14). American Medical Association. https://www.ama-assn.org/medical-residents/medical-resident-wellness/insights-exclusive-ama-report-resident-well-being-mark Leach, P. K., Nygaard, R. M., Chipman, J. G., Brunsvold, M. E., & Marek, A. P. (2019). Impostor Phenomenon and Burnout in General Surgeons and General Surgery Residents. Journal of Surgical Education , 76 (1), 99–106. https://doi.org/10.1016/j.jsurg.2018.06.025 Mazzocco, K., Petitti, D. B., Fong, K. T., Bonacum, D., Brookey, J., Graham, S., Lasky, R. E., Sexton, J. B., & Thomas, E. J. (2009). Surgical team behaviors and patient outcomes. American Journal of Surgery , 197 (5), 678–685. https://doi.org/10.1016/j.amjsurg.2008.03.002 Medline, A., Grissom, H., Guissé, N. F., Kravets, V., Hobson, S., Samora, J. B., & Schenker, M. (2022). From Self-efficacy to Imposter Syndrome: The Intrapersonal Traits of Surgeons. JAAOS Global Research & Reviews , 6 (4), e22.00051. https://doi.org/10.5435/JAAOSGlobal-D-22-00051 Mutabdzic, D., Mylopoulos, M., Murnaghan, M. L., Patel, P., Zilbert, N., Seemann, N., Regehr, G., & Moulton, C.-A. (2015). Coaching Surgeons: Is Culture Limiting Our Ability to Improve? Annals of Surgery , 262 (2), 213–216. https://doi.org/10.1097/SLA.0000000000001247 Nituica, C., Bota, O. A., & Blebea, J. (2021). Specialty differences in resident resilience and burnout—A national survey. American Journal of Surgery , 222 (2), 319–328. https://doi.org/10.1016/j.amjsurg.2020.12.039 Pattani, R., Wu, P. E., & Dhalla, I. A. (2014). Resident duty hours in Canada: Past, present and future. CMAJ : Canadian Medical Association Journal , 186 (10), 761–765. https://doi.org/10.1503/cmaj.131053 Physician wellness: New 2021 National Physician Health Survey findings — burnout, short-staffing and an overburdened system take their toll . (n.d.). Canadian Medical Association. Retrieved December 28, 2023, from https://www.cma.ca/physician-wellness-hub/content/physician-wellness-new-2021-national-physician-health-survey Raj, K. S. (2016). Well-Being in Residency: A Systematic Review. Journal of Graduate Medical Education , 8 (5), 674–684. https://doi.org/10.4300/JGME-D-15-00764.1 Safety, I. of M. (US) C. on O. G. M. T. (Resident) H. and W. S. to I. P., Ulmer, C., Wolman, D. M., & Johns, M. M. E. (2009). Improving the Resident Learning Environment. In Resident Duty Hours: Enhancing Sleep, Supervision, and Safety . National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK214936/ Schwartz, S. I., Galante, J., Kaji, A., Dolich, M., Easter, D., Melcher, M. L., Patel, K., Reeves, M. E., Salim, A., Senagore, A. J., Takanishi, D. M., Jr, & de Virgilio, C. (2013). Effect of the 16-Hour Work Limit on General Surgery Intern Operative Case Volume: A Multi-institutional Study. JAMA Surgery , 148 (9), 829–833. https://doi.org/10.1001/jamasurg.2013.2677 Scott, I. M., Matejcek, A. N., Gowans, M. C., Wright, B. J., & Brenneis, F. R. (2008). Choosing a career in surgery: Factors that influence Canadian medical students’ interest in pursuing a surgical career. Canadian Journal of Surgery , 51 (5), 371–377. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556546/ Serenari, M., Cucchetti, A., Russo, P. M., Fallani, G., Mattarozzi, K., Pinna, A. D., Colonnello, V., Poggioli, G., & Cescon, M. (2019). Burnout and psychological distress between surgical and non-surgical residents. Updates in Surgery , 71 (2), 323–330. https://doi.org/10.1007/s13304-019-00653-0 Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., West, C. P., Sloan, J., & Oreskovich, M. R. (2012). Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of Internal Medicine , 172 (18), 1377–1385. https://doi.org/10.1001/archinternmed.2012.3199 Sun, R., Marshall, D. C., Sykes, M. C., Maruthappu, M., & Shalhoub, J. (2018). The impact of improving teamwork on patient outcomes in surgery: A systematic review. International Journal of Surgery , 53 , 171–177. https://doi.org/10.1016/j.ijsu.2018.03.044 Tricco, A. C., Lillie, E., Zarin, W., O’Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M. D. J., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., … Straus, S. E. (2018). PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine , 169 (7), 467–473. https://doi.org/10.7326/M18-0850 West, C. P., Drefahl, M. M., Popkave, C., & Kolars, J. C. (2009). Internal Medicine Resident Self-report of Factors Associated with Career Decisions. Journal of General Internal Medicine , 24 (8), 946–949. https://doi.org/10.1007/s11606-009-1039-0 Wild, J. R. L., Ferguson, H. J. M., McDermott, F. D., Hornby, S. T., & Gokani, V. J. (2015). Undermining and bullying in surgical training: A review and recommendations by the Association of Surgeons in Training. International Journal of Surgery , 23 , S5–S9. https://doi.org/10.1016/j.ijsu.2015.09.017 Woodside, J. R., Miller, M. N., Floyd, M. R., McGowen, K. R., & Pfortmiller, D. T. (2008). Observations on burnout in family medicine and psychiatry residents. Academic Psychiatry: The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry , 32 (1), 13–19. https://doi.org/10.1176/appi.ap.32.1.13 Zhang, L. M., Ellis, R. J., Ma, M., Cheung, E. O., Hoyt, D. B., Bilimoria, K. Y., & Hu, Y.-Y. (2020). Prevalence, Types, and Sources of Bullying Reported by US General Surgery Residents in 2019. JAMA , 323 (20), 2093–2095. https://doi.org/10.1001/jama.2020.2901 Additional Declarations No competing interests reported. Supplementary Files OnlineResource1.pdf Search strategies are reported in Online Material 1. OnlineResource2.pdf Study characteristics and specific burnout factors reported in each study are summarized in Online Material 2. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4584396","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317787454,"identity":"f847047f-b374-46ab-a439-705b77f6feb8","order_by":0,"name":"Wei Cen Wang","email":"","orcid":"","institution":"Schulich School of Medicine and Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"Cen","lastName":"Wang","suffix":""},{"id":317787455,"identity":"b9ce91ee-9a00-47b9-b219-d8aee33d1d98","order_by":1,"name":"Abhirup Biswas","email":"","orcid":"","institution":"Western University","correspondingAuthor":false,"prefix":"","firstName":"Abhirup","middleName":"","lastName":"Biswas","suffix":""},{"id":317787456,"identity":"413b70dd-b724-41a9-aeec-089605e86c54","order_by":2,"name":"Amrit Kirpalani","email":"","orcid":"","institution":"Schulich School of Medicine and Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Amrit","middleName":"","lastName":"Kirpalani","suffix":""},{"id":317787457,"identity":"c3066325-9cfc-43bf-b0d8-42f32199690d","order_by":3,"name":"Peter Zhan Tao Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYHAD5oOHiVUJY7AlkKyFx4A4Lebs/QcfVzAcljfnX/PhcMEfOwZ+6QbGDz/waLHsOcxseIbhsOHOGW83HJ7ZlswgOecAs2QPHi0GN5LZJBsYbjNuuHF2w2HehgNAkQQ2Bh58Wu4/Zv8J1GK/4caZB4d5/kC0MP7BawszGyNQS+KG8z0Mh3nYIFqY8dli2ZNsLNlg8D95ww02g8O8bck8kjMSm6Vl8GgxZz/48GNDRZrthvOHHz7m+WMnxy+RfPDjG3wOg5MSCWAm0ElAh+IDBnAW/wG8CkfBKBgFo2AEAwBMuk98ENLeAQAAAABJRU5ErkJggg==","orcid":"","institution":"Schulich School of Medicine and Dentistry","correspondingAuthor":true,"prefix":"","firstName":"Peter","middleName":"Zhan Tao","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-06-15 01:08:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4584396/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4584396/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60337623,"identity":"73a46b5c-4cc2-4605-99d4-96d0c51e7bde","added_by":"auto","created_at":"2024-07-15 17:40:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":142104,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram of the screening process\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4584396/v1/95c43fd602d9db2b44324365.png"},{"id":78114789,"identity":"edc8453a-48d3-48ef-8441-084dd51b5977","added_by":"auto","created_at":"2025-03-10 06:04:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1075064,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4584396/v1/7f3d1ecd-8372-42d8-aa49-2146e183ae9e.pdf"},{"id":60337622,"identity":"74846c60-8e09-4a56-8fb3-00e6215090cc","added_by":"auto","created_at":"2024-07-15 17:40:36","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":76432,"visible":true,"origin":"","legend":"\u003cp\u003eSearch strategies are reported in Online Material 1.\u003c/p\u003e","description":"","filename":"OnlineResource1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4584396/v1/43815cae356de92335b314a6.pdf"},{"id":60337624,"identity":"e3b5a774-21a8-47f3-ad13-50adf13dd3b4","added_by":"auto","created_at":"2024-07-15 17:40:36","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":325123,"visible":true,"origin":"","legend":"\u003cp\u003eStudy characteristics and specific burnout factors reported in each study are summarized in Online Material 2.\u003c/p\u003e","description":"","filename":"OnlineResource2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4584396/v1/e794f462d15dc3d1571d36e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Burnout factors among residents in surgical and non-surgical specialties: a scoping review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBurnout is widely regarded as a work-related stress syndrome with a disproportionally high prevalence among physicians compared to the general population (Shanafelt et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). This prevalence is higher among residents compared to practising physicians due to chronic stressors associated with residency, such as demanding work hours and responsibilities, steep learning curves, and poor work life balance (\u003cem\u003ePhysician Wellness\u003c/em\u003e, 2022). Despite anti-burnout policies and guidelines such as national mandated work hour limitations (WHL) and requirements for all residency programs to establish policies to optimize resident wellbeing, the prevalence of burnout is still 41% and 58% among American and Canadian residents, respectively (\u003cem\u003eCreating a Culture of Wellness in Medicine\u003c/em\u003e, 2022; \u003cem\u003eInsights from Exclusive AMA Report on Resident Well-Being with Mark Greenawald, MD\u003c/em\u003e, 2023). Furthermore, WHL has received varying degrees of backlash from both residents and faculties due to decreased satisfaction on quality of education and perceived patient care (Schwartz et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Awan et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Antiel et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe complexity of burnout is further dissected by Dr. Mamta Gautham (\u003cem\u003eCJPL Turning Burnout into Joy\u003c/em\u003e, 2018), who categorizes its drivers into intrinsic factors, such as personality traits inherent to physicians, extrinsic factors tied to the practice environment, and the pervasive culture within medicine that often perpetuates these stressors. Notably, the manifestation and determinants of burnout vary significantly across specialties, with a distinct dichotomy between surgical and non-surgical fields. These domains differ not only in the technical nature of work but also in the cultural and lifestyle expectations placed on these residents (Bui et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Woodside et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe existing literature hints at these differences, with research in Italy revealing variance in work-related burnout factors between surgical and non-surgical residents (Serenari et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) and a large-scale American study observing comparable burnout rates but higher levels of depersonalization among surgical residents (Nituica et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Such findings suggest that the underlying causes of burnout may not be uniformly addressed across specialties. Therefore, a nuanced understanding of these specialty-specific stressors is crucial for developing targeted, effective interventions.\u003c/p\u003e \u003cp\u003eThis scoping review aims to bridge this gap by examining the literature on resident burnout factors within surgical versus non-surgical specialties. By identifying and comparing the unique challenges faced by residents in these distinct fields, this study seeks to illuminate the specific factors contributing to burnout and inform the development of tailored strategies to enhance resident well-being and resilience.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe methods of this scoping review are designed according to the framework reported by Arksey and O\u0026rsquo;Malley (Arksey \u0026amp; O\u0026rsquo;Malley, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist to guide the reporting of this scoping review (Tricco et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). A review protocol was not registered.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eIdentifying the Research Question\u003c/h2\u003e \u003cp\u003eGiven the distinct dichotomy in technical nature of work, culture, and lifestyle between surgical and non-surgical specialties, our central research objective is to identify factors contributing to burnout among surgical versus non-surgical specialties reported in literature. These factors will be analyzed to identify common and unique challenges within either medical discipline, which can serve to illuminate effective targeted strategies for residency reforms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eIdentifying Relevant Studies\u003c/h2\u003e \u003cp\u003eThe literature search was conducted on the OVID Medline, ERIC, Embase Classic\u0026thinsp;+\u0026thinsp;Embase, APA PsychInfo, and SCOPUS databases from 1970 \u0026ndash; June 2023. The search strategy was designed to capture original research reporting burnout factors within medical residency. Given that burnout is a subjective experience, we included \u0026ldquo;self-reporting qualitative burnout assessment\u0026rdquo; as one of the domains of the search strategy to focus on research that captured direct experiences of residents. The search strategy used both index terms and text words to identify articles that included terms in all 4 of the following domains: 1. medical residency, 2. burnout, 3. factors, 4. surveys, questionnaires, or other burnout assessment measures. The full search strategy used for the SCOPUS database is as follows, with a time filter of \u0026ldquo;1970 and onwards\u0026rdquo; manually applied to the results: ( ( TITLE-ABS-KEY ( ( surg* OR medic* OR physician* ) W/3 ( residen* OR intern* ) ) ) OR ( TITLE-ABS-KEY ( \"internship and residency\" ) ) ) AND ( TITLE-ABS-KEY ( \"psychological burnout\" OR \"occupational burnout\" OR exhaustion OR burnout OR \"burn* out\" ) ) AND ( TITLE-ABS-KEY ( \"maslach burnout inventory\" OR \"maslach burnout index\" OR \"oldenburg burnout inventory\" OR \"single item burnout measure\" OR \"copenhagen burnout inventory\" ) ) AND ( EXCLUDE ( DOCTYPE, \"re\" ) OR EXCLUDE ( DOCTYPE, \"cp\" ) OR EXCLUDE ( DOCTYPE, \"le\" ) OR EXCLUDE ( DOCTYPE, \"no\" ) OR EXCLUDE ( DOCTYPE, \"ed\" ) OR EXCLUDE ( DOCTYPE, \"er\" ) ). Search strategies used for the other databases are included in Online Resource 1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eOriginal manuscripts reporting factors of burnout among residents in surgical and non-surgical specialties within North America and written in English were included. Surgical specialties included: cardiothoracic surgery, general surgery, obstetrics and gynecologic, neurological surgery, ophthalmic surgery, oral and maxillofacial surgery, orthopaedic surgery, otorhinolaryngology, plastic surgery, urology, and vascular surgery. All other specialties were considered \u0026ldquo;non-surgical\u0026rdquo;, such as family medicine, internal medicine, radiology, pediatrics, \u003cem\u003eetc\u003c/em\u003e. Articles that aggregated surgical and non-surgical residents as one sample, conducted on medical students/physicians/other healthcare workers, military residency programs, non-MD/non-DO programs, outside of North America, non-English, and solely within the context of Covid-19 were excluded. A time restriction was set to only include studies published after 1970 as the term \u0026ldquo;burnout\u0026rdquo; gained usage after being coined by Herbert Freudenberger in the 1970s (Freudenberger, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1974\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eArticle Screening\u003c/h2\u003e \u003cp\u003eStudies extracted from the database were imported into Covidence for removal of duplicates and screening. Screening was performed by two independent reviewers based on the predetermined inclusion and exclusion criteria (WCW, PW). Both reviewers first conducted a title and abstract screen and proceeded to do a full text screen with the articles selected from the first screen. Screening conflicts were resolved via discussion and consensus between the two reviewers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Extraction and Reporting the Results\u003c/h2\u003e \u003cp\u003eStudy characteristics including author, year of publication, residency specialty, burnout measure tool, sample size, and identified burnout factors were extracted and charted manually in Excel (by WCW, Online Resource 2).\u003c/p\u003e \u003cp\u003eThe articles are divided into either the surgical specialty or non-surgical specialty category. Within both categories, a frequency is calculated for each factor reported to have a statistically significant association with burnout by dividing the number of articles reporting the factor by the total number of surgical or non-surgical specialty articles and multiplied by 100 (by WCW and AB). The calculated frequencies are used to compare the prevalence and interpret the significance of burnout factors within either medical discipline.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 97 articles were included in the final analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eEighty-nine studies were conducted in the United States and 8 studies were conducted in Canada. There were 87 observational studies and 10 interventional studies. There were 46 studies in surgical specialties (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A) and 50 studies in non-surgical specialties (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. B), and 1 study including both surgical and non-surgical specialties (Online Resource 2, Supplementary Table\u0026nbsp;3). General surgery, orthopedics, otolaryngology, obstetrics and gynecology were the most common surgical specialties studied, whereas internal medicine, emergency medicine, family medicine, and radiology are the most common non-surgical specialties studied. Nighty-five percent of studies used the Maslach Burnout Inventory (MBI)-HSS or other MBI variations as the burnout assessment tool. Other burnout assessment tools included the Mini Z Survey, Personal Well-being Score (PWS), Professional Quality of Life Scale (PROQoL), Copenhagen Burnout Inventory (CBI), and a single-item measure of burnout (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy Characteristics A. Studies on surgical specialties\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of studies\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal # of articles\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCountries\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBurnout Assessment Tool\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMBI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTypes of studies\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObservational studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterventional studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical Subspecialties\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopedics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOtolaryngology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetrics and gynecology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlastic surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple specialties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*\u0026ldquo;Overall, based on your definition of burnout, how would you rate your level of burnout?\u0026rdquo;, MiniZ.\u003c/p\u003e \u003cp\u003eB. Studies on non-surgical specialties\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Studies\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal # of articles\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCountries\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBurnout Assessment Tool\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMBI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTypes of studies\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObservational studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterventional studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNon-surgical Subspecialties\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePediatrics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDermatology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnesthesiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePM\u0026amp;R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychiatry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple non-surgical specialties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e*Personal well-being score (PWS), Professional Quality of Life Scale, Copenhagen Burnout Inventory), MiniZ work-life survey,\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCategories of burnout factors\u003c/h2\u003e \u003cp\u003eThere was a total of 65 factors significantly associated with resident burnout, which can be divided into 4 categories: personal, external, institutional, and program-related (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Specific burnout factors reported in each study are summarized in Online Resource 2. Personal factors included one\u0026rsquo;s intrinsic characters, values, perceptions, and controllable personal situations. Program-related factors characterize the learning environment of residency programs. Institutional factors include those determined or greatly affected by medical administrative policies and regulations. Lastly, external factors are aspects of one\u0026rsquo;s social network, finances, and professional setting that aren\u0026rsquo;t particularly driven by the healthcare institution or specific residency program. Personal factors had the highest frequency, followed by program-related factors, external factors, and institutional factors.\u003c/p\u003e \u003cp\u003eFor the personal factor category, the top three factors were gender, mindset and mentality, and having a partner or children for both surgical and non-surgical residencies. Only the female gender was associated with higher EE and global burnout and only the male gender was associated with higher DP and lower PA among surgical residents. Meanwhile, an equal number of articles found either the male or female gender associated with higher global burnout among non-surgical residents. Among both surgical and non-surgical residents, lower grit and resilience were associated with higher EE, DP, and global burnout and lower PA. Having a partner or children was shown to be protective across all burnout components among surgical and non-surgical residents alike, except for 1 study, which reported male emergency medicine residents in a relationship had a higher prevalence of burnout compared to female residents in a relationship, and single female and male residents.\u003c/p\u003e \u003cp\u003eFor the program related factor category, the top two factors were stage of training and workload for both surgical and non-surgical residents, and the top third factor was faculty mentorship/support for surgical residents and work-life balance for non-surgical residents. Post graduate year 1\u0026ndash;3 was associated with EE, DP, and global burnout for both surgical and non-surgical specialties. However, junior years were associated with lower PA in non-surgical specialties but higher PA in surgical specialties. Increased workload, such as \u0026gt;\u0026thinsp;80 hour work week and duty hour violations, was associated with increased EE, DP, global burnout and decreased PA, while WHL was protective of EE and global burnout for both surgical and non-surgical residents. However, more internal medicine residents reported WHL having a negative effect on their quality of education and patient care than they did a positive or neutral effect, despite the decrease in measured burnout. For surgical specialties, having strong faculty support and mentorship, such as adequate constructive feedback and strong role models, was protective of EE, DP, and global burnout. For non-surgical specialties, poor work-life balance was associated with global burnout and emotional exhaustion.\u003c/p\u003e \u003cp\u003eFor the external factor category, workplace relations, rotations, and co-resident support were the top 3 factors for both surgical and non-surgical residents. Toxic workplace relations, such as hostile co-workers, public humiliation, discrimination, was associated with EE, DP, and global burnout among surgical residents and global burnout for non-surgical residents. Meanwhile, the perception of staff and faculty working well together was protective against burnout in non-surgical residents. High acuity rotations were associated with higher prevalence of EE, DP, but protective of PA for both surgical and non-surgical specialties. Inpatient rotations were associated with burnout in non-surgical specialties. Feeling well supported by co-residents was protective against burnout in both surgical and non-surgical residents.\u003c/p\u003e \u003cp\u003eFor the institutional factor category, the top factor was autonomy and secondly administrative tasks for surgical residents, and vice versa for non-surgical residents. Lack of autonomy, including poor control over one\u0026rsquo;s work, lack of independence, and working under close supervision was commonly associated with increased EE, DP, and global burnout among surgical residents. Meanwhile, more papers reported administrative concerns, such as inappropriate clerical burden and time pressure with electronic medical records documentation, as factors of burnout than lack of autonomy for non-surgical residents. Inadequate vacation time, duty hour violations and lack of job resources were institutional factors of burnout among surgical residents only.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of statistically significant burnout factors\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFactor Categories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency in surgical specialty studies (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrequency in non-surgical specialty studies (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"22\" rowspan=\"23\"\u003e \u003cp\u003ePersonal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19% (9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20% (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMindset/mentality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13% (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25% (13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePartner/children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17% (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16% (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10% (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14% (7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCareer/program choice satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8% (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12% (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8% (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10% (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8% (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8% (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf perception/expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12% (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotional intelligence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10% (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10% (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRacial background\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8% (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerceived stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMindfulness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerceived value of work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6% (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8% (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubstance use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoping mechanism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6% (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpirituality/faith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFear of making a Mistake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponsibility to patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11% (5)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10% (5)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"10\" rowspan=\"11\"\u003e \u003cp\u003eProgram-related\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage of training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38% (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22% (11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorkload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29% (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20% (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFaculty mentorship/support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27% (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8% (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWork-life balance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10% (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12% (6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProgram design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8% (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProgram size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWellness programs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNightshift/calls\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProgram expectations/values (including hidden curriculum)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvolvement in program decisions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4% (2)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2% (1)\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003eExternal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorkplace Relations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21% (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6% (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRotations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6% (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8% (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoresident Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6% (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6% (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6% (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWork location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient relations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eColleague burnout\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9% (4)\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6% (3)\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eInstitutional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAutonomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10% (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6% (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdministrative tasks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6% (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8% (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVacation time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6% (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDuty hour violations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4% (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJob resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2% (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003e Hobbies, future career goal, work engagement, self-care, feeling appreciated.\u003c/p\u003e \u003cp\u003e \u003csup\u003eb\u003c/sup\u003e Personality, breadth of knowledge, worrying, moral distress, test score.\u003c/p\u003e \u003cp\u003e \u003csup\u003ec\u003c/sup\u003e Co-resident attrition, professional development opportunities.\u003c/p\u003e \u003cp\u003e \u003csup\u003ed\u003c/sup\u003e Space for error discussion.\u003c/p\u003e \u003cp\u003e \u003csup\u003ee\u003c/sup\u003e Mental health services, food access at work, personal reputation, family member in medicine.\u003c/p\u003e \u003cp\u003e \u003csup\u003ef\u003c/sup\u003e Exams, confronting tragedy, other doctors\u0026rsquo; value towards the specialty\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eInterventional Studies\u003c/h2\u003e \u003cp\u003eThere were 10 interventional studies included that reported interventions which had a statistically significant effect on burnout, with 7 in surgical specialties and 3 in non-surgical specialties (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The Accreditation Council for Graduate Medical Education (ACGME) mandated WHL, which came into effect in July 2003, was the most studied. One study showed a decrease in EE among surgical residents following WHL. Two articles showed decrease in EE and global burnout following WHL among non-surgical residents. As previously mentioned, more non-surgical residents in one study reported WHL having a negative effect on their education and patient care than a positive or neutral effect, despite decreasing burnout. Weekly protected non-clinical time, formal mentorship program, resident wellness programs, narrative medicine curriculum, and reflective writing workshop were all found to be protective against burnout among surgical residents. Resiliency workshop was found to effectively decrease EE and DP among non-surgical residents.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterventional Studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor, Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSample Size\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvecedo, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOtolaryngology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResident wellness program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurnet, 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneral Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResident wellness program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHutter, 2006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDepartment of Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMandated work hour restrictions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStevens, 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOtolaryngology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWeekly protected non-clinical time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWinkle, 2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObstetrics and gynecology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReflective writing workshop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWinkle, 2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObstetrics and gynecology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNarrative medicine curriculum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZhang, 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOtolaryngology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFormal mentorship program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrennan, 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFamily Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResiliency program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoitein, 2005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInternal Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMandated work hour restrictions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGopal, 2005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInternal Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMandated work hour restrictions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study, factors associated with burnout fell under 4 categories: personal, program related, external, and institutional. The top factors associated with burnout were very similar between surgical and non-surgical specialties. These include stage of training, workload, specific rotations, gender, mindset, and having a partner or children. Interventional studies also revealed WHL, formal mentorship programs and resident wellness programs to be protective against burnout among surgical residents and WHL and resiliency programs to be protective for non-surgical residents. These factors are consistently reported in literature in association with resident well-being and are focused areas of residency program improvements (Raj, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Ahart et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Safety et al., 2009). These also highlight ubiquitous fundamental principles of high-quality residency education shared across all medical specialties.\u003c/p\u003e \u003cp\u003eSome factors were uniquely significant within surgical and non-surgical specialties. Burnout factors more frequently or uniquely associated with surgical residencies included faculty support and mentorship, workplace relations, coresident attrition, and autonomy. The first three factors highlight that burnout within surgical residencies largely stems from the particular working and learning environments shaped by those working in surgery (Mutabdzic et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This is supported by well documented incidences of mistreatment such as bullying, discrimination, and undermining, with attendings and senior coresidents being the most common perpetrators (Gianakos et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Zhang et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Wild et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Furthermore, the significance of coresident attrition reflects the heavily team-based nature of surgical care, as positive teamwork is associated with improved operative outcomes (Sun et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Mazzocco et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Autonomy highlights residents\u0026rsquo; struggles with developing surgical independence from attendings and the lack of control and resulting moral injury regarding hospital administrative oversights over procedures (Geevarghese \u0026amp; Pomfret, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Meanwhile, having a good perceived quality of life was uniquely protective among non-surgical residents. This could suggest that non-surgical residents place a greater value on personal life compared to surgical residents, which is consistent with non-surgical residents ranking medical lifestyle and social-orientation, especially family time, as more important influencers for career choice than surgical residents (Scott et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; West et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Lastly, our study found that self-perception and expectations was far more frequently associated with burnout among non-surgical residents than surgical residents. Interestingly, intrapersonal traits such as imposter syndrome and self-efficacy are more studied in surgical residents, so there appears to be a gap in literature to explain this difference of effect on burnout (Chodoff et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Bhama et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Leach et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Medline et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWork hour limitations are implemented based on concerns for resident well-being and patient safety. Gotein \u003cem\u003eet al\u003c/em\u003e (Goitein et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) interestingly found that more internal medicine residents reported WHL having a negative effect on their education and patient care than a positive or neutral effect, with reasons including increased crossovers resulting in less active patient management, cutting corners to comply with WHL, inadequate teaching time, and missing or cutting short specific learning activities. Furthermore, a crossover study conducted by Desai \u003cem\u003eet al\u003c/em\u003e (Desai et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) found that shortened WHL and decreased frequency of overnight calls in internal medicine resulted in increased post-call sleep but reduced availability for teaching conferences and resident presence during daytime work hours. Meanwhile, the ACGME mandated WHL also resulted in decreased operative cases for junior surgical residents, reports of adverse effect on surgical junior residency education, and senior surgical residents becoming more fatigued due to shift of duties from PGY-1 trainees (Schwartz et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Awan et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Residency program directors overall believed that WHL will decrease residents' ability to develop core competencies, with surgery program directors more likely to believe that the WHL will decrease residents' competency in patient care, medical knowledge, and practice-based learning and improvement than internal medicine program directors (Antiel et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Furthermore, Gelfand \u003cem\u003eet al\u003c/em\u003e (Gelfand et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) reported no significant changes in burnout parameters following WHL among surgical residents. This highlights the importance of considering balancing factors to avoid a narrowed focus on strictly tackling burnout through decreasing clinical workload at the expense of other valuable residency outcomes, such as education quality, patient care, and resident satisfaction.\u003c/p\u003e \u003cp\u003eLastly, a hidden curriculum likely plays a role in shaping the burnout experience given that successful progression through residency requires the adoption of specific values, paradigms and work ethic perpetrated within each discipline. For example, a study by Hill \u003cem\u003eet al\u003c/em\u003e (Hill et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) suggested that medical students had a clear sense of the surgical hidden curriculum and that successful negotiation of a surgical career involved uncovering and enacting such curriculum. Therefore, the differences in values between surgical and non-surgical residents is a combined product of self-selection and hidden curriculums. Furthermore, the dissonance between self-beliefs and expected norms can further perpetuate burnout, so the identification of hidden curriculums is a key consideration for residency program refinement (Billings et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Bennett et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2004\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis scoping review is the first to present, in parallel, the burnout factors within surgical and non-surgical specialties reported in current literature. We presented an extensive compilation of burnout factors that effectively highlighted the ubiquitous and unique challenges faced by surgical and non-surgical residents. We\u0026rsquo;ve also categorized the extensive list of factors into the personal, external, program-related and institutional factor category to better illustrate the roles of fundamental sources of residency burnout. Such information can provide valuable references and insight for targeted wellness strategies across all residency programs. One limitation of this study is the broad categorization of all medical specialties as either surgical or non-surgical. Given the advent of interventional medicine, future studies should consider this as a third category that falls between the surgical versus non-surgical dichotomy. Social desirability bias also presents another possible limitation as burnout studies are based on subjective resident reports. This calls for employing strategies to detect and limit social desirability bias in future resident burnout studies, such as incorporating validated social desirability scales and obtaining secondary perspectives from staff, friends or family (Bispo, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bergen \u0026amp; Labont\u0026eacute;, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Althubaiti, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis scoping review serves to explore burnout factors within surgical versus non-surgical residencies and to identify unique challenges within each discipline. There were numerous common burnout factors suggesting ubiquitous fundamental principles in resident wellness but also differences between surgical and non-surgical specialties that reflected the specific nature, culture and characteristics of professionals within either discipline. Implementation of protective strategies would require thorough consideration of such similarities and differences in the context of a hidden curriculum, and control for balancing factors to maintain the quality of education and patient care. Overall, this scoping review captures the key overarching patterns of burnout factors within surgical and non-surgical residencies that can serve as critical guides for promoting medical education and resident wellness.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e: We would like to thank Maren Goodman, Teaching and Learning Librarian at Western University for the support in the literature search strategy design.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e: The authors report no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This manuscript did not receive any funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData accessibility:\u003c/strong\u003e Search strategies and pre-analysed data are available to all in Online Resource 1 and 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval Statement:\u003c/strong\u003e This scoping review did not involve direct participants and did not require an approval by the ethics committee.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWei Cen Wang: conceptualization, methodology, data curation, analysis, writing - original draft preparation. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbhirup Biswas: Data curation, formal analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmrit Kirpalani: conceptualization, methodology, writing - review and editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePeter Zhan Tao Wang: conceptualization, methodology, data curation, writing - review and editing, supervision.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAhart, E. R., Gilmer, L., Tenpenny, K., \u0026amp; Krase, K. (2023). Improving resident well-being: A narrative review of wellness curricula. \u003cem\u003ePostgraduate Medical Journal\u003c/em\u003e, \u003cem\u003e99\u003c/em\u003e(1173), 679\u0026ndash;686. https://doi.org/10.1136/postgradmedj-2022-141541\u003c/li\u003e\n \u003cli\u003eAlthubaiti, A. (2016). Information bias in health research: Definition, pitfalls, and adjustment methods. \u003cem\u003eJournal of Multidisciplinary Healthcare\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e, 211\u0026ndash;217. https://doi.org/10.2147/JMDH.S104807\u003c/li\u003e\n \u003cli\u003eAntiel, R. M., Thompson, S. M., Hafferty, F. W., James, K. M., Tilburt, J. C., Bannon, M. P., Fischer, P. R., Farley, D. R., \u0026amp; Reed, D. A. (2011). Duty Hour Recommendations and Implications for Meeting the ACGME Core Competencies: Views of Residency Directors. \u003cem\u003eMayo Clinic Proceedings\u003c/em\u003e, \u003cem\u003e86\u003c/em\u003e(3), 185\u0026ndash;191. https://doi.org/10.4065/mcp.2010.0635\u003c/li\u003e\n \u003cli\u003eArksey, H., \u0026amp; O\u0026rsquo;Malley, L. (2005). Scoping studies: Towards a methodological framework. \u003cem\u003eInternational Journal of Social Research Methodology\u003c/em\u003e. https://doi.org/10.1080/1364557032000119616\u003c/li\u003e\n \u003cli\u003eAwan, M., Zagales, I., McKenney, M., Kinslow, K., \u0026amp; Elkbuli, A. (2021). ACGME 2011 Duty Hours Restrictions and Their Effects on Surgical Residency Training and Patients Outcomes: A Systematic Review. \u003cem\u003eJournal of Surgical Education\u003c/em\u003e, \u003cem\u003e78\u003c/em\u003e(6), e35\u0026ndash;e46. https://doi.org/10.1016/j.jsurg.2021.06.001\u003c/li\u003e\n \u003cli\u003eBennett, N., Lockyer, J., Mann, K., Batty, H., LaForet, K., Rethans, J.-J., \u0026amp; Silver, I. (2004). Hidden curriculum in continuing medical education. \u003cem\u003eThe Journal of Continuing Education in the Health Professions\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(3), 145\u0026ndash;152. https://doi.org/10.1002/chp.1340240305\u003c/li\u003e\n \u003cli\u003eBergen, N., \u0026amp; Labont\u0026eacute;, R. (2020). \u0026ldquo;Everything Is Perfect, and We Have No Problems\u0026rdquo;: Detecting and Limiting Social Desirability Bias in Qualitative Research. \u003cem\u003eQualitative Health Research\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(5), 783\u0026ndash;792. https://doi.org/10.1177/1049732319889354\u003c/li\u003e\n \u003cli\u003eBhama, A. R., Ritz, E. M., Anand, R. J., Auyang, E. D., Lipman, J., Greenberg, J. A., \u0026amp; Kapadia, M. R. (2021). Imposter Syndrome in Surgical Trainees: Clance Imposter Phenomenon Scale Assessment in General Surgery Residents. \u003cem\u003eJournal of the American College of Surgeons\u003c/em\u003e, \u003cem\u003e233\u003c/em\u003e(5), 633\u0026ndash;638. https://doi.org/10.1016/j.jamcollsurg.2021.07.681\u003c/li\u003e\n \u003cli\u003eBillings, M. E., Lazarus, M. E., Wenrich, M., Curtis, J. R., \u0026amp; Engelberg, R. A. (2011). The effect of the hidden curriculum on resident burnout and cynicism. \u003cem\u003eJournal of Graduate Medical Education\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(4), 503\u0026ndash;510. https://doi.org/10.4300/JGME-D-11-00044.1\u003c/li\u003e\n \u003cli\u003eBispo, J. P. (2022). Social desirability bias in qualitative health research. \u003cem\u003eRevista de Sa\u0026uacute;de P\u0026uacute;blica\u003c/em\u003e, \u003cem\u003e56\u003c/em\u003e, 101. https://doi.org/10.11606/s1518-8787.2022056004164\u003c/li\u003e\n \u003cli\u003eBui, A. H., Ripp, J. A., Oh, K. Y., Basloe, F., Hassan, D., Akhtar, S., \u0026amp; Leitman, I. M. (2020). The impact of program-driven wellness initiatives on burnout and depression among surgical trainees. \u003cem\u003eAmerican Journal of Surgery\u003c/em\u003e, \u003cem\u003e219\u003c/em\u003e(2), 316\u0026ndash;321. https://doi.org/10.1016/j.amjsurg.2019.10.027\u003c/li\u003e\n \u003cli\u003eChodoff, A., Conyers, L., Wright, S., \u0026amp; Levine, R. (2023). \u0026ldquo;I never should have been a doctor\u0026rdquo;: A qualitative study of imposter phenomenon among internal medicine residents. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1), 57. https://doi.org/10.1186/s12909-022-03982-8\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eCJPLTurning Burnout into Joy Mamta Gautam, MD\u003c/em\u003e. (n.d.). Retrieved March 25, 2024, from https://cjpl.ca/burnjoy.html\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eCommon Program Requirements\u003c/em\u003e. (n.d.). Retrieved December 28, 2023, from https://www.acgme.org/programs-and-institutions/programs/common-program-requirements/\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eCreating a Culture of Wellness in Medicine: Medical Education Recommendations from the Royal College Physician Wellness Task Force\u003c/em\u003e. (n.d.). Canadian Medical Association. Retrieved December 28, 2023, from https://www.cma.ca/physician-wellness-hub/content/creating-culture-wellness-medicine-medical-education-recommendations-royal-college-physician\u003c/li\u003e\n \u003cli\u003eDesai, S. V., Feldman, L., Brown, L., Dezube, R., Yeh, H.-C., Punjabi, N., Afshar, K., Grunwald, M. R., Harrington, C., Naik, R., \u0026amp; Cofrancesco, J. (2013). Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: A randomized trial. \u003cem\u003eJAMA Internal Medicine\u003c/em\u003e, \u003cem\u003e173\u003c/em\u003e(8), 649\u0026ndash;655. https://doi.org/10.1001/jamainternmed.2013.2973\u003c/li\u003e\n \u003cli\u003eDoolittle, B. R., Windish, D. M., \u0026amp; Seelig, C. B. (2013). Burnout, Coping, and Spirituality Among Internal Medicine Resident Physicians. \u003cem\u003eJournal of Graduate Medical Education\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(2), 257\u0026ndash;261. https://doi.org/10.4300/JGME-D-12-00136.1\u003c/li\u003e\n \u003cli\u003eFreudenberger, H. J. (1974). Staff Burn-Out. \u003cem\u003eJournal of Social Issues\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(1), 159\u0026ndash;165. https://doi.org/10.1111/j.1540-4560.1974.tb00706.x\u003c/li\u003e\n \u003cli\u003eGeevarghese, S. K., \u0026amp; Pomfret, E. A. (2021). Peer support networks: A local approach to the global issue of moral injury in surgical training and practice. \u003cem\u003eCanadian Urological Association Journal\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(6 Suppl 1), S33\u0026ndash;S35. https://doi.org/10.5489/cuaj.7300\u003c/li\u003e\n \u003cli\u003eGelfand, D. V., Podnos, Y. D., Carmichael, J. C., Saltzman, D. J., Wilson, S. E., \u0026amp; Williams, R. A. (2004). Effect of the 80-hour workweek on resident burnout. \u003cem\u003eArchives of Surgery (Chicago, Ill.: 1960)\u003c/em\u003e, \u003cem\u003e139\u003c/em\u003e(9), 933\u0026ndash;938; discussion 938-940. https://doi.org/10.1001/archsurg.139.9.933\u003c/li\u003e\n \u003cli\u003eGianakos, A. L., Freischlag, J. A., Mercurio, A. M., Haring, R. S., LaPorte, D. M., Mulcahey, M. K., Cannada, L. K., \u0026amp; Kennedy, J. G. (2022). Bullying, Discrimination, Harassment, Sexual Harassment, and the Fear of Retaliation During Surgical Residency Training: A Systematic Review. \u003cem\u003eWorld Journal of Surgery\u003c/em\u003e, \u003cem\u003e46\u003c/em\u003e(7), 1587\u0026ndash;1599. https://doi.org/10.1007/s00268-021-06432-6\u003c/li\u003e\n \u003cli\u003eGoitein, L., Shanafelt, T. D., Wipf, J. E., Slatore, C. G., \u0026amp; Back, A. L. (2005). The Effects of Work-Hour Limitations on Resident Well-being, Patient Care, and Education in an Internal Medicine Residency Program. \u003cem\u003eArchives of Internal Medicine\u003c/em\u003e, \u003cem\u003e165\u003c/em\u003e(22), 2601\u0026ndash;2606. https://doi.org/10.1001/archinte.165.22.2601\u003c/li\u003e\n \u003cli\u003eHill, E., Bowman, K., Stalmeijer, R., \u0026amp; Hart, J. (2014). You\u0026rsquo;ve got to know the rules to play the game: How medical students negotiate the hidden curriculum of surgical careers. \u003cem\u003eMedical Education\u003c/em\u003e, \u003cem\u003e48\u003c/em\u003e(9), 884\u0026ndash;894. https://doi.org/10.1111/medu.12488\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eInsights from exclusive AMA report on resident well-being with Mark Greenawald, MD\u003c/em\u003e. (2023, September 14). American Medical Association. https://www.ama-assn.org/medical-residents/medical-resident-wellness/insights-exclusive-ama-report-resident-well-being-mark\u003c/li\u003e\n \u003cli\u003eLeach, P. K., Nygaard, R. M., Chipman, J. G., Brunsvold, M. E., \u0026amp; Marek, A. P. (2019). Impostor Phenomenon and Burnout in General Surgeons and General Surgery Residents. \u003cem\u003eJournal of Surgical Education\u003c/em\u003e, \u003cem\u003e76\u003c/em\u003e(1), 99\u0026ndash;106. https://doi.org/10.1016/j.jsurg.2018.06.025\u003c/li\u003e\n \u003cli\u003eMazzocco, K., Petitti, D. B., Fong, K. T., Bonacum, D., Brookey, J., Graham, S., Lasky, R. E., Sexton, J. B., \u0026amp; Thomas, E. J. (2009). Surgical team behaviors and patient outcomes. \u003cem\u003eAmerican Journal of Surgery\u003c/em\u003e, \u003cem\u003e197\u003c/em\u003e(5), 678\u0026ndash;685. https://doi.org/10.1016/j.amjsurg.2008.03.002\u003c/li\u003e\n \u003cli\u003eMedline, A., Grissom, H., Guiss\u0026eacute;, N. F., Kravets, V., Hobson, S., Samora, J. B., \u0026amp; Schenker, M. (2022). From Self-efficacy to Imposter Syndrome: The Intrapersonal Traits of Surgeons. \u003cem\u003eJAAOS Global Research \u0026amp; Reviews\u003c/em\u003e, \u003cem\u003e6\u003c/em\u003e(4), e22.00051. https://doi.org/10.5435/JAAOSGlobal-D-22-00051\u003c/li\u003e\n \u003cli\u003eMutabdzic, D., Mylopoulos, M., Murnaghan, M. L., Patel, P., Zilbert, N., Seemann, N., Regehr, G., \u0026amp; Moulton, C.-A. (2015). Coaching Surgeons: Is Culture Limiting Our Ability to Improve? \u003cem\u003eAnnals of Surgery\u003c/em\u003e, \u003cem\u003e262\u003c/em\u003e(2), 213\u0026ndash;216. https://doi.org/10.1097/SLA.0000000000001247\u003c/li\u003e\n \u003cli\u003eNituica, C., Bota, O. A., \u0026amp; Blebea, J. (2021). Specialty differences in resident resilience and burnout\u0026mdash;A national survey. \u003cem\u003eAmerican Journal of Surgery\u003c/em\u003e, \u003cem\u003e222\u003c/em\u003e(2), 319\u0026ndash;328. https://doi.org/10.1016/j.amjsurg.2020.12.039\u003c/li\u003e\n \u003cli\u003ePattani, R., Wu, P. E., \u0026amp; Dhalla, I. A. (2014). Resident duty hours in Canada: Past, present and future. \u003cem\u003eCMAJ : Canadian Medical Association Journal\u003c/em\u003e, \u003cem\u003e186\u003c/em\u003e(10), 761\u0026ndash;765. https://doi.org/10.1503/cmaj.131053\u003c/li\u003e\n \u003cli\u003e\u003cem\u003ePhysician wellness: New 2021 National Physician Health Survey findings \u0026mdash; burnout, short-staffing and an overburdened system take their toll\u003c/em\u003e. (n.d.). Canadian Medical Association. Retrieved December 28, 2023, from https://www.cma.ca/physician-wellness-hub/content/physician-wellness-new-2021-national-physician-health-survey\u003c/li\u003e\n \u003cli\u003eRaj, K. S. (2016). Well-Being in Residency: A Systematic Review. \u003cem\u003eJournal of Graduate Medical Education\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(5), 674\u0026ndash;684. https://doi.org/10.4300/JGME-D-15-00764.1\u003c/li\u003e\n \u003cli\u003eSafety, I. of M. (US) C. on O. G. M. T. (Resident) H. and W. S. to I. P., Ulmer, C., Wolman, D. M., \u0026amp; Johns, M. M. E. (2009). Improving the Resident Learning Environment. In \u003cem\u003eResident Duty Hours: Enhancing Sleep, Supervision, and Safety\u003c/em\u003e. National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK214936/\u003c/li\u003e\n \u003cli\u003eSchwartz, S. I., Galante, J., Kaji, A., Dolich, M., Easter, D., Melcher, M. L., Patel, K., Reeves, M. E., Salim, A., Senagore, A. J., Takanishi, D. M., Jr, \u0026amp; de Virgilio, C. (2013). Effect of the 16-Hour Work Limit on General Surgery Intern Operative Case Volume: A Multi-institutional Study. \u003cem\u003eJAMA Surgery\u003c/em\u003e, \u003cem\u003e148\u003c/em\u003e(9), 829\u0026ndash;833. https://doi.org/10.1001/jamasurg.2013.2677\u003c/li\u003e\n \u003cli\u003eScott, I. M., Matejcek, A. N., Gowans, M. C., Wright, B. J., \u0026amp; Brenneis, F. R. (2008). Choosing a career in surgery: Factors that influence Canadian medical students\u0026rsquo; interest in pursuing a surgical career. \u003cem\u003eCanadian Journal of Surgery\u003c/em\u003e, \u003cem\u003e51\u003c/em\u003e(5), 371\u0026ndash;377. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556546/\u003c/li\u003e\n \u003cli\u003eSerenari, M., Cucchetti, A., Russo, P. M., Fallani, G., Mattarozzi, K., Pinna, A. D., Colonnello, V., Poggioli, G., \u0026amp; Cescon, M. (2019). Burnout and psychological distress between surgical and non-surgical residents. \u003cem\u003eUpdates in Surgery\u003c/em\u003e, \u003cem\u003e71\u003c/em\u003e(2), 323\u0026ndash;330. https://doi.org/10.1007/s13304-019-00653-0\u003c/li\u003e\n \u003cli\u003eShanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., West, C. P., Sloan, J., \u0026amp; Oreskovich, M. R. (2012). Burnout and satisfaction with work-life balance among US physicians relative to the general US population. \u003cem\u003eArchives of Internal Medicine\u003c/em\u003e, \u003cem\u003e172\u003c/em\u003e(18), 1377\u0026ndash;1385. https://doi.org/10.1001/archinternmed.2012.3199\u003c/li\u003e\n \u003cli\u003eSun, R., Marshall, D. C., Sykes, M. C., Maruthappu, M., \u0026amp; Shalhoub, J. (2018). The impact of improving teamwork on patient outcomes in surgery: A systematic review. \u003cem\u003eInternational Journal of Surgery\u003c/em\u003e, \u003cem\u003e53\u003c/em\u003e, 171\u0026ndash;177. https://doi.org/10.1016/j.ijsu.2018.03.044\u003c/li\u003e\n \u003cli\u003eTricco, A. C., Lillie, E., Zarin, W., O\u0026rsquo;Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M. D. J., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., \u0026hellip; Straus, S. E. (2018). PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. \u003cem\u003eAnnals of Internal Medicine\u003c/em\u003e, \u003cem\u003e169\u003c/em\u003e(7), 467\u0026ndash;473. https://doi.org/10.7326/M18-0850\u003c/li\u003e\n \u003cli\u003eWest, C. P., Drefahl, M. M., Popkave, C., \u0026amp; Kolars, J. C. (2009). Internal Medicine Resident Self-report of Factors Associated with Career Decisions. \u003cem\u003eJournal of General Internal Medicine\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(8), 946\u0026ndash;949. https://doi.org/10.1007/s11606-009-1039-0\u003c/li\u003e\n \u003cli\u003eWild, J. R. L., Ferguson, H. J. M., McDermott, F. D., Hornby, S. T., \u0026amp; Gokani, V. J. (2015). Undermining and bullying in surgical training: A review and recommendations by the Association of Surgeons in Training. \u003cem\u003eInternational Journal of Surgery\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e, S5\u0026ndash;S9. https://doi.org/10.1016/j.ijsu.2015.09.017\u003c/li\u003e\n \u003cli\u003eWoodside, J. R., Miller, M. N., Floyd, M. R., McGowen, K. R., \u0026amp; Pfortmiller, D. T. (2008). Observations on burnout in family medicine and psychiatry residents. \u003cem\u003eAcademic Psychiatry: The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(1), 13\u0026ndash;19. https://doi.org/10.1176/appi.ap.32.1.13\u003c/li\u003e\n \u003cli\u003eZhang, L. M., Ellis, R. J., Ma, M., Cheung, E. O., Hoyt, D. B., Bilimoria, K. Y., \u0026amp; Hu, Y.-Y. (2020). Prevalence, Types, and Sources of Bullying Reported by US General Surgery Residents in 2019. \u003cem\u003eJAMA\u003c/em\u003e, \u003cem\u003e323\u003c/em\u003e(20), 2093\u0026ndash;2095. https://doi.org/10.1001/jama.2020.2901\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"residency, burnout, factors, medical culture, hidden curriculum","lastPublishedDoi":"10.21203/rs.3.rs-4584396/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4584396/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eResident burnout is heterogeneous across specialties. This scoping review explores burnout factors within surgical and non-surgical specialties and how unique challenges within each discipline contribute to burnout.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA literature search was conducted on OVID Medline and 4 other databases with terms in: 1. residency, 2. burnout, 3. factors, and 4. burnout assessment measures. Original English articles published in North America were included. A frequency is calculated for each factor reported to have a statistically significant association with burnout within the surgical residency category and non-surgical residency category.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere were 46, 50, and 1 study in surgical specialties, non-surgical specialties, and both, respectively. Sixty-five burnout factors were identified. The top personal factors were gender, mindset/mentality, and having a partner/children for both disciplines. The top program-related factors for both disciplines were training stage and workload, and mentorship for surgical specialties and work-life balance for non-surgical specialties. The top external factors for both disciplines were workplace relations, rotations, and co-resident support. The top two institutional factors were autonomy and administrative tasks for surgical specialties, and vice versa for non-surgical specialties.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCommon burnout factors suggest ubiquitous challenges in residency. The differences in the burnout experience are driven by innate personal differences, medical culture, and hidden curriculum. Implementation of protective strategies would require thorough consideration of such similarities and differences and control for balancing factors to maintain the quality of education and patient care.\u003c/p\u003e","manuscriptTitle":"Burnout factors among residents in surgical and non-surgical specialties: a scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-15 17:40:31","doi":"10.21203/rs.3.rs-4584396/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f1cb6111-d2df-4f13-b112-099c6a583f98","owner":[],"postedDate":"July 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-10T05:55:38+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-15 17:40:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4584396","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4584396","identity":"rs-4584396","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}