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Letters to the Editor

In Reply to Fortenberry et al

Ripp, Jonathan MD, MPH; Bazari, Hasan MD; West, Colin P. MD, PhD

Author Information
doi: 10.1097/ACM.0000000000002092
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We thank the authors for their comments on our article and commend them for including the resident voice in the national conversation addressing physician well-being. It is perhaps not surprising that the authors found that residents desire more time both personally and professionally. Developing individual resilience techniques within our suggested “menu” of wellness curricular offerings does not remove the overwhelming demands placed on trainees who work and learn in the clinical setting. Indeed, when medical students are queried, they too prefer nonprogrammatic self-care practices.1 We believe that what the authors have uncovered in demonstrating the residents’ desire for more time aligns with the growing understanding of the importance of system-level drivers of job burnout.

Providing residents with individual skills to combat burnout and protected curricular time to develop these skills is just one part of a possible solution. Improving the system within which residents train is a necessary and likely more impactful component of a multifactorial approach to promoting physician well-being. Some have argued for an “80–20” emphasis, in which 80% of the focus is on reducing system-level drivers and 20% on individual-level drivers. The importance of addressing system-level factors has not gone unnoticed in the literature. Physician burnout has been referred to as a “system-level problem driven by excess job demands and inadequate resources and support, not an individual problem triggered by personal limitations.”2 The Accreditation Council for Graduate Medical Education has also recognized, in its July 2017 Revision of the Common Program Requirements (CPRs), the importance of the system by emphasizing that residents need increased support to unload clerical burden.3 The CPRs call for medical centers to continue to focus on work intensity for trainees while maintaining work hours limitations. These CPRs also specifically address some of the authors’ concerns by mandating that residents be provided protected time to address self-care needs.3

We believe that greater attention and resources directed toward system-level drivers of burnout will free up resident time spent on unnecessary tasks and allow trainees to participate more in the activities (e.g., direct patient care) through which they derive the greatest meaning in work.

Jonathan Ripp, MD, MPH
Associate professor, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; ORCID:; e-mail: jonathan.ripp@mountsinaiorg.

Hasan Bazari, MD
Program director emeritus, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; ORCID:

Colin P. West, MD, PhD
Professor, Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota; ORCID:


1. Ayala EE, Omorodion AM, Nmecha D, Winseman JS, Mason HRC. What do medical students do for self-care? A student-centered approach to well-being. Teach Learn Med. 2017;29:237–246.
2. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826–1832.
3. Accreditation Council for Graduate Medical Education. Summary of changes to ACGME Common Program Requirements section VI. Approved March 10, 2017. Accessed December 4, 2017.
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