Teaching and Learning in Medicine

An International Journal

ISSN: 1040-1334 (Print) 1532-8015 (Online) Journal homepage: http://www.tandfonline.com/loi/htlm20

Adapting Maslow's Hierarchy of Needs as a

Framework for Resident Wellness

Andrew J. Hale, Daniel N. Ricotta, Jason Freed, C. Christopher Smith & Grace
C. Huang

To cite this article: Andrew J. Hale, Daniel N. Ricotta, Jason Freed, C. Christopher Smith & Grace
C. Huang (2018): Adapting Maslow's Hierarchy of Needs as a Framework for Resident Wellness,
Teaching and Learning in Medicine, DOI: 10.1080/10401334.2018.1456928

To link to this article: https://doi.org/10.1080/10401334.2018.1456928

Published online: 30 Apr 2018.

Submit your article to this journal

Article views: 88

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=htlm20
TEACHING AND LEARNING IN MEDICINE
https://doi.org/10.1080/10401334.2018.1456928

OBSERVATIONS

Adapting Maslow’s Hierarchy of Needs as a Framework for Resident Wellness

a
Andrew J. Hale , Daniel N. Ricottab, Jason Freedb, C. Christopher Smithb, and Grace C. Huangb
a
Infectious Diseases, University of Vermont Medical Center, Burlington, Vermont, USA; bDepartment of Medicine, Harvard Medical School,
Boston, Massachusetts, USA

ABSTRACT KEYWORDS
Issue: Burnout in graduate medical education is pervasive and has a deleterious impact on career burnout; graduate medical
satisfaction, personal well-being, and patient outcomes. Interventions in residency programs have education; medical
often addressed isolated contributors to burnout; however, a more comprehensive framework for education; wellness
conceptualizing wellness is needed. Evidence: In this article the authors propose Maslow’s hierarchy
of human needs (physiologic, safety, love/belonging, esteem, and self-actualization) as a potential
framework for addressing wellness initiatives. There are numerous contributors to burnout among
physician-trainees, and programs to combat burnout must be equally multifaceted. A holistic
approach, considering both the trainees personal and professional needs, is recommended.
Maslow’s Needs can be adapted to create such a framework in graduate medical education. The
authors review current evidence to support this model. Implications: This work surveys current
interventions to mitigate burnout and organizes them into a scaffold that can be used by residency
programs interested in a complete framework to supporting wellness.

Introduction
Burnout in graduate medical education is pervasive, as
evidenced by the recent proliferation of literature on the
topic1–15 and several calls to action.16–19 Several studies
have demonstrated significantly higher rates of depres-
sion and feelings of hopelessness among residents com-
pared to the general public.6–8 A recent meta-analysis
found a 28.8% prevalence of depression among resident
physicians.20 In addition, residents’ well-being fares
poorly when compared to medical students and attend-
ings.9 Of special concern are emerging data showing an
association between resident burnout and worse patient
outcomes,10,11,21 which invokes the link to physician per-
formance and the need for competency frameworks to
more explicitly address wellness, as the CanMEDS model
does.22
Several studies have articulated the myriad factors
contributing to burnout and decreased wellness, which
include poor access to food, insufficient sleep, social
isolation, negative or stressful work environments, exces-
sive paperwork, work hours, lack of time for self-care,
poor relationships with colleagues, loss of control, and
poor mentorship.12–14 Several interventions have been
instituted to address these specific contributors to
resident wellness, with variable success.12,17,20–28
In this current context, the need for a comprehen-
sive framework for conceptualizing wellness in resi-
dents has never been more evident. Abraham
Maslow’s 1943 seminal work “A Theory of Human
Motivation” provides a potential scaffold for a holistic
consideration of trainees’ needs.29 His model depicted
five fundamental desires of human beings: physiologic
needs, safety, love and belonging, esteem, and self-
actualization. He originally described each level as
contingent on “baser” needs, resulting in Maslow’s
Pyramid (Figure 1). However, modern-day theorists
have amended this conceptualization of the needs to
coexist with one another, stating that humans still
possess higher order needs even if their rudimentary
ones are not met. Prominent critiques to the hierar-
chical formulation of Maslow’s framework include the
observation that even populations living in scarcity
are capable of articulating higher order needs, and
that highly self-actualized artists were impoverished.
Despite criticisms of its empiric basis and proposed
reorderings of the pyramid,30–32 after 75 years it
remains a common application for sociology, manage-
ment, psychology, and education,33,34 and it offers a
framework germane to residency programs for sup-
porting wellness and preventing resident burnout. We

CONTACT Andrew Hale Andrew.Hale@UVMhealth.org University of Vermont Medical Center, Infectious Disease Unit, 111 Colchester Avenue, Mailstop
115 SM2, Burlington, VT 05401, USA.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/htlm.
© 2018 Taylor & Francis Group, LLC
2 A. J. HALE ET AL.
Self-
actualizaon
Esteem
Love/belonging
Safety
Physiologic
Figure 1. Maslow's original hierarchy of needs was depicted as a
pyramid whereby higher-order needs were dependent on baser-
needs.
thus present a modified Maslow’s Hierarchy of Needs
as an organizing model for residency wellness initia-
tives, removing the hierarchical nature to keep in line
with more modern conceptions of Maslow’s original
work and to acknowledge the multiple concurrent
threats to human needs that the intensity of residency
can incite (Table 1 and Figure 2).
Physiologic needs
According to Maslow, the most fundamental humans
needs are physiologic, namely, air, water, food, shelter,
and rest. For medical trainees, we extend this to include
basic determinants of good health.
Food
Although the Accreditation Council for Graduate Medi-
cal Education (ACGME) requires that food be made
available to residents working overnight,35 no require-
ment exists that food be nutritious or available during
the day. Besides improving lecture attendance,36 provid-
ing healthy food to busy residents who may not other-
wise have time for a meal can contribute to their overall
health and well-being.37
Sleep
Adequate sleep is a fundamental human need and
often suffers in residency.38 Although guidelines sug-
gest 7 to 9 hours of sleep nightly for young adults, a
majority of residents do not achieve this.39,40 Given
the well-established negative effects of poor sleep on
resident wellness, ACGME sleep requirements should
represent bare minimums rather than a goal, and
creating a culture of respect, not just compliance, for
clinical and educational work hour policies may
ensure that residents get appropriate amounts of
sleep.41–43 Protected sleeping time during long call
shifts has been proposed, though further long-term
data on the effect of such an intervention on resident
wellness are required.44 Positioning resident call
rooms close to their clinical responsibilities and keep-
ing them well maintained and free of excessive
disturbances may also improve both sleep quality and
workflow efficiency.45,46
Physical health and activity
Many residents experience the irony of caring for others
all day and night at the expense of caring for themselves.
Providing flexibility in work hours affords residents
opportunities to look after their own health. Such flexi-
bility can apply to day-to-day work or longitudinally
throughout training.47,48 Flex Days have been used in
some programs to allow each resident a finite number of
days for work coverage to see their own physicians, go to
the bank, or otherwise manage issues that must be
accomplished during business hours.49
In addition, exercise as an essential component of
physical health may be overlooked during residency.
Although the American Heart Association recom-
mends at least 30 minutes of daily exercise 5 days a
week for all healthy adults,50 one study reported that
no resident exercised more than 150 minutes per
week during inpatient rotations and just 6.9% of the
time on non-inpatient rotations.51 Residency pro-
grams can subsidize gym memberships, provide onsite
exercise facilities, offer yoga classes, or form softball
or other group sport teams. Some programs offer
organized, active events as part of the residency
experience.52 Weight et al. showed that such team-
based, incentivized exercise is linked to higher quality
of life for trainees.53
Mental health
Depression and other mental health disorders are
prevalent in residency training in the United
States20,54 Quick, reliable, and confidential access to
mental health professionals is an essential component
of a residency program, as described by Ey et al.55
Programs can meet this need by designating psychia-
trists who can be readily available as resources for
house staff in need and by providing flexible sched-
ules or reduced work duties for residents suffering
from mental health issues. In addition, mindfulness
programs have been proposed as a means to increase
 TEACHING AND LEARNING IN MEDICINE 3

Table 1. Framework to support resident wellness.

Adapted Maslow Need Self-Inquiry Questions for Residency
Theme Specific Interventions Programs to Consider

Physiologic Food  Healthy, nutritious, available, free or  Do we provide sufficient food options?
Needs reduced price
Sleep  Adequate amount, in line with ACGME  Are residents getting appropriate amounts of
guidelines at a minimum sleep?
 Clean, available onsite sleeping facilities  Are sleeping facilities adequate for rest?
 X C Y schedule to allow regular noncall periods  Does the schedule balance call versus noncall time
throughout the year?
Physical Health  Flex Time  How do we offer flexibility in day-to-day resident
schedules?
 Program support for exercise  How do we promote adequate exercise and healthy
living?
 Subsidized gym memberships, yoga classes
or onsite exercise facilities
 Team sports
Mental Health  Clear mechanism for quick, reliable, confidential  What mental health professionals are available to
access to psychiatric care residents?
 Schedule flexibility for residents suffering  What are our accommodations for residents with
from mental health disorders mental health issues?
Safety Personal Security  Training in recognizing potentially violent  How do we train residents in avoiding physical
situations, de-escalation, and accessing injury?
security resources
 Safe-transport programs  What are our safe transport options after hours?
Financial Security  Accessible information about finances and  How do we assist residents with financial debt?
managing debt
Love and Belonging Group gatherings  Intern retreat, parties for entire residency,  How do we build community and relaxation?
group activities outside of work, resident
birthday parties
 Special meals for residents working over holidays  How can we commemorate special events?
Supporting family  Spouse and significant other orientation  How do we support our residents’ partners and
relationships children?
 Encouraging family to attend program social events
Shared reflection  Regular facilitated group reflection  How do we promote reflection on residency
experiences?
 Big Sibling program  How can we provide peer mentoring?
 Residency newsletter
 Recruitment dinners
Esteem Respect  Highlight exemplary behavior  How do we recognize outstanding work?
 Identify and respond promptly to mistreatment  Do we have mechanisms to report mistreatment?
 Do we respond in a timely and adequate fashion to
reports of mistreatment?
Fairness  Clear, transparent, accessible policies  Are our policies (such as parental leave) up to date,
equitable, and available to residents?
 Residents involved in programmatic decisions and  How do we seek the input of residents in major
distribution of resources (house staff council) programmatic decisions?
Control  Accommodation of reasonable scheduling requests  How can we offer flexibility with resident
scheduling?
 Long-term schedule available early to allow
for planning
 Flex days
Self-Actualization Mentorship  Trainee/mentor matching programs  What mentoring supports do we provide?
Support for academic  Research and other career advancing electives  How can we provide protected time for academic
flexibility pursuits?
Fellowship and job  Program takes over fellowship and job  Do we have a means to cover job and fellowship
support interview coverage interviews?
Track programs  Longitudinal experiences that provide advanced  How do we individualize training for particular
training and help residents achieve career goals career trajectories?

Note: ACGME D Accreditation Council for Graduate Medical Education.

resident resiliency and decrease stress, though results Personal security

have been mixed.56–58
Physical violence toward physicians is not uncommon, is
often unreported, and can have a devastating impact on
Safety wellness.59–61 Physicians in earlier years of training may
We build upon the original basic human need of safety be at particular risk,62 possibly related to less experience
from physical threats to include the contemporary issues and training with situations that have the potential to
of personal and financial security. become violent. Training resident physicians in de-
4 A. J. HALE ET AL.
Figure 2. In a modern revision of Maslow's original work, the
needs are no longer hierarchical. Each need supports all others
and in sum create an integrated wellness framework.
escalation, security resources, and how to interact with
potentially violent patients is crucial to their personal
safety.
Financial security
Resident physicians may experience a significant burden
of financial debt from medical school or undergraduate
education.63 However, they often have little understand-
ing of how to best manage their short- and long-term
finances, leading to significant stress.54 Offering talks on
debt management, availing residents of financial advisors
through institutional human resources, and identifying
faculty who can informally advise on managing student
debt may be helpful.64
Love and belonging
Maslow believed that friendly and intimate relationships
and identifying with a particular group or groups were
essential human needs. Although residents have a built-in
community, residency programs can prioritize wellness by
proactively nurturing companionship and collegiality.
Group gatherings
Isolation is a driver of resident burnout,14 whereas feeling
connected to colleagues is a marker of resilience.65,66
Retreats at offsite locations with provided work coverage
create dedicated times to promote bonding over shared
experiences.67 Such retreats can include structured group
discussions, storytelling, and skits as a venue for reflection
and self-expression, and they have shown benefits in team
building and group dynamics.68–71 As mentioned previ-
ously, social and athletic group activities foster teamwork
and camaraderie. Special celebrations (e.g., winter parties,
birthdays) recognize familiar traditions and allow more
relaxed venues to socialize while serving as tangible mile-
posts for the passage of time.72 For residents working over
major holidays (e.g., Thanksgiving, New Year’s Eve), pro-
viding onsite meals or treats may temper the sense of loss
from being away from loved ones.
Supporting family relationships
Residency training results in stress on family members
and loved ones,73,74 which can add worries for residents
trying to balance work–life demands.75 Offering a Spouse
and Significant Other session during intern orientation
allows partners time to discuss issues related to having a
significant other in medical training.76 In addition, invit-
ing spouses and significant others to social events fosters
inclusiveness and allows peers and partners to become
acquainted with each other.
Shared reflection
Discussing shared hardships and successes can be a power-
ful bonding experience. Several institutions have imple-
mented facilitated group discussions led by expert
facilitators to provide a forum for these discussions, though
effects on resident wellness have been mixed.27,28 “Big Sib-
ling” programs that pair incoming interns with current resi-
dents help formalize resources for guidance and may help
interns transition into their new role.77–79 House staff news-
letters create a venue for residents to share announcements,
short stories, poetry, easy recipes, and humor.80 Recruitment
lunches and dinners, although ostensibly intended for intern
applicants, are built-in chances to reflect on the residency
experience in a positive light.
Esteem
Maslow’s fourth level of needs is esteem, which serves as
the backdrop for the modern conceptualization of pro-
fessional wellness as respect, fairness, and control.23
Respect
Respect is an affirmation of an individual’s abilities, qual-
ities, or identity. Lack of respect lies at the root of mis-
treatment, which takes different forms in graduate
medical education, and has resulted in decreased

satisfaction among residents.81,82 Surveillance for mis-
treatment, whether by anonymous reporting systems,
rotation and faculty evaluations, or confidential commu-
nications, followed by timely action is necessary to
ensure that residents feel respected in their work envi-
ronment. Conversely, publicly highlighting good deeds
and exemplary behavior helps to instill a culture of posi-
tivity and to affirm the value of work. Literature from the
business world has demonstrated that a positive, respect-
ful work environment nurtures both wellness and
productivity.83,84
Fairness
Witnessing unfairness, whether real or perceived, can be
highly detrimental to resident wellness.54 In an insular
community, residents are acutely aware of how other res-
idents within their own program and at other programs
are being treated. Perceptions of favoritism, unequal bur-
dens of call- or night-duty, or otherwise being treated
differently can threaten trainees’ sense of justice. Having
transparent and accessible policies can alleviate concerns
of inequity about matters that affect residents, such as
parental leave, major programmatic decisions, and distri-
bution of resources.
Control
By nature of their role, residents require supervision,
which can deprive them of a sense of autonomy and self-
efficacy. The rigors of training and reliance on residents
as the primary clinical workforce can translate into a
lack of control over their day-to-day activities, their
workload, and their schedules and contribute to resident
burnout.54 This factor can be mitigated by soliciting the
input of resident representatives, such as a house staff
council,85 for major programmatic decisions. Scheduling
strategies that offer some elements of control include
respecting reasonable requests for time away from clini-
cal responsibilities and dissemination of schedules for
the entire academic year, not just in pieces, so that resi-
dents can make plans outside of work. Certain “X C Y”
schedule templates have been advocated as allowing resi-
dents more control and educational flexibility.86 A lim-
ited number of flex days, as mentioned in Physical
Health, may additionally be beneficial.
Self-actualization
Self-actualization, which Maslow defined as the realiza-
tion of one’s full potential in realms such as athletics,
poetry, or science, is relevant in our adapted framework
TEACHING AND LEARNING IN MEDICINE 5
as the realization of one’s professional potential, be it as
a clinician, researcher, educator, or leader.
Mentorship
Adequate mentorship is essential to the success of aspir-
ing physicians.78,79 Connecting each resident with men-
tors can provide guidance toward their professional
goals,87 and programs that take a proactive approach
have seen increased resident satisfaction.88–90
Support for academic flexibility
Some residents may desire significant time in a labora-
tory doing basic research, whereas others will seek global
health opportunities abroad. Programmatic and schedul-
ing flexibility that accommodates resident academic
interests and facilitates achievement of career goals fos-
ters a sense of control and autonomy in their lives. At
many institutions, residents can apply for research or
independent elective time for up to 12 weeks, in accor-
dance with certifying boards’ training requirements.91
Fellowship and job support
Balancing workload requirements and interviews for fel-
lowship and jobs can be challenging for residents.92,93
Arranging coverage for job and fellowship interviews can
optimize residents’ future opportunities. In some pro-
grams, the chief residents facilitate all coverage arrange-
ments, freeing residents from this burden, though data
are lacking regarding the effect on wellness.
Track programs
Many residencies offer dedicated tracks for residents
who have self-identified interests in particular areas.
Such opportunities may include research, global health,
primary care, HIV, and clinician-educator tracks to allow
residents to explore these fields in depth and help achieve
career goals.94–97
Implementation of initiatives to mitigate
burnout
Enacting a wellness enterprise that spans all levels of
Maslow’s model may at first seem a daunting task, espe-
cially in resource-constrained environments. We suspect
that many of the preceding initiatives already exist to
some extent in graduate medical education programs and
simply require reframing to ensure that all elements of the
framework are being addressed. In addition, overarching
strategies exist to implement initiatives in an integrated
6 A. J. HALE ET AL.
fashion. For instance, utilizing chief medical residents as
“wellness officers” takes advantage of their intermediary
roles as former residents and “junior” faculty who have
the best sense of resident morale. A house staff wellness
committee may offer valuable insight into the larger
groups’ difficulties and may facilitate identifying issues
likely to resonate with their peers. Funds obtained either
as direct line items in the budget or through philanthropic
sources can be set aside as wellness funds for social or
athletic events. It is also important to recognize that an
obstacle to the implementation of wellness initiatives
(besides lack of resources or champions) is a noncondu-
cive culture;98 wellness initiatives cannot be forced upon
an institution, and their fullest potential arises only out of
a culture that fosters continuous improvement, that
normalizes the behavior of seeking help, and that values
the morale of the workforce, not just their productivity.
Limitations to our formulation of human needs
through the prism of Maslow’s framework include the
lack of evidence about the comprehensiveness of this
model. In addition, a recent systematic review of burnout
interventions confirmed that no comparison of single
approaches with multifaceted ones has been performed,1
which highlights a fruitful area of future inquiry. This
framework may be beyond the reach of smaller programs
that lack the resources to meaningfully address all aspects
of their residents’ needs. However, those programs may
be encouraged that lower cost interventions (e.g., small-
group discussions, mobile apps such as Headspace) have
similar effectiveness to high-intensity interventions (e.g.,
mindfulness-based stress reduction)99 and thus should
prioritize problematic areas specific to their institutions.
A myriad of other physician wellness frameworks
have been recently proposed5,100–103 that have overlap
with Maslow’s model. Specifically, work by Sklar5
emphasizes the importance of supporting individuals’
health, improving social support networks, and improv-
ing the clinical learning environment; it even espouses
Maslow’s Hierarchy as an applicable organizing frame-
work, though it serves more as a broad call-to-action
than a specific, actionable schematic. Chaukos and Ves-
tal’s work offers a different approach to burnout through
the lens of prevention, though theirs centers on mental
health and thus was not aimed at addressing needs such
as physical safety or the goal for self-actualization.100
The STEPS Forward campaign by the American Medical
Association outlines a process charter rather than
identify content domains to target.101 Eckleberry-Hunt
shared a list of 20 “wellness tools” to improving wellness
within a small family medicine residency, but this work
was intended neither to represent a unifying model for
how the tools could be implemented nor to assess
whether they comprehensively addressed all types of
needs.102 The framework extended by the Institute for
Physician Wellness103 comes closest to our interpretation
of Maslow’s work in that it outlines seven domains of
wellness (environmental, financial, spiritual, emotional,
intellectual, physical, and social). At this point, their scaf-
fold for well-being is at a largely descriptive, intuitive
stage and is not accompanied by evidence. On the whole,
these frameworks lack the supportive research base of
Maslow’s work and are less well established. The power
of Maslow’s work arises from its familiarity among train-
ees and faculty alike, and its orientation on human needs
has both a tangible quality of accessibility as well as the
stance of an ethical imperative, if residency programs are
committed to seeing their trainees through a formative
but tumultuous time in their personal development.
Conclusions
Residency training can be a tumultuous time of transition
for individuals in their formative years. Interventions to
confront the problem of burnout should be as multifaceted
as the many contributors of burnout, and the adapted
framework presented here may help guide graduate medi-
cal education programs toward comprehensive wellness
initiatives. This model could also hold value for resident
assessment and program evaluation; a Maslow-based
instrument could be developed and examined against
other burnout measures and other related constructs.104,105
Maslow’s framework may also have value as a scorecard
for future ACGME Clinical Learning Environment Review
visits; the five domains could form the basis for a scoring
rubric used by the ACGME for assessing an institution’s
attention to the well-being of residents. A research agenda
centered on Maslow’s model would powerfully advance its
applicability as a contemporary paradigm for addressing
professional well-being and could encompass examination
of the incremental value of multipronged approaches over
singular ones and comparative effectiveness studies of
higher level interventions compared to lower level ones.
Metrics of importance should also include measurements
of sustained effects and long-term outcomes. Fundamen-
tally, the greatest contribution of Maslow’s framework in
this context is that it focuses on residents’ needs not just
as professionals but as human beings.
ORCID
Andrew J. Hale http://orcid.org/0000-0001-7038-1353
References
1. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions
to prevent and reduce physician burnout: a systematic

review and meta-analysis. Lancet. 2016;388:2272–81.
doi:10.1016/S0140-6736(16)31279-X. PMID: 27692469.
2. Ripp J, Fallar R, Babyatsky M, et al. Prevalence of res-
ident burnout at the start of training. Teach Learn
Med. 2010;22:172–5. doi:10.1080/10401334.2010.488
194. PMID: 20563935.
3. Raj KS. Well-being in residency: A systematic review. J
Grad Med Educ. 2016;8:674–84. doi:10.4300/JGME-D-
15-00764.1. PMID: 28018531.
4. Panagioti M, Panagopoulou E, Bower P, et al. Controlled
interventions to reduce burnout in physicians: A system-
atic review and meta-analysis. JAMA Intern Med.
2017;177:195–205. doi:10.1001/jamainternmed.2016.
7674. PMID: 27918798.
5. Sklar DP. Fostering student, resident, and faculty
wellness to produce healthy doctors and a healthy
population. Acad Med. 2016;91:1185–8. doi:10.1097/
ACM.0000000000001298. PMID: 27576028.
6. Shanafelt TD, Oreskovich MR, Dyrbye LN, et al.
Avoiding burnout: the personal health habits and
wellness practices of US surgeons. Ann Surg.
2012;255:625–33. doi:10.1097/SLA.0b013e31824b2fa0.
PMID: 22388107.
7. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S.
medical students, residents, and early career physicians
relative to the general U.S. population. Acad Med.
2014;89:443–51. doi:10.1097/ACM.0000000000000134.
PMID: 24448053.
8. West CP, Shanafelt TD, Kolars JC. Quality of life, burn-
out, educational debt, and medical knowledge among
internal medicine residents. JAMA. 2011;306:952–60.
doi:10.1001/jama.2011.1247. PMID: 21900135.
9. Hull SK, DiLalla LF, Dorsey JK. Prevalence of health-
related behaviors among physicians and medical trainees.
Acad Psychiatry. 2008;32:31–8. doi:10.1176/appi.ap.32.1.
31. PMID: 18270278.
10. Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of
medication errors among depressed and burnt out resi-
dents: prospective cohort study. BMJ. 2008;336:488–91.
doi:10.1136/bmj.39469.763218.BE. PMID: 18258931.
11. Halbesleben JRB, Rathert C. Linking physician burnout
and patient outcomes: exploring the dyadic relationship
between physicians and patients. Health Care Manage
Rev. 2008;33:29–39. doi:10.1097/01.HMR.0000304493.
87898.72. PMID: 18091442.
12. Eckleberry-Hunt J, Lick D, Boura J, et al. An exploratory
study of resident burnout and wellness. Acad Med.
2009;84:269–77. doi:10.1097/ACM.0b013e3181938a45.
PMID: 19174684.
13. Block L, Wu AW, Feldman L, Yeh H-C, Desai SV. Resi-
dency schedule, burnout and patient care among first-year
residents. Postgrad Med J. 2013;89:495–500. doi:10.1136/
postgradmedj-2012-131743. PMID: 23852828.
14. Kassam A, Horton J, Shoimer I, Patten S. Predictors of
well-being in resident physicians: A descriptive and psy-
chometric study. J Grad Med Educ. 2015;7:70–4.
doi:10.4300/JGME-D-14-00022.1. PMID: 26217426.
15. Thomas NK. Resident burnout. JAMA. 2004;292:2880–9.
doi:10.1001/jama.292.23.2880. PMID: 15598920.
16. Lefebvre DC. Resident physician wellness: a new hope.
Acad Med. 2012;87:598–602. doi:10.1097/ACM.0b013e
31824d47ff. PMID: 22450179.
TEACHING AND LEARNING IN MEDICINE 7
17. Salles A, Liebert CA, Greco RS. Promoting balance in the
lives of resident physicians: A call to action. JAMA Surg.
2015;150:607–8. doi:10.1001/jamasurg.2015.0257. PMID:
25992632.
18. Daskivich TJ, Jardine DA, Tseng J, et al. Promotion of
wellness and mental health awareness among physicians
in training: Perspective of a national, multispecialty panel
of residents and fellows. J Grad Med Educ. 2015;7:143–7.
doi:10.4300/JGME-07-01-42. PMID: 26217450.
19. Ripp JA, Privitera MR, West CP, et al. Well-being in
graduate medical education: a call for action. Acad Med.
2017;92:914–7. doi:10.1097/ACM.0000000000001735.
PMID: 28471780.
20. Mata DA, Ramos MA, Bansal N, et al. Prevalence of
depression and depressive symptoms among resident
physicians: A systematic review and meta-analysis.
JAMA. 2015;314:2373–83. doi:10.1001/jama.2015.15845.
PMID: 26647259.
21. Lafreniere JP, Rios R, Packer H, et al. Burned out at the
bedside: patient perceptions of physician burnout in an
internal medicine resident continuity clinic. J Gen Intern
Med. 2016;31:203–8. doi:10.1007/s11606-015-3503-3.
PMID: 26340808.
22. The Royal College of Physicians and Surgeons of Canada.
CanMEDS. Available at: http://www.royalcollege.ca/
rcsite/canmeds/framework/canmeds-role-professional-e.
Accessed December 18, 2017.
23. Jennings ML, Slavin SJ. Resident wellness matters: opti-
mizing resident education and wellness through the
learning environment. Acad Med. 2015;90:1246–50.
doi:10.1097/ACM.0000000000000842. PMID: 26177527.
24. Broquet KE, Rockey PH. Teaching residents and pro-
gram directors about physician impairment. Acad Psychi-
atry. 2004;28:221–5. doi:10.1176/appi.ap.28.3.221. PMID:
15507558.
25. Dunn PM, Arnetz BB, Christensen JF, Homer L. Meeting
the imperative to improve physician well-being: assess-
ment of an innovative program. J Gen Intern Med.
2007;22:1544–52. doi:10.1007/s11606-007-0363-5.
PMID: 17891503.
26. McCue JD, Sachs CL. A stress management workshop
improves residents’ coping skills. Arch Intern Med.
1991;151:2273–7. doi:10.1001/archinte.1991.0040011011
7023. PMID: 1953233.
27. Ripp JA, Fallar R, Korenstein D. A randomized con-
trolled trial to decrease job burnout in first-year internal
medicine residents using a facilitated discussion group
intervention. J Grad Med Educ. 2016;8:256–9. doi:10.
4300/JGME-D-15-00120.1. PMID: 27168899.
28. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to
promote physician well-being, job satisfaction, and pro-
fessionalism: A randomized clinical trial. JAMA Intern
Med. 2014;174:527–33. doi:10.1001/jamainternmed.2013.
14387. PMID: 24515493.
29. Maslow A. A theory of human motivation. Psychol Rev.
1943;50:370–396. doi:10.1037/h0054346..
30. Wahba MA, Bridwell LG. Maslow reconsidered: A review
of research on the need hierarchy theory. Organ Behav
Hum Perform. 1976;15:212–40. doi:10.1016/0030-5073
(76)90038-6..
31. Kenrick DT, Griskevicius V, Neuberg SL, Schaller M.
Renovating the pyramid of needs: Contemporary
8 A. J. HALE ET AL.
extensions built upon ancient foundations. Perspect Psy-
chol Sci. 2010;5:292–314. doi:10.1177/174569161036
9469. PMID: 21874133.
32. Heylighen F. A cognitive-systemic reconstruction of mas-
low’s theory of self-actualization. Behav Sci. 1992;37
:39–58. doi:10.1002/bs.3830370105..
33. Benson SG, Dundis SP. Understanding and motivating
health care employees: integrating Maslow’s hierarchy of
needs, training and technology. J Nurs Manag.
2003;11:315–20. doi:10.1046/j.1365-2834.2003.00409.x.
PMID: 12930537.
34. Kiel JM. Reshaping Maslow’s hierarchy of needs to reflect
today’s educational and managerial philosophies. J Instr
Psychol. 1999;26:167.
35. Accreditation Council for Graduate Medical Education
Institutional Requirements. Available at https://www.
acgme.org/Portals/0/PDFs/FAQ/InstitutionalRequire
ments_07012015.pdf. Accessed July 31, 2017.
36. Segovis CM, Mueller PS, Rethlefsen ML, et al. If you feed
them, they will come: A prospective study of the effects
of complimentary food on attendance and physician atti-
tudes at medical grand rounds at an academic medical
center. BMC Med Educ. 2007;7:22. doi:10.1186/1472-
6920-7-22. PMID: 17626625.
37. Hulsegge G, Looman M, Smit HA, et al. Lifestyle changes
in young adulthood and middle age and risk of cardio-
vascular disease and all-cause mortality: The doetinchem
cohort study. J Am Heart Assoc. 2016;5(1):pii e002432.
doi:10.1161/JAHA.115.002432. PMID: 26764411.
38. Mansukhani MP, Kolla BP, Surani S, Varon J, Ramar K.
Sleep deprivation in resident physicians, work hour limi-
tations, and related outcomes: a systematic review of the
literature. Postgrad Med. 2012;124:241–9. doi:10.3810/
pgm.2012.07.2583. PMID: 22913912.
39. Hirshkowitz M, Whiton K, Albert SM, et al. National
Sleep Foundation’s sleep time duration recommenda-
tions: methodology and results summary. Sleep Health.
2015;1:40–3. doi:10.1016/j.sleh.2014.12.010. PMID:
29073412.
40. Baldwin DC, Daugherty SR. Sleep deprivation and fatigue
in residency training: results of a national survey of first-
and second-year residents. Sleep. 2004;27:217–23.
doi:10.1093/sleep/27.2.217. PMID: 15124713.
41. Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of
sleep quantity, sleep deprivation, mood disturbances,
empathy, and burnout among interns. Acad Med.
2006;81:82–5. doi:10.1097/00001888-200601000-00020.
PMID: 16377826.
42. Papp K, Stoller R, Sage P, et al. The effects of sleep loss and
fatigue on resident–physicians: a multi-institutional, mixed-
method study. Acad Med. 2004;79:394–406. doi:10.1097/
00001888-200405000-00007. PMID: 15107278.
43. Shea JA, Bellini LM, Dinges DF, et al. Impact of protected
sleep period for internal medicine interns on overnight
call on depression, burnout, and empathy. J Grad Med
Educ. 2014;6:256–63. doi:10.4300/JGME-D-13-00241.1.
PMID: 24949128.
44. Shea JA, Dinges DF, Small DS, et al. A randomized trial
of a three-hour protected nap period in a medicine train-
ing program: sleep, alertness, and patient outcomes.
Acad Med. 2014;89:452–9. doi:10.1097/ACM.00000
00000000144. PMID: 24448046.
45. Olson EJ, Drage LA, Auger RR. Sleep deprivation, physi-
cian performance, and patient safety. Chest.
2009;136:1389–96. doi:10.1378/chest.08-1952. PMID:
19892678.
46. Gabow P, Karkhanis A, Knight A, et al. Observations of
residents’ work activities for 24 consecutive hours: impli-
cations for workflow redesign. Acad Med. 2007;81
:766–775. doi:10.1097/00001888-200608000-00016..
47. Hendricks CH. Experience with flexibility in an aca-
demic residency program. Am J Obstet Gynecol.
1986;154:780–5. doi:10.1016/0002-9378(86)90457-6.
PMID: 3963068.
48. Kamei RK, Chen HC, Loeser H. Residency is not a race:
our ten-year experience with a flexible schedule residency
training option. Acad Med. 2004;79:447–52. doi:10.1097/
00001888-200405000-00015. PMID: 15107284.
49. Baylor College of Medicine Benefits. Available at: https://
www.bcm.edu/departments/pediatrics/education/pediat
ric-residency-program/benefits. Accessed July 31, 2017.
50. Haskell WL, Lee I-M, Pate RR, et al. Physical activity and
public health: updated recommendation for adults from
the American College of Sports Medicine and the Ameri-
can Heart Association. Med Sci Sports Exerc.
2007;39:1423–34. doi:10.1249/mss.0b013e3180616b27.
PMID: 17762377.
51. Williams AS, Williams CD, Cronk NJ, et al. Understand-
ing the exercise habits of residents and attending physi-
cians: a mixed methodology study. Fam Med.
2015;47:118–23. PMID: 25646983.
52. American Medical Association. How one program
achieved resident wellness, work-life balance. Available
at: https://wire.ama-assn.org/life-career/how-one-pro
gram-achieved-resident-wellness-work-life-balance.
Accessed August 30, 2017.
53. Weight CJ, Sellon JL, Lessard-Anderson CR, et al. Physi-
cal activity, quality of life, and burnout among physician
trainees: the effect of a team-based, incentivized exercise
program. Mayo Clin Proc. 2013;88:1435–42. doi:10.1016/
j.mayocp.2013.09.010. PMID: 24290117.
54. Prins JT, Gazendam-Donofrio SM, Tubben BJ, et al.
Burnout in medical residents: a review. Med Educ.
2007;41:788–800. doi:10.1111/j.1365-2923.2007.02797.x.
PMID: 17661887.
55. Ey S, Moffit M, Kinzie JM, Brunett PH. Feasibility of a
comprehensive wellness and suicide prevention program:
A decade of caring for physicians in training and prac-
tice. J Grad Med Educ. 2016;8:747–53. doi:10.4300/
JGME-D-16-00034.1. PMID: 28018541.
56. Goldhagen BE, Kingsolver K, Stinnett SS, Rosdahl JA.
Stress and burnout in residents: impact of mindfulness-
based resilience training. Adv Med Educ Pract.
2015;6:525–32. PMID: 26347361.
57. Rosdahl JA, Kingsolver K. Mindfulness training to
increase resilience and decrease stress and burnout in
ophthalmology residents: a pilot study. Invest Ophthal-
mol Vis Sci. 2014;55:5579–5579.
58. Milstein JM, Raingruber BJ, Bennett SH, et al. Burnout
assessment in house officers: evaluation of an interven-
tion to reduce stress. Med Teach. 2009;31:375–8.
doi:10.1080/01421590802208552..
59. Morrison JL, Lantos JD, Levinson W. Aggression and
violence directed toward physicians. J Gen Intern Med.

1998;13:556–61. doi:10.1046/j.1525-1497.1998.00167.x.
PMID: 9734793.
60. Paola F, Malik T, Qureshi A. Violence against physicians.
J Gen Intern Med. 1994;9:503–6. doi:10.1007/BF0
2599220. PMID: 7996293.
61. Wyatt R, Anderson-Drevs K, Van Male LM. Workplace
violence in health care: A critical issue with a promising
solution. JAMA. 2016;316:1037–8. doi:10.1001/
jama.2016.10384. PMID: 27429201.
62. Barlow CB, Rizzo AG. Violence against surgical residents.
West J Med. 1997;167:74–8. PMID: 9291743.
63. Association of American Medical Colleges, Medical
Student Debt Card. Available at: https://members.aamc.
org/eweb/upload/2016_Debt_Fact_Card.pdf. Accessed
August 30, 2017.
64. Ahmad FA, White AJ, Hiller KM, Amini R, Jeffe DB. An
assessment of residents’ and fellows’ personal finance lit-
eracy: an unmet medical education need. Int J Med Educ.
2017;8:192–204. doi:10.5116/ijme.5918.ad11. PMID:
28557777.
65. McKenna KM, Hashimoto DA, Maguire MS, Bynum
WE. The missing link: connection is the key to resilience
in medical education. Acad Med. 2016;91:1197–9.
doi:10.1097/ACM.0000000000001311. PMID: 27438155.
66. Law M, Lam M, Wu D, Veinot P, Mylopoulos M.
Changes in personal relationships during residency and
their effects on resident wellness: a qualitative study.
Acad Med. 2017;92:1601–06. doi:10.1097/
ACM.0000000000001711. PMID: 28445221.
67. Klein EJ, Marcuse EK, Jackson JC, Watkins S, Hudgins L.
The pediatric intern retreat: 20-year evolution of a con-
tinuing investment. Acad Med. 2000;75:853–7. doi:10.
1097/00001888-200008000-00022. PMID: 10965868.
68. Bergman AB, Rothenberg MB, Telzrow RW. A “Retreat”
for pediatric interns. Pediatrics. 1979;64:528–32. PMID:
492818.
69. Winter RJ, Unti SM, Rubenstein JS, Burg FD, Stockman
JA. Resident, faculty, and residency program develop-
ment. An integrated approach through annual retreats.
Am J Dis Child. 1991;145:1191–4. doi:10.1001/
archpedi.1991.02160100123036. PMID: 1928015.
70. Kling PJ, Fost NC. A faculty-house staff retreat. Am J Dis
Child. 1992;146:243–8. PMID: 1733157.
71. Stoller JK, Rose M, Lee R, Dolgan C, Hoogwerf BJ. Team-
building and leadership training in an internal medicine
residency training program. J Gen Intern Med.
2004;19:692–7. doi:10.1111/j.1525-1497.2004.30247.x.
PMID: 15209609.
72. Etzioni A, Bloom J. We Are What We Celebrate: Under-
standing Holidays and Rituals. New York, NY. NYU
Press; 2004.
73. Powers AS, Myers JE, Tingle LR, Powers JC. Wellness,
perceived stress, mattering, and marital satisfaction
among medical residents and their spouses: implications
for education and counseling. Fam J. 2004;12:26–36.
doi:10.1177/1066480703258802..
74. Landau C, Hall S, Wartman SA, Macko MB. Stress in
social and family relationships during the medical resi-
dency. J Med Educ. 1986;61:654–60. PMID: 3735367.
75. Law M, Lam M, Wu D, Veinot P, Mylopoulos M.
Changes in personal relationships during residency and
their effects on resident wellness: a qualitative study.
TEACHING AND LEARNING IN MEDICINE 9
Acad Med. 2017;92:1601. doi:10.1097/ACM.000000
0000001711. PMID: 28445221.
76. Perlman RL, Ross PT, Lypson ML. Understanding the
medical marriage: physicians and their partners share
strategies for success. Acad Med. 2015 Jan;90:63–68.
doi:10.1097/ACM.0000000000000449..
77. Parker P, Hall DT, Kram KE. Peer coaching: a relational
process for accelerating career learning. Acad Manag
Learn Educ. 2008;7:487–503. doi:10.5465/AMLE.
2008.35882189..
78. Sambunjak D, Straus SE, Marusic A. Mentoring in aca-
demic medicine: a systematic review. JAMA.
2006;296:1103–15. doi:10.1001/jama.296.9.1103. PMID:
16954490.
79. Jackson V, Palepu A, Szalacha L, et al.. “Having the right
chemistry”: A qualitative study of mentoring in academic
medicine. Acad Med. 2003;78:328–334. doi:10.1097/
00001888-200303000-00020. PMID: 12634219.
80. University of Colorado School of Medicine Physical
Medicine and Rehabilitation Residency Newsletter.
Available at http://www.ucdenver.edu/academics/col
leges/medicalschool/departments/pmr/media/Docu
ments/ResidencyNewsletter/ResidencyNewsletter_Issue1.
pdf. Accessed August 30, 2017.
81. Daugherty SR, Baldwin, JR DC, Rowley BD. Learning,
satisfaction, and mistreatment during medical internship:
A national survey of working conditions. JAMA.
1998;279:1194–9. doi:10.1001/jama.279.15.1194. PMID:
9555759.
82. Baldwin DC, Daugherty SR. Do residents also feel
“abused”? Perceived mistreatment during internship.
Acad Med. 1997;72:S51–53. doi:10.1097/00001888-1997
10001-00018. PMID: 9347738.
83. Seppala E, Cameron K. Harvard business review, proof
that positive work cultures are more productive. Avail-
able from: https://hbr.org/2015/12/proof-that-positive-
work-cultures-are-more-productive. Accessed December
18, 2017.
84. McKee A. Harvard Business Review, Being Happy at
Work Matters. Available from: https://hbr.org/2014/11/
being-happy-at-work-matters. Accessed December 18,
2017.
85. Johns Hopkins Medicine House Staff Council. Available
at http://www.hopkinsmedicine.org/housestaffcouncil.
Accessed August 30, 2017.
86. Shalaby M, Yaich S, Donnelly J, et al. X C Y scheduling
models for internal medicine residency programs—a
look back and a look forward. J Grad Med Educ.
2014;6:639–42. doi:10.4300/JGME-D-14-00034.1. PMID:
26140111.
87. Levy BD, Katz JT, Wolf MA, et al. An initiative in men-
toring to promote residents’ and faculty members’
careers. Acad Med. 2004;79:845–50. doi:10.1097/
00001888-200409000-00006. PMID: 15326007.
88. Flint JH, Jahangir AA, Browner BD, Mehta S. The value
of mentorship in orthopaedic surgery resident education:
the residents’ perspective. J Bone Jt Surg Am.
2009;91:1017–22. doi:10.2106/JBJS.H.00934.
89. Galicia AR, Klima RR, Date ES. Mentorship in physical
medicine and rehabilitation residencies. Am J Phys Med
Rehabil. 1997;76:268–75. doi:10.1097/00002060-19970
7000-00004. PMID: 9267185.
10 A. J. HALE ET AL.
90. Cain J, Schulkin J, Parisi V, et al. Effects of perceptions
and mentorship on pursuing a career in academic medi-
cine in obstetrics and gynecology. Acad Med.
2001;76:628–634. doi:10.1097/00001888-200106000-
00015. PMID: 11401809.
91. American Board of Internal Medicine Certification Poli-
cies. Available at http://www.abim.org/certification/poli
cies/internal-medicine-subspecialty-policies/internal-
medicine.aspx. Accessed August 30, 2017.
92. Frishman GN, Bell CL, Botros S, et al. Applying to sub-
specialty fellowship: clarifying the confusion and con-
flicts! Am J Obstet Gynecol. 2016;214:243–6. doi:10.1016/
j.ajog.2015.10.936. PMID: 26582169.
93. Watson SL, Hollis RH, Oladeji L, et al. The burden of the
fellowship interview process on general surgery residents
and programs. J Surg Educ. 2017;74:167–172. doi:10.
1016/j.jsurg.2016.06.008. PMID: 27425434.
94. Regan L, Stahmer S, Nyce A, et al. Scholarly tracks in
emergency medicine. Acad Emerg Med. 2010;17:S87–94.
doi:10.1111/j.1553-2712.2010.00890.x. PMID: 21199090.
95. Lin S, Sattler A, Chen Yu G, Basaviah P, Schillinger E.
Training future clinician-educators: a track for family
medicine residents. Fam Med. 2016;48:212–6. PMID:
26950910.
96. Smith CC, McCormick I, Huang GC. The clinician-edu-
cator track: training internal medicine residents as clini-
cian-educators. Acad Med. 2014;89:888–91. doi:10.1097/
ACM.0000000000000242. PMID: 24871239.
97. Fessler DA, Huang GC, Potter J, Baker JJ, Libman H.
Development and implementation of a novel HIV pri-
mary care track for internal medicine residents. J Gen
Intern Med. 2017;32(3):350–4. doi:10.1007/s11606-016-
3878-9. PMID: 27704368.
98. Wei J, Rosen P, Greenspan JS. Physician burnout: What
can chairs, chiefs, and institutions do? J Pediatr.
2016;175:5–6. doi:10.1016/j.jpeds.2016.05.054. PMID:
27297205.
99. Taylor M, Hageman J, Brown M. A mindfulness inter-
vention for residents: relevance for pediatricians. Pediat-
ric Annals. 2016;45:e373–e376. doi:10.3928/19382359-
20160912-01. PMID: 27735974.
100. Chaukos D, Vestal HS, Bernstein CA, et al. An ounce of
prevention: A public health approach to improving phy-
sician well-being. Acad Psychiatry. 2018;42:150–154.
doi:10.1007/s40596-017-0751-z. PMID: 28685352.
101. American Medical Association. Physician wellness: Pre-
venting resident and fellow burnout – STEPS forward.
Available from: https://www.stepsforward.org/modules/
physician-wellness. Accessed on December 18, 2017.
102. Eckleberry-Hunt J, Van Dyke A, Lick D, Tucciarone J.
Changing the conversation from burnout to wellness:
Physician well-being in residency training programs. J
Grad Med Educ. 2009;1:225–30. doi:10.4300/JGME-D-
09-00026.1. PMID: 21975983.
103. The Institute for Physician Wellness. Physician wellness
at the personal level. Available from: https://www.institu
teforphysicianwellness.com/physician-wellness-at-the-
personal-level/. Accessed December 18, 2017.
104. Maslach C, Jackson S. The measurement of experienced
burnout. J Organiz Behav. 1981;2:99–113. doi:10.1002/
job.4030020205.
105. Demerouti E, Bakker B, Vardakou I, Kantas A. The con-
vergent validity of two burnout instruments: A multi-
trait-multimethod analysis. European Journal of
Psychological Assessment. 2006;19:12–23. doi:10.1027//
1015-5759.19.1.12.