Research

JAMA Pediatrics | Original Investigation

Effect of a Novel Mindfulness Curriculum on Burnout

During Pediatric Internship
A Cluster Randomized Clinical Trial
Yarden S. Fraiman, MD, MPH; Christine C. Cheston, MD; Howard J. Cabral, PhD, MPH; Celeste Allen, MD;
Andrea G. Asnes, MD, MSW; Jefferson T. Barrett, MD, MPH; Maneesh Batra, MD, MPH; William Bernstein, MD;
Tammy Bleeker, MEd; Pam M. Dietz, MD; Joanna Lewis, MD; Su-Ting T. Li, MD, MPH; T. Marsha Ma, MD;
John D. Mahan, MD; Catherine D. Michelson, MD, MMSc; Sue E. Poynter, MD, MEd; Mark A. Vining, MD;
Katherine Watson, DO; Colin M. Sox, MD, MS

Visual Abstract
IMPORTANCE Mindfulness curricula can improve physician burnout, but implementation Supplemental content
during residency presents challenges.

OBJECTIVE To examine whether a novel mindfulness curriculum implemented in the first 6

months of internship reduces burnout.

DESIGN, SETTING, AND PARTICIPANTS This pragmatic, multicenter, stratified cluster

randomized clinical trial of a mindfulness curriculum randomized 340 pediatric interns to the
intervention or control arm within program pairs generated based on program size and
region. Fifteen US pediatric training programs participated from June 14, 2017, to February
28, 2019.

INTERVENTIONS The intervention included 7 hour-long sessions of a monthly mindfulness

curriculum (Mindfulness Intervention for New Interns) and a monthly mindfulness refresher
implemented during internship. The active control arm included monthly 1-hour social
lunches.

MAIN OUTCOMES AND MEASURES The primary outcome was emotional exhaustion (EE) as
measured by the Maslach Burnout Inventory 9-question EE subscale (range, 7-63; higher
scores correspond to greater perceived burnout). Secondary outcomes were
depersonalization, personal accomplishment, and burnout. The study assessed mindfulness
with the Five Facet Mindfulness Questionnaire and empathy with the Interpersonal Reactivity
Index subscales of perspective taking and empathetic concern. Surveys were implemented at
baseline, month 6, and month 15.

RESULTS Of the 365 interns invited to participate, 340 (93.2%; 255 [75.0%] female; 51
[15.0%] 30 years or older) completed surveys at baseline; 273 (74.8%) also participated at
month 6 and 195 (53.4%) at month 15. Participants included 194 (57.1%) in the Mindfulness
Intervention for New Interns and 146 (42.9%) in the control arm. Analyses were adjusted for
baseline outcome measures. Both arms’ EE scores were higher at 6 and 15 months than at
baseline, but EE did not significantly differ by arm in multivariable analyses (6 months: 35.4 vs
32.4; adjusted difference, 3.03; 95% CI, −0.14 to 6.21; 15 months: 33.8 vs 32.9; adjusted
difference, 1.42; 95% CI, −2.42 to 5.27). None of the 6 secondary outcomes significantly
differed by arm at month 6 or month 15.

CONCLUSIONS AND RELEVANCE A novel mindfulness curriculum did not significantly affect EE,
burnout, empathy, or mindfulness immediately or 9 months after curriculum
implementation. These findings diverge from prior nonrandomized studies of mindfulness
interventions, emphasizing the importance of rigorous study design and suggesting that
additional study is needed to develop evidence-based methods to reduce trainee burnout.

TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03148626 Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: Yarden S.
Fraiman, MD, Department of
Neonatology, Beth Israel Deaconess
Medical Center, 330 Brookline Ave,
JAMA Pediatr. 2022;176(4):365-372. doi:10.1001/jamapediatrics.2021.5740 Rose 3, Boston, MA 02215 (yfraiman
Published online January 24, 2022. @bidmc.harvard.edu).

(Reprinted) 365
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 Research Original Investigation
B
urnout is a triad of emotional exhaustion (EE), deper-
sonalization, and feelings of inefficacy.1 Between 39%
and 75% of pediatric trainees experience burnout, with
a worsening trend in prevalence during the past few decades.2-5
Burnout affects physicians’ well-being, performance during
training, risk of suicide, and patient care. Physicians with burn-
out are more likely to make medical errors and be less empa-
thetic, and the patients of physicians with burnout are less
likely to adhere to medical plans.6-11 Physician burnout costs
the US health care system approximately $4.6 billion per year
related to physician turnover and reduced productivity.12
Mindfulness, a state of nonjudgmental awareness in the
present moment, can prevent burnout. Mindfulness curri-
cula can reduce burnout among physicians and other
professionals.13-18 Mindfulness is the only evidence-based ap-
proach to reduce burnout included in an Accreditation Coun-
cil for Graduate Medical Education and American Academy of
Pediatrics call for systems-level change to address trainee
burnout.19 Although mindfulness curricula are effective, po-
tential barriers to implementing mindfulness curricula in-
clude time required by the trainees and availability of facili-
tators with content expertise. Small single-center trials17,18,20,21
of mindfulness have found variable effects. We know of no pub-
lished multicenter randomized clinical trials of mindfulness
curricula that target trainee burnout. To assess the effective-
ness of a novel mindfulness curriculum that does not require
prior facilitator training, Mindfulness Intervention for New In-
terns (MINdI),22 on burnout among pediatric interns, we con-
ducted a multicenter cluster randomized clinical trial. We hy-
pothesized that interns training in programs randomized to the
mindfulness curriculum would have less burnout than in-
terns randomized to the control arm.
Methods
Study Sample and Randomization
We conducted a pragmatic, multicenter, stratified cluster ran-
domized clinical trial of a mindfulness curriculum during pe-
diatric internship. See Supplement 1 for full trial protocol. We
recruited 15 US pediatric residency programs to participate in
this study and sent surveys to 365 eligible interns (Figure 1).
All sites’ institutional review boards approved the study. To
be eligible for inclusion, each participating pediatric resi-
dency program agreed to be randomized to have their interns
experience the MINdI curriculum or social lunches. From June
14 to September 29, 2017, pediatric and medicine-pediatric in-
terns training in study programs gave implied written con-
sent by returning the baseline survey. All data were deidenti-
fied. This study followed the Consolidated Standards of
Reporting Trials (CONSORT) reporting guideline.
After pairing programs by location and size, we used a
random-number generator to assign, within a pair, each program’s
cluster of interns to experience a novel 7-session MINdI curricu-
lum or an active control experience of nondidactic social lunch.
Because an odd number of programs participated, we created 1
dummy variable for paired randomization. Each program’s interns
had the same arm-specific unblinded training experience.
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Effect of a Novel Mindfulness Curriculum on Burnout During Pediatric Internship
Key Points
Question Can a novel mindfulness curriculum designed for
implementation in residency that does not require facilitator
training reduce burnout among pediatric interns?
Findings This cluster randomized clinical trial found that the levels
of emotional exhaustion, depersonalization, burnout, empathy,
and mindfulness among pediatric interns who completed the
6-month mindfulness curriculum did not significantly differ from
those assigned to social lunches both immediately after
completing the training experience and 9 months later.
Meaning A novel mindfulness curriculum did not affect pediatric
interns’ levels of burnout, empathy, and mindfulness compared
with social time only, suggesting that additional study is needed to
develop evidence-based methods to reduce trainee burnout.
Intervention Arm
A 6-step approach to curricular design informed the devel-
opment of MINdI.22,23 The MINdI curriculum easily inte-
grates into existing 1-hour didactic time ubiquitous among
training programs and requires no additional facilitator
training.22 Intervention programs received the MINdI facili-
tator manual and all necessary curriculum implementation
supplies. The intervention was delivered monthly, starting
during the first quarter of the intern year and continuing for
6 months, for a total of 7 sessions; programs were encour-
aged to facilitate interns’ attendance at MINdI sessions,
although attendance was not required.
The MINdI curriculum was developed by a multidisciplinary
team of medical education experts, residency program leader-
ship, a chief resident, mindfulness practitioners, and trainees.
Briefly, each session begins with a social lunch, followed by a min-
ute of silence, introductory remarks regarding the mindfulness
exercise, a mindfulness exercise, and a debriefing period. The cur-
riculum is designed to provide mindfulness exercises that can eas-
ily be integrated into a medical trainee’s day or highlight a unique
aspect of mindfulness that can be beneficial to medical trainees.
In addition to the monthly curriculum, intervention programs
were encouraged to invite participants to conduct a short mind-
fulness refresher, a 10-minute prerecorded body scan exercise,
2 weeks after each MINdI session.
Control Arm
In the active control arm, participants were scheduled to at-
tend 6 interns-only, 1-hour social lunches that involved no
mindfulness activities, as other mindfulness curricula ran-
domized clinical trials have done.18
Outcomes
Outcomes were measured through surveys at baseline,
month 6, and month 15. The Maslach Burnout Inventory
Human Services Survey was used under license with Mind
Garden Inc. The primary outcome (EE) was measured using
the Maslach Burnout Inventory 9-question EE subscale
(range, 7-63; higher scores correspond to higher degrees of
perceived burnout). 1 Prespecified secondary outcomes
included dichotomized burnout and the Maslach Burnout
jamapediatrics.com
 Effect of a Novel Mindfulness Curriculum on Burnout During Pediatric Internship
Inventory 5-item depersonalization subscale (range, 7-35;
higher scores correspond to higher degrees of perceived
burnout) and 8-item personal accomplishment subscale
(range, 7-56; higher scores correspond to lower degrees of
perceived burnout), as well as mindfulness and empathy.
We defined burnout as having an EE score of 27 or higher
and/or a depersonalization score of 10 or higher. 1,24 We
measured mindfulness using the 39-item Five Facet Mind-
fulness Questionnaire, on which higher scores on a scale of
39 to 195 are interpreted as increased mindfulness. 25,26
We assessed empathy using the Interpersonal Reactivity
Index’s Perspective Taking and Empathic Concern sub-
scales, on which higher scores are interpreted as increased
empathy.27,28
The baseline survey also collected demographic informa-
tion and report of prior mindfulness behaviors; surveys at
months 6 and 15 also collected self-report of mindfulness-
related knowledge, attitudes, and behaviors. Surveys at base-
line were implemented before participants completed the first
study session, and those at month 6 were implemented after
completing the final study session. Participants were offered
a $5 coffee gift card after completing each survey.
Statistical Analysis
To examine whether subject characteristics varied by study arm
while addressing hierarchical effects of cluster randomiza-
tion, we conducted bivariate linear generalized estimating
equations and logistic regressions clustered on center. To es-
timate the between-group difference in outcome between the
randomized groups while addressing hierarchical effects of
cluster randomization, we used multivariate generalized es-
timating equations and logistic regressions clustered on cen-
ter. All regressions included study arm, independent mea-
sures that significantly differed by study arm, or measures that
were of a priori clinical interest, including self-identified gen-
der and age. Race and ethnicity data were not collected be-
cause we did not consider race or ethnicity to be significantly
associated with burnout during the study design. To address
the concern of including independent variables possibly in the
causal pathway, we performed additional sensitivity analy-
ses without these variables and that included only baseline
variables.
In addition, analyses of data at month 6 and/or month 15
controlled for the outcome at baseline, baseline survey month,
prior weekend off at month 6, inpatient or intensive care ro-
tation at month 15, and an arm × survey period interaction term
based on prior data.29 If the arm × survey month interaction
term was statistically significant, we conducted stratified analy-
ses of the month 6 and month 15 data. If the interaction term
was not significant, then we removed the interaction term and
conducted longitudinal analyses comparing the pooled out-
comes at month 6 and month 15 while controlling for
baseline.
Because 29.8% of data was missing, we conducted all
multivariable analyses on 20 imputed data sets created
using individual-level data following standard imputation
procedures using PROC MI and PROC MI ANALYZE in SAS
software, version 9.4 (SAS Institute Inc). These imputations
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Original Investigation Research
Figure 1. CONSORT Study Flow Diagram
365 Assessed for eligibility
6 Excluded for declining
participation
359 Randomized
204 Allocated to MINdI intervention 155 Allocated to control arm
194 Baseline questionnaire returned 146 Baseline questionnaire returned
148 6-mo Questionnaire returned 125 6-mo Questionnaire returned
106 15-mo Questionnaire returned 89 15-mo Questionnaire returned
194 Analyzed 146 Analyzed
MINdI indicates Mindfulness Intervention for New Interns.
were performed in PROC MI via a multiple imputation with
chained equations approach with fully conditional specifi-
cation. Data were imputed when missing at baseline given
variables with fully observed values. Then the baseline data
and fully observed variables at 6 months were used to
impute values for variables with missing data at 6 months.
This process continued in a similar fashion, with prior data
and variables fully observed at 15 months used to impute
missing values at 15 months. We report effect sizes as linear
regression coefficients quantifying differences in means or
in logistic model odds ratios (ORs) with 95% CIs, as well as
2-sided P values for primary outcome analyses. A 2-sided
P < .05 was considered statistically significant.
Setting 1 − β = 0.8 and 2-sided α = .05, our a priori
power calculations determined that at least 139 participants
per group were needed to determine a 0.29 difference in
mean EE to be statistically significant, a threshold selected
because a meta-analysis 30 found that burnout reduction
interventions significantly lowered EE scores by 0.28. These
c alculations, however, did not account for possible
clustering by site. Had this been done, applying a reason-
able intraclass correlation of 0.01 would have yielded a
required enrollment sample with an additional 256 partici-
pants to achieve 80% power with a 2-sided α = .05. This
addition of participants to the sample would not have been
feasible, however, given the planned study period. We note
that our sample as implemented was larger than other ran-
domized clinical trials of mindfulness curricula that have
intended to address burnout. We have provided 95% CIs
with all estimates of group differences so that readers can
judge the precision, or lack thereof, of our findings in this
sample, in particular with respect to prior research14-17 with
smaller samples.
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 Research Original Investigation Effect of a Novel Mindfulness Curriculum on Burnout During Pediatric Internship

Table 1. Study Sample Characteristics and Outcome at Baselinea

All MINdI arm Control arm
Characteristic or outcome (N = 340) (n = 194) (n = 146)
Personal characteristics
Gender
Female 255 (75.0) 153 (78.9) 102 (69.9)
Abbreviation: MINdI, Mindfulness
Male 85 (25.0) 41 (21.1) 44 (30.1) Intervention for New Interns.
Age ≥30 y 51 (15.0) 32 (16.6) 19 (13.0) a
Data are presented as number
No prior mindfulness training 103 (30.5) 61 (31.6) 42 (29.0) (percentage) of interns unless
No prior mindfulness practice 56 (16.5) 30 (15.5) 26 (17.8) otherwise indicated.
Program characteristics b
On the basis of analyses of
Program with <20 interns 93 (27.4) 48 (24.7) 45 (30.8) nonimputed responses from study
US region participants measured at baseline.
c
Eastern 159 (44.3) 66 (34.0) 91 (62.3) Total scores on the 9-item
Central 118 (32.9) 59 (30.4) 42 (27.8) emotional exhaustion subscale
(range, 7-63; higher scores
Western 82 (22.8) 69 (35.6) 13 (8.9)
correspond to higher degrees of
Medicine-pediatrics residents 16 (4.7) 11 (5.7) 5 (3.5)
perceived burnout).
Survey implementation d
Total scores on the 5-item
Baseline (survey during intern orientation) 213 (62.7) 118 (60.8) 95 (65.1) depersonalization subscale (range,
Month 6 7-35; higher scores correspond to
Vacation in prior month 77 (30.4) 43 (31.4) 34 (29.3) higher degrees of perceived
Prior weekend off 108 (42.7) 54 (39.4) 54 (46.6) burnout).
e
Rotating on inpatient or intensive care service 184 (73.0) 104 (76.5) 80 (69.0) Total scores on the 8-item personal
Month 15 accomplishment subscale (range,
Vacation in prior month 61 (32.8) 29 (28.2) 32 (38.6) 7-56; higher scores correspond to
lower degrees of perceived
Prior weekend off 98 (52.7) 58 (56.3) 40 (48.2)
burnout).
Rotating on inpatient or intensive care service 92 (50.0) 44 (43.1) 48 (58.5) f
Total scores on the 7-item
Outcomes at baselineb
perspective taking subscale (range,
Burnout 233 (68.5) 145 (74.7) 88 (60.3) 7-35; higher scores correspond to
Emotional exhaustion, mean (SD)c 27.2 (9.7) 28.2 (10.1) 25.9 (8.9) higher degrees of perceived
Depersonalization, mean (SD)d 11.5 (5.1) 11.9 (5.0) 11.0 (4.8) empathy).
Personal accomplishment, mean (SD)e 39.3 (8.2) 41.5 (4.1) 36.3 (10.9) g
Total scores on the 39-item Five
Empathetic concerns, mean (SD)f 17.9 (2.2) 18.0 (2.0) 17.9 (2.2) Facet Mindfulness scale (range,
Perspective taking, mean (SD)f 19.3 (2.9) 19.4 (3.0) 19.2 (2.8) 39-195; higher scores correspond to
higher degrees of perceived
Mindfulness, mean (SD)g 127.7 (16.3) 126.7 (16.5) 126.7 (16.1)
mindfulness).

[10.9]; P = .003). Although burnout and mean EE and deper-

Results
Study Participants
Of the 359 consenting interns, 340 (94.7%; 255 [75.0%] fe-
male; 51 [15.0%] 30 years or older) completed surveys at base-
line, 273 at month 6 (76.0%), and 195 at month 15 (54.3%); the
19 interns who did not complete the baseline survey were ex-
cluded. Analyses included 194 intervention participants (57.1%)
and 146 control participants (42.9%). The dropout rate was
19.7% at 6 months and 42.6% at 15 months. Characteristics be-
tween those who were lost to follow-up and those who com-
pleted the study were not markedly different (eTable in
Supplement 2).
Table 1 presents the study population characteristics. Gen-
der was the only personal or program characteristic that sig-
nificantly differed by arm, with more female interns in the
MINdI arm than in the control arm (female vs male: 255 [75.0%]
vs 85 [25.0%] for all interns; 153 [78.9%] vs 41 [21.1%] for MINdI
arm; and 102 [69.9%] vs 44 [30.1%] for the control arm;
P = .002). The only outcome that significantly differed at base-
line in bivariate analyses was personal accomplishment, with
the MINdI arm’s mean (SD) personal accomplishment score
being higher than that in the control group (41.5 [4.1] vs 36.3
sonalization scores did not differ at baseline by arm, these mea-
sures significantly increased during the 78-day enrollment pe-
riod for 4 months in both groups (Figure 2). At month 6, MINdI
participants were significantly less likely to have had the prior
weekend off than controls (54 [39.4%] vs 54 [46.6%]; P = .04).
At month 15, MINdI participants were significantly less likely
to be rotating on an inpatient or intensive care service than con-
trols (44 [43.1%] vs 48 [58.5%]; P = .02). Table 2 and Table 3
present results of multivariable analyses of 20 imputed data
sets conducted to determine the effect of arm on continuous
and dichotomous outcomes, respectively.
Primary Outcomes
In multivariable analyses of imputed data, EE at baseline did not
significantly differ between the MINdI and control arms (adjusted
difference, −0.37; 95% CI, −3.03 to 3.77) (Table 2). The MINdI and
control arms’ mean (SD) EE scores were higher at month 6 (35.4
vs 32.4) than baseline (28.3 vs 25.6); however, multivariable analy-
ses controlling for baseline EE revealed that EE at month 6 did not
significantly differ by study arm (adjusted difference, 3.03; 95%
CI, −0.14 to 6.21). Both arms’ mean EE scores remained higher
than baseline at month 15 (33.8 vs 32.9). In multivariable longi-
tudinal analyses, the arm-period interaction term was statistically

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 Effect of a Novel Mindfulness Curriculum on Burnout During Pediatric Internship
significant (P = .02); in stratified multivariable analyses, EE did
not significantly differ by arm at month 15 (adjusted difference,
1.42; 95% CI, −2.42 to 5.27).
Secondary Outcomes
Most respondents had burnout at baseline (74.7% in the
MINdI arm and 60.3% in the control arm, month 6 (92.0%
in the MINdI arm and 80.5% in the control arm), and month
15 (83.7% in the MINdI arm and 88.3% in the control arm)
(Table 3). At baseline, no differences by arm were found in
burnout, depersonalization (mean [SD] scores, 11.9 [5.0] for
the MINdI arm and 11.0 [4.8] for the control arm), mindful-
ness (mean [SD] scores, 126.6 [16.4] for the MINdI arm and
126.5 [16.1] for the control arm), empathetic concerns (mean
[SD] scores, 18.0 [2.0] for the MINdI arm and 17.9 [2.2] for
the control arm), or perspective taking (mean [SD] scores
19.4 [3.0] for the MINdI arm and 19.2 [2.8] for the control
arm).
No significant differences by arm were found in prior mind-
fulness training (31.6% in the MINdI arm and 29.0% in the con-
trol arm) or practice (15.5% in the MINdI arm and 17.8% in the
control arm) at baseline. Multivariable longitudinal analyses
revealed that levels of mindfulness (adjusted difference, −1.07;
95% CI, −5.27 to 3.13), empathetic concerns (adjusted differ-
ence, 0.27; 95% CI, −0.54 to 1.08), perspective taking (ad-
justed difference, 0.74; 95% CI, −0.53 to 2.02), and personal
accomplishment (adjusted difference, 0.14; 95% CI, −1.70 to
1.98) did not significantly differ by arm between month 6 and
month 15. The arm × period interaction term was statistically
significant in multivariable longitudinal analyses conducted
to the effect of arm on depersonalization (P < .001) and burn-
out (P = .004); subsequent multivariable analyses stratified by
period revealed that these outcomes did not significantly dif-
fer by arm at month 15.
At month 6, multivariable analyses identified significant
increases in report of knowing the evidence to support mind-
fulness (adjusted OR, 3.23; 95% CI, 1.63-6.39), how to apply
mindfulness (adjusted OR, 3.99; 95% CI, 3.25-4.90), the be-
lief that mindfulness benefited their life (adjusted OR, 2.51; 95%
CI, 1.03-6.11), and having a positive attitude toward mindful-
ness (adjusted OR, 2.60; 95% CI, 1.67-4.07). Most of these
changes were not persistent over time. Self-reported fre-
quency of mindfulness practice at baseline and month 6 did
not significantly differ by arm (adjusted OR, 1.48; 95% CI, 0.72-
3.02). The odds of using these techniques more after the cur-
riculum did not significantly differ by arm between month 6
and month 15 (adjusted OR, 1.02; 95% CI, 0.57-1.82). The
arm × period interaction term was statistically significant
(P < .001) in multivariable longitudinal analyses conducted to
test the effect of arm on reporting to know how to apply, be-
lief in the benefit of, and having a positive attitude toward
mindfulness; subsequent multivariable analyses stratified by
period revealed that none of these outcomes significantly dif-
fered by arm at month 15.
In the sensitivity analyses in which time-dependent vari-
ables were removed, the results relating to intervention ef-
fects were similar to those described above and in the tables
of our regression models.
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Original Investigation Research
Figure 2. Burnout at Baseline Measurement
Emotional exhaustion (MINdI) Emotional exhaustion (control)
Depersonalization (MINdI) Depersonalization (control)
Personal accomplishment (MINdI) Personal accomplishment (control)
50 100
40 80
Mean subscale score
Burnout, %
30 60
20 40
10 20
0 0
June July-September
Month of baseline survey
MINdI indicates Mindfulness Intervention for New Interns.
Discussion
Our multicenter cluster randomized clinical trial of a novel mind-
fulness curriculum implemented early in pediatric internship
found that the intervention did not significantly affect interns’
EE, depersonalization, burnout, personal accomplishment, mind-
fulness, or empathy immediately after curriculum implementa-
tion and 15 months later. After the 6-month curriculum was com-
pleted, MINdI participants were significantly more likely than con-
trols to report knowing how to apply mindfulness techniques and
their evidence, as well as having a positive attitude about mind-
fulness and believing it benefited their life. Fifteen months after
curriculum implementation, the only measure with a statistically
significant between-arm difference was in knowledge of the evi-
dence supporting the use of mindfulness.
In contrast to prior studies14,15,17,18 of mindfulness curricu-
lum, our study found no changes in burnout rates or levels of EE,
depersonalization, mindfulness, or empathy between interven-
tion and control participants. Our study intervention differs from
prior studies14,15 in a number of important ways. First, our cur-
riculum was not facilitated by an experienced mindfulness prac-
titioner. Recognizing the limitation of facilitation by a local con-
tentexpertonthefeasibilityofwidespreaddisseminationofmind-
fulness curricula, our curriculum relied on a scripted curriculum
that did not require a content expert to facilitate education. How-
ever, our results prompt us to question the potential effect of
greater facilitator experience in mindfulness training on curricu-
lum effectiveness.
Second, prior curricula have been more robust compared
with MINdI.13-15,21,30,31 For example, the mindfulness-based
stress reduction curriculum published by Krasner et al14 was
composed of an 8-week intensive phase that included 2.5 hours
per week and a 7-hour retreat followed by a 2.5-hour per month
maintenance period for 10 months. In contrast, our 7-session
monthly curriculum was specifically designed to integrate into
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 Research Original Investigation Effect of a Novel Mindfulness Curriculum on Burnout During Pediatric Internship

Table 2. Impact of the MINdI Curriculum on Continuous Measures of Burnout, Mindfulness, and Empathy at Baseline, Month 6, and Month 15a

Baseline, Month 6 Month 15 Pooled MINdI vs control

unadjusted Unadjusted Adjusted difference Unadjusted Adjusted difference Unadjusted Adjusted difference
Outcomes mean mean (95% CI)b mean (95% CI)c mean (95% CI)d
Emotional exhaustion
MINdI arm 28.3 35.4 33.8 NA NA
3.03 (−0.14 to 6.21) 1.42 (−2.42 to 5.27)
Control arm 25.6 32.4 32.9 NA NA
Depersonalization
MINdI arm 11.9 16.0 15.0 NA NA
1.2 (−0.56 to 2.96) −0.27 (−2.37 to 1.83)
Control arm 11.0 14.8 15.5 NA NA
Personal accomplishment
MINdI arm 41.5 41.6 NA NA 40.5
0.06 (−1.80 to 7.91) 0.14 (−1.70 to 1.98)
Control arm 36.3 41.6 NA NA 39.5
Mindfulness
MINdI arm 126.6 125.5 NA NA 128.6
−0.91 (−5.67 to 3.85) −1.07 (−5.27 to 3.13)
Control arm 126.5 126.4 NA NA 127.1
Empathetic concerns
MINdI arm 18.0 17.2 NA NA 16.7
0.24 (−0.71 to 1.18) 0.27 (−0.54 to 1.08)
Control arm 17.9 17.0 NA NA 17.0
Perspective taking
MINdI arm 19.4 21.5 NA NA 20.7
1.02 (−0.36 to 2.41) 0.74 (−0.53 to 2.02)
Control arm 19.2 20.4 NA NA 20.8
Abbreviations: MINdI, Mindfulness Intervention for New Interns; NA, not 15 clustered on site while controlling for gender, age, month at baseline,
applicable (pooled analyses were not completed based on the interaction baseline personal accomplishment, current inpatient rotation, and the level of
term). the outcome at month 6. The longitudinal data were stratified by assessment
a
Mean results are from multivariable analyses of 20 imputed data sets. period (month 6 and month 15) because preliminary models that included a
b
MINdI arm × period interaction term were statistically significant.
Results of multivariable generalized estimating equation regressions at month
d
6 clustered on site while controlling for gender, age, month at baseline, Results of multivariable longitudinal generalized estimating equation
baseline personal accomplishment, prior weekend off, and the outcome of regressions comparing pooled month 6 and month 15 while controlling for
interest at baseline. gender, age, month at baseline, baseline personal accomplishment, current
c
inpatient rotation, and the outcome at baseline.
Results of multivariable generalized estimating equation regressions at month

preexisting residency didactic time. It is possible our curricu-
lum may not have been robust enough to induce a change in
behavior and objective metrics of burnout, mindfulness, or em-
pathy, although changes in mindfulness-related knowledge and
attitudes were apparent. Although programs were encour-
aged to take attendance, it was not required. Thus, we have
no consistent data on how many training sessions each intern
experienced. We wonder whether there could be a dose
response in the mindfulness training that we are not able to
assess in which more participation may have led to better out-
comes among trainees.
In our study population, most participants in both arms
had scores indicating burnout at baseline, and burnout wors-
ened during the study period. Because most participants com-
pleted the baseline survey before internship began, efforts to
reduce burnout among trainees should be integrated into un-
dergraduate medical education. Despite reporting increased
mindfulness-related knowledge and positive attitudes to-
ward mindfulness after completing the curriculum, partici-
pants did not report corresponding increases in mindfulness
practice or objective measures of mindfulness. Perhaps com-
peting demands and priorities early in medical training, in-
cluding a primary focus on increasing clinical competence, per-
sistently outweighed prioritization of new self-care techniques
to prevent burnout.
Finally, selection bias may have influenced prior
cohort studies13-16 conducted among physicians who chose
to participate in the mindfulness training that found
mindfulness to be associated with decreased burnout.
Small studies and those among medical trainees have often
failed to show large or statistically significant effects of
mindfulness on objective measures of burnout, empathy, or
mindfulness.13,16,17,20,21,30
Limitations
This study has several limitations. First, cluster randomiza-
tion resulted in an imbalance in gender and baseline personal
accomplishment between study arms. Second, our study is lim-
ited by missing data, a common limitation that may intro-
duce bias into the results; to address this, we estimated miss-
ing values by multiple imputation, which may have resulted
in underestimation of SEs. Third, our sample size was based
on power calculations that did not account for possible clus-
tering by site. Thus, findings of clinical importance that were
not statistically significant should be cautiously interpreted
and their precision judged by the widths of their 95% CIs.
Fourth, our pragmatic trial design allowed variation in month
of the intervention and control experiences and survey imple-
mentation, so temporal trends in burnout during training may
have influenced intervention efficacy and our findings.

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 Effect of a Novel Mindfulness Curriculum on Burnout During Pediatric Internship Original Investigation Research

Table 3. Impact of the MINdI Curriculum on Dichotomous Measure of Burnout and Mindfulness-Related Knowledge,
Behavior, and Attitudes at Baseline, Month 6, and Month 15a

Baseline, Month 6 Month 15 Pooled MINdI vs control

unadjusted Unadjusted Unadjusted Unadjusted
b c
Outcomes rate rate, % AOR (95% CI) rate, % AOR (95% CI) rate, % AOR (95% CI)d
Burnoute
MINdI arm 74.7 92.0 83.7 NA NA
2.28 (0.77-6.71) 0.60 (0.17-2.20)
Control arm 60.3 80.5 88.3 NA NA
Knows evidence supporting mindfulness
MINdI arm NA 69.4 NA NA 68.3
3.23 (1.63-6.39) 2.56 (1.46-4.47)
Control arm NA 40.4 NA NA 58.1
Knows how to apply mindfulness in own life
MINdI arm NA 76.9 80.4 NA NA
3.99 (3.25-4.90) 1.64 (0.66-4.10)
Control arm NA 42.5 71.0 NA NA
Believes mindfulness benefited their life
MINdI arm NA 60.1 73.0 NA NA
2.51 (1.03-6.11) 1.24 (0.44-3.49)
Control arm NA 27.0 63.2 NA NA
Holds positive attitude toward mindfulness
MINdI arm NA 72.2 64.1 NA NA
2.60 (1.67-4.07) 0.64 (0.24-1.74)
Control arm NA 56.5 67.8 NA NA
Uses mindfulness techniques more often
MINdI arm NA 38.9 NA NA 64.7
1.48 (0.72-3.02) 1.02 (0.57-1.82)
Control arm NA 25.9 NA NA 61.9
Abbreviations: AOR, adjusted odds ratio; MINdI, Mindfulness Intervention for the outcome at month 6. The longitudinal data were stratified by assessment
New Interns; NA, not applicable (pooled analyses were not completed based on period (month 6 and month 15) because preliminary models that included a
the interaction term). MINdI arm × period interaction term were statistically significant.
a d
Mean results are from multivariable analyses of 20 imputed data sets. Results of multivariable longitudinal logistic regressions comparing month 6 to
b
Results of multivariable logistic regressions at month 6 clustered on site while month 15 while controlling for gender, age, month at baseline, baseline
controlling for gender, age, month at baseline, baseline personal personal accomplishment, prior weekend off, current inpatient rotation, the
accomplishment, prior weekend off, current inpatient rotation, and the outcome at baseline, assessment period, and a MINdI arm × period interaction
outcome of interest at baseline. term.
e
c
Results of multivariable logistic regressions at month 15 clustered on site while Because initial logistic regressions models analyzing burnout at month 6 that
controlling for gender, age, month at baseline, baseline personal clustered on site did not converge, the final regression model for burnout at
accomplishment, prior weekend off, current inpatient rotation, and the level of month 6 did not cluster on site.

The mixed results of our methodologically rigorous
cluster randomized clinical trial of MINdI may indicate that
trainees face unique challenges in integrating mindfulness
knowledge into behavior change. The study demonstrated
that improvements in mindfulness-related knowledge and
attitudes failed to translate into effects on burnout, empa-
thy, and mindfulness. Although we cannot be sure why the
intervention did not have its intended effect, we hypoth-
esize 2 explanations. First, although MINdI was robust
enough to affect knowledge and attitudes, it was not strong
enough to affect distal outcomes. Second, our study identi-
fied higher rates of burnout than previously reported in the
literature of pediatric trainees. It is possible that the high
levels of burnout we detected represent a meaningful tem-
poral shift and the diminished efficacy of individual-level
interventions, such as mindfulness, to address epidemic
levels of burnout. Burnout in medical training may be
driven more at a systems level than a personal one, and in
the context of pediatric internship, efforts to reduce burn-
out should focus more on system reform than personal
training.21,30,32
Conclusions
This multicenter cluster randomized clinical trial of a novel
mindfulness curriculum demonstrated that the intervention
did not significantly affect measures of burnout, mindful-
ness, or empathy among pediatric interns training across the
US. However, intervention participants reported improved
mindfulness-related knowledge, behaviors, and attitudes. The
mixed results of this large, multicenter randomized clinical trial
suggest that there is a need for further study, mechanism elu-
cidation for behavior change, and curriculum optimization.

ARTICLE INFORMATION
Accepted for Publication: October 4, 2021.
Published Online: January 24, 2022.
doi:10.1001/jamapediatrics.2021.5740
Author Affiliations: Department of Neonatology,
Beth Israel Deaconess Medical Center, Boston,
Massachusetts (Fraiman); Division of Newborn
Medicine, Department of Pediatrics, Boston
Children’s Hospital, Boston, Massachusetts
(Fraiman); Department of Pediatrics, Harvard
Medical School, Boston, Massachusetts (Fraiman);
Boston Medical Center, Department of Pediatrics,
Boston University School of Medicine, Boston,
Massachusetts (Cheston, Michelson, Sox);
Deparment of Biostatistics, Boston University
School of Public Health, Boston, Massachusetts
(Cabral); University of California, San Francisco
Benioff Children’s Hospital Oakland, Oakland
(Allen); Yale-New Haven Hospital, New Haven,
Connecticut (Asnes); Floating Hospital for Children–
Tufts Medical Center, Boston, Massachusetts
(Barrett); Division of Emergency Medicine,
Department of Pediatrics, Boston Children’s
Hospital, Boston, Massachusetts (Barrett);
Department of Pediatrics, The Children’s Hospital at
Montefiore, Bronx, New York (Barrett); Division of

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 Research Original Investigation
Neonatology, Department of Pediatrics, Seattle
Children’s Hospital, University of Washington,
Seattle (Batra); Department of Pediatrics, Saint
Peter’s University Hospital, New Brunswick, New
Jersey (Bernstein); Department of Pediatrics,
University of Florida, Gainesville (Bleeker);
Department of Pediatrics, Maine Medical Center,
Portland, Maine (Dietz); Department of Pediatrics,
Advocate Children’s Hospital, Park Ridge, Illinois
(Lewis); Department of Pediatrics, University of
California, Davis, Sacramento (Li); Pediatric
Cardiology, Loyola Medicine, Maywood, Illinois
(Ma); Division of Nephrology and Hypertension,
Department of Pediatrics, Nationwide Children’s,
Columbus, Ohio (Mahan); Division of Critical Care,
Department of Pediatrics, Cincinnati Children’s
Hospital, University of Cincinnati, Cincinnati, Ohio
(Poynter); Department of Pediatrics, University of
Massachusetts Medical School, Worcester (Vining);
Division of General Academic Pediatrics, Children’s
Hospital of Pittsburgh, Pittsburgh, Pennsylvania
(Watson).
Author Contributions: Drs Cabral and Sox had full
access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Concept and design: Fraiman, Cheston, Ma, Mahan,
Michelson, Poynter, Watson, Sox.
Acquisition, analysis, or interpretation of data:
Fraiman, Cheston, Cabral, Allen, Asnes, Barrett,
Batra, Bernstein, Bleeker, Dietz, Lewis, Li, Mahan,
Michelson, Poynter, Vining, Sox.
Drafting of the manuscript: Fraiman, Cheston,
Cabral, Bleeker, Poynter, Sox.
Critical revision of the manuscript for important
intellectual content: Cheston, Cabral, Allen, Asnes,
Barrett, Batra, Bernstein, Dietz, Lewis, Li, Ma,
Mahan, Michelson, Poynter, Vining, Watson, Sox.
Statistical analysis: Fraiman, Cabral, Sox.
Obtained funding: Fraiman, Sox.
Administrative, technical, or material support:
Fraiman, Cheston, Allen, Asnes, Bernstein, Bleeker,
Ma, Mahan, Michelson, Poynter, Vining,
Watson, Sox.
Supervision: Cheston, Allen, Bernstein,
Watson, Sox.
Other - implementation of the mindfulness course at
1 institution: Dietz.
Other - coordination and implementation of
curriculum at 1 site: Barrett.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported in
part by the Association of Pediatric Program
Directors’ Special Projects Program (Drs Fraiman
and Sox) and the Fred Lovejoy House-staff
Research and Education Fund at Boston Children’s
Hospital (Dr Fraiman). Dr Fraiman was supported by
grant T32HS000063 from the Agency for
Healthcare Research and Quality as part of the
Harvard-wide Pediatric Health Services Research
Fellowship Program.
Role of the Funder/Sponsor: The funding sources
had no role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Data Sharing Statement: See Supplement 3.
Additional Contributions: We acknowledge the
voluntary contributions made by faculty and
administrators at each site who facilitated
implementing the study activities.
372 JAMA Pediatrics April 2022 Volume 176, Number 4 (Reprinted)
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Effect of a Novel Mindfulness Curriculum on Burnout During Pediatric Internship
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