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pants to self-identify as burned out, which qualified
them as experiencing burnout. Complete data were
not reported in one of the included studies (15) in
which the authors did not describe the total number
of physicians available to be surveyed; this report by
Kao et al. is a published abstract with minimal metho-
dological information (15). No other sources of bias
were identified. The overall study quality is low, due
to the survey methodology, small sample sizes, and
population-based assessment of burnout. Based on the
Cochrane Collaboration’s tool for assessing risk of bias
(14), all studies may be subject to detection bias, and 2
studies have a very high risk of reporting bias (12, 15).
Burnout prevalence
The prevalence of burnout in PM&R specialists was
reported in 3 studies (1, 2, 12); the weighted mean
prevalence of burnout amongst PM&R specialists was
51.6%. In a survey of physicians from multiple special-
ties, burnout amongst physiatrists increased from 48%
to 62% between 2012 and 2015, respectively, and was
consistently higher than the mean for physicians across
all specialties (1, 2). During this time, the prevalence of
burnout increased by 29% amongst PM&R specialists,
1.5 times the rate for all specialists. Out of 24 special-
ties, PM&R increased from 10 th highest prevalence of
burnout to 3 rd highest. Being a specialist in PM&R was
an independent predictor of having burnout (1). The
odds ratio for burnout in PM&R specialists compared
with primary care physicians was 1.6 (1). In a 2019
survey of 1,536 American board-certified physiatrists,
50.7% self-identified as being burned out based on the
Mini-Z Burnout Survey (12).
Amongst PM&R residents, Kao et al. found the pre-
valence of burnout ranged from 22.2% in new PGY4
residents to 83.3% in residents at the end of PGY2 in
their convenience sample of 53 residents and fellows
at one institution (15). The national survey of second-
year residents carried out by Dyrbye et al. found the
prevalence of burnout in PM&R residents to be 50.0%
based on 30 survey respondents (11). This was higher
than the mean for all residents (45.2%). The relative
risk for burnout in PM&R residents was 1.17 compared
with internal medicine residents (11).
Other measures of physician distress and wellness
Only one study (12) characterized factors that specia-
lists in PM&R felt contributed to burnout. It found
that increasing regulatory demands, workload and job
demands, and practice efficiency or lack of resources
were the causes physicians identified as contributing
to burnout. This was true for burned out PM&R spe-
cialists and those that did not meet the criteria for
www.medicaljournals.se/jrm
burnout. In this study, job satisfaction, stress, control
over workload, insufficient time for documentation,
and misalignment of values with departmental leaders
were significantly associated with burnout. No indi-
vidual factors, such as age, sex, or number of years in
clinical practice, were associated with burnout.
With respect to other measures of physician well-
being or distress, 3 studies (1, 2, 12) characterized
work-life balance satisfaction in PM&R specialists,
and 1 (11) characterized career choice regret amongst
resident physicians. PM&R specialists reported slight-
ly below-mean satisfaction with work-life balance in
2012, and slightly above-mean satisfaction with work
life balance in 2015, despite an overall decrease in
satisfaction and an above-mean rate of burnout in both
studies (1, 2). Residents in PM&R were more likely
to experience career choice regret (prevalence 16.7%)
than residents on average (prevalence 14.1%) (11); the
relative risk for career choice regret was 1.37 compared
with internal medicine residents (11). Two (1, 2) stu-
dies characterized risk factors for burnout in specialist
physicians and one (11) in second-year residents across
all specialties, but did not report PM&R-specific data.
DISCUSSION
Current evidence about burnout amongst physiatry
specialists and trainees is limited. The available data
consists of 5 studies examining 1,886 PM&R specia-
lists and trainees in an exclusively American context.
Given this narrow focus, the authors take a cautious
approach to generalizing these results to the field of
PM&R as a whole. However, physicians in PM&R
must not dismiss burnout based solely on limited evi-
dence; this limited data paints an alarming picture of
higher than average prevalence of burnout in PM&R
specialists and trainees. At present, there is no available
data to explain why physiatrists experience the third
highest rates of burnout amongst specialists and, as
such, comprehensive analysis is beyond the scope of
the present review. However, amongst all physicians,
system and institutional factors were identified as the
greatest contributors to the development of burnout
(12). It is possible that system factors, such as challen-
ges accessing affordable allied healthcare specialists,
such as physiotherapy, appropriate equipment, and
affordable accessible housing, may disproportionately
affect physiatrists. Alternatively, institutions may not
provide adequate access to administrative and allied
healthcare team supports. Although possible, it is
difficult for the authors to accept that such problems
are unique to specialists and trainees in physiatry.
The present study emphasizes the need for additional
research to understand whether high rates of burnout