The Mini Z Resident (Mini ReZ): Psychometric Assessment of a Brief Burnout Reduction Measure

The Mini Z is a psychometrically sound measure of worklife and wellness in practicing clinicians. Measures in residents address slightly different issues and are moderately longer, potentially limiting response rates. We adapted the Mini Z for use in residents (the Mini ReZ), using the Mini Z core 10 questions and 5 additional questions reflecting domains identified by Trockel. Validating the new variation on the Mini Z would provide program directors the means to assess well-being within their programs (in collaboration with their residents), and determine actionable steps for improvement. The objective of this report is to demonstrate the validation of the Mini ReZ.


INTRODUCTION
The Mini Z is a psychometrically sound measure of worklife and wellness in practicing clinicians. 1 Measures in residents address slightly different issues and are moderately longer, potentially limiting response rates. 2 We adapted the Mini Z for use in residents (the Mini ReZ), using the Mini Z core 10 questions and 5 additional questions reflecting domains identified by Trockel. 3 Validating the new variation on the Mini Z would provide program directors the means to assess well-being within their programs (in collaboration with their residents), and determine actionable steps for improvement. The objective of this report is to demonstrate the validation of the Mini ReZ.

METHODS
The American Medical Association (AMA) enrolled multiple US residencies in a worklife and wellness measurement program using a measure based on the Mini Z. The measure ( Fig.  1) was distributed via a data platform through the AMA and Forward Health Group (Madison, WI) with data collected within the data lab. The core questions #1-10 (adapted in part from the Physician Worklife Survey) 4 included satisfaction, stress, burnout, work control, chaos (work atmosphere), teamwork, values alignment, and electronic health record (EHR) challenges. A single-item 5-choice burnout measure, validated against emotional exhaustion in the Maslach Burnout Inventory, was scaled with the lower 3 choices representing "burnout." Five additional questions (#11-15) reflected domains from Trockel's work (interruptions, sleep impairment, support staff relationships, peer support, and program recognition). An intercorrelation matrix using Spearman's method focused on relationships with burnout and a job satisfaction question from the Physician Worklife Survey. 4 Correlations 0.35-0.69 represented modest to moderate correlations. 5 An initial (derivation) set of correlations was performed for a 2019-2020 sample in 1792 US residents in 13 programs, with confirmatory correlations performed in 1097 residents in 12 programs (validation sample) surveyed in 2020-2021. Linear regressions adjusting for gender and program year assessed potential contributors to burnout.

RESULTS
In the derivation sample, 43% of programs were in the Northeast, 25% Southeast, and 25% Midwest; 25% of respondents were PGY1's, 22% PGY2's, 30% PGY3's, 13% PGY4's, 5% PGY5's, and 17% were fellows. Fifty-one percent were female and 46% were male. Thirty-five percent were persons of color. The largest number of residents was in internal medicine (16%); other programs with high representation included surgery (12%) and obstetrics and gynecology (6%). Correlation data are shown in Tables 1 and 2. Program satisfaction was most strongly associated with values alignment (r 0.67), teamwork (0.55), department recognition (0.50), work control (0.49), peer support (0.43), and positive staff relationships (0.42, all p's < 0.0001). The burnout item provided good validation for the contributions of 4 of the 5 new single-item domains, including sleep impairment (r 0.54), program recognition (0.46), interruptions (0.43), and positive staff relationships (0.36, p's < 0.0001). The only new item not reaching a 0.35 correlation was peer support (r 0.29). As in prior studies, burnout correlated significantly and meaningfully with work conditions, including values alignment, teamwork, work control, chaos, and time pressure (r's 0.46-0.58). The validation sample showed comparable findings, with burnout related to most work conditions (values, teamwork, control, and chaos), and burnout and satisfaction both related to sleep impairment, department recognition, support staff relationships, peer support, and interruptions. Regressions

DISCUSSION
Understanding resident worklife and wellness is currently of profound importance. High burnout and low job satisfaction are associated with depression, absenteeism, changing programs, or adverse personal outcomes. 6 A brief mea-sure, completed in a few minutes, could be valuable for programs wishing to sample their residents' current state and build wellness-enhancing change together. These findings offer new insights into sources of job satisfaction for residents, including values alignment, teamwork, and recognition by their program, as well as validation of the importance of Mini Z work condition domains and 5 new items derived from well-tested surveys. Limitations include not having tested this against prior longer measures, a convenience sample of programs, and lack of information on the measure's clinical utility. Use of the Mini ReZ to 4=I am under stress, and don't always have as much energy as I did, but I don't feel burned out.
3=I am definitely burning out and have more than one symptom of 2=My symptoms of burnout won't go away 1=I feel completely burned out. I am at the point where I may need to seek help.  confirmed strong contributions of dissatisfaction, stress, sleep impairment, and lack of recognition to burnout (R squared = 60% of burnout variance explained).

Which number best describes the atmosphere in your work area (for the majority of the past month)? [Scoring: Responses 1-2 = chaos]
Busy, but reasonable Calm 1 2 3 4 5       Correlations greater than or equal to 0.35 and less than 0.50 are highlighted in orange; correlations greater than or equal to 0.50 are highlighted in red. All correlations had p values < 0.0001. EHR electronic health record