The Relationship between Burnout and Sense of School Belonging among the Resident Physicians in the Standardization Training in China

ABSTRACT

Background

As an important part in medical training in graduate school, 33-month medical residency training could be a stressful period inducing burnout (i.e. emotional exhaustion, depersonalization, and low personal accomplishment). Despite that existing literature has found that sense of belonging may have merits for residents’ well-being, it has remained unclear how sense of school belonging affects burnout and the potential moderators. To address this question, a cross-sectional survey has been conducted among the residents of the physicians standardized residency training program in China.

Methods

Seven hundred (N = 700) resident physicians from different majors (i.e. clinical medicine, clinical Stomatology, and Chinese medicine) and grades have participated in the survey. Resident’s sense of school belonging was assessed with the psychological sense of school membership scale (PSSM, mean = 45.12, SD = 11.14). Burnout was measured by the 22-item Maslach Burnout Inventory (MBI-HSS, mean = 65.80, SD = 15.89), including three subscales of emotional exhaustion, depersonalization, and personal accomplishment.

Results

The results showed that over 80% of the residents reported moderate or high level of emotional exhaustion and reduced personal accomplishment during residency training. Meanwhile, higher level of sense of school belonging was associated with lower overall burnout (B = −0.722, p < 0.001), less emotional exhaustion, reduced depersonalization, and higher personal accomplishment. In particular, the benefits of sense of belonging seem more pronounced among female and those at earlier stage of residency. No interaction effect was found between sense of belonging and major, while those from Chinese medicine reported lower scores in overall burnout and the three dimensions.

Conclusions

Burnout was a prevalent issue among the resident physicians, and our findings confirmed the protective effects of sense of school belonging against burnout. Therefore, support service should be developed to cultivate resident’s sense of school belonging and social connections, particularly for female and those at earlier stage of residency.

KEYWORDS:

• Sense of school belonging
• burnout
• resident physicians
• vocational training
• graduate medical education

Introduction

The standardized residency training system has been launched in 2014 by the National Health Commission (NHC) in mainland, China, and was expected to be carried out nation-wide in 2020. The purpose of residency program with a duration of at least 33 months was to improve the quality of physician’s professional training [1]. According to the NHC, graduate students majored in any clinical programs, i.e., clinical medicine, clinical Stomatology, and Chinese medicine, are required to compete the standardized residency training of inpatient physicians as a part of the accredited program. The programs for three majors had no significant differences in graduate education settings (i.e., curriculum and residency training), and the residency training programs include four components: general clinical training, clinical training in specialties, supervised practice, and qualification assessment [2]. Different from the residency program in the U.S., most of Chinese trainees are newly enrolled graduate students who just completed 4- or 5-year of undergraduate study, and are usually younger, with little or no clinical experiences [3]. Therefore, although residency training was designed for the trainees to obtain knowledge and develop skills, they may experience significant difficulties and challenges in this period. Existing literature on the resident physicians in the U.S. reported increased psychological burnout [4] due to the heavy workload [5], sleep deprivation [6], and difficulties in work-study balance. A previous systematic review on burnout among Chinese medical students found that from 25.8% to 52.1% have reported moderate or severe burnout [7]. Therefore, it is pivotal to identify the protective factors that can buffer against psychological burnout. Although previous evidence showed that school climate is important in coping with resident’s burnout, how school belonging affects burnout among Chinese residents has remained unclear. By investigating the effects of sense of school belonging on burnout and the potential moderators, the current study would provide critical insights for better integrating residency training in graduate medical education programs.

Burnout was defined by Maslach (1993) as a continued psychological response to chronic interpersonal stressors related to work [8]. A meta-analysis found that, even before residency training, medical students’ burnout prevalence is about 44% [9], and resident physicians are facing higher risk, with a prevalence exceeding 50% [10]. Burnout was characterized by three dimensions, namely emotional exhaustion, depersonalization, and diminished personal accomplishment [11], and has become a major threat to the physical and mental health of healthcare professionals. Serious consequences of physician burnout were reported in the existing literature. Enduring burnout can lead to mental disorders such as depression or anxiety, decreased productivity and professionalism [12], more medical errors [13], career choice regret [14], and even suicidal ideation [15].

Burnout has been a well-recognized threat for mental health and well-being among resident physicians, and emerging evidences were found on the importance of social or contextual factors such as sense of school belonging that may prevent burnout. A recent study on Chinese medical students suggested that school climate plays a critical role in students’ burnout, by cultivating students’ psychological capitals such as self-esteem it may help preventing burnout [16]. For Chinese medical graduates, medical school is the most important social groups and micro-system for them. The sense of school belonging would be an important source for their connectedness. Sense of school belonging refers to “the subjective feeling of the extent to which the student is respected, included, and supported by others at school” [17,18]. Evidence from medical students showed that sense of belonging has significant impact on their specialty choice [19], and possibly improves overall well-being and academic motivation [20], as well as contributes to reduced depression and burnout [21]. Sense of belonging was also associated with resident’s retention and well-being in general surgery [22]. Although substantial evidence was found on the protective effects of sense of belonging among medical students, little research has focused on ‘school belonging’. Among non-medical students, greater school belonging was associated with improved academic outcomes, greater engagement, persistent and effect, and self-efficacy [23]. Evidence from preclinical medical students showed that with higher sense of school belonging they are more likely to have better academic accomplishment and low burnout [18].

To extend the existing findings on sense of school belonging and burnout among resident physicians, the current study has investigated the effect of school belonging on residents’ burnout and the moderating roles of sex, residency year, and clinical programs. The findings would provide critical insights for developing the graduate medical education in China, and shed lights on tailoring support service for the residency trainees.

Methods

Sample and study design

A cross-sectional survey has been conducted among medical graduates who are in the residency training program. Participants were recruited from three clinical programs, i.e., clinical medicine, clinical Stomatology, and Chinese medicine, and were distributed randomly to the 10 hospitals that were affiliated or cooperative institutions of the medical school (sample size in each hospital ranging from 10 to 600). In total, 1000 participants were invited by email or text messages, and the questionnaire were administered by the participants themselves. 701 responses were collected, after excluding 1 response with missing values, the data of 700 were included in the analysis.

Measurements

Burnout was measured by the Maslach Burnout Inventory- Human Services Survey (MBI-HSS). The MBI-HSS consisted of 22 items, which are from three dimensions of emotional exhaustion (9 items, e.g., “I feel emotionally drained from my work”), depersonalization (5 items, e.g., I have become more insensitive to people since I’ve been working”), and diminished personal accomplishment (8 items, e.g., “I fell I don’t have achievements at work”). The participants were asked to respond to each item on a 7-point Likert scale from 0 “never” to 7 “everyday”. The total scores of emotional exhaustion, depersonalization, and personal accomplishment were calculated. The Cronbach alpha of MBI-HSS in the current sample is 0.858, and 0.965, 0.928, 0.948 respectively of the three dimensions, suggesting good reliability of the questionnaire.

Sense of school belonging was measured using the Psychological Sense of School Membership scale (PSSM), which was frequently utilized to assess students’ sense of school membership. The original Chinese version of PSSM scale consists of 18 items [24], including 13 positive items assessing school belonging (e.g., “I feel like a real part of this school”), and 5 negative items assessing feeling of rejection. Participants were asked to respond with a 5-point Likert scale, ranging from 1 “never” to 5 “always”. The current study only adopted the subscale of school belonging, and the “school” here refers to the graduate medical school (instead of the hospital) where they complete curriculum, conduct research, and obtain degree. Higher score indicating a greater sense of school belonging. The Cronbach alpha in our sample was 0.968, suggesting good reliability.

Participants were also asked to provide demographic information such as sex, age, region of origin (mainland, Hong Kong/Macau, Taiwan, other region/countries), year of residency, resident hospital, and major (clinical medicine, clinical stomatology, and Chinese medicine).

Statistical analysis

Data analysis was performed using SPSS 25.0, T-test and one-way ANOVA were used to capture the group differences in burnout and sense of belonging. Linear regression was conducted to address the main effect of sense of school belonging on burnout and the interaction effects with sex, year of residency, and major. A significance level of 0.05 was used.

Results

A total of 700 participants’ responses were included in the analysis, and the majority (54.9%) were female. 78.6% Of the participants were from the program of clinical medicine and 42.0% were in the first year of residency. The mean score of burnout items was 65.80 (SD = 15.89), with the mean score of emotional exhaustion, depersonalization, and personal accomplishment being 28.36 (SD = 12.56), 9.07 (SD = 6.27), and 28.37 (SD = 8.80), respectively. According to the cutoff of burnout from previous literature on Chinese medical residents [25], in our sample, 50.3% of the participants showed high emotional exhaustion, with 35.5% scoring moderate level. 38.6% reported moderate depersonalization and 23.3% with high depersonalization. 21.6% and 62.6% of the participants showed moderate and high level of diminished personal accomplishment, respectively. Note that over 80% of the participants showed moderate/high level of emotional exhaustion or diminished personal accomplishment in our sample, suggesting a high prevalence of burnout.

With T-test and ANOVA to compare the participants across sex, major, and residency year, it was found that male had higher score in personal accomplishment. Compared with the participants from other majors, those majored in clinical medicine showed higher scores in overall burnout, emotional exhaustion, and depersonalization. Details of the descriptive results are presented in Table 1.

Table 1. Descriptive results of sense of school belonging and burnout (N = 700).

					Burnout
			Sense of school belonging		Total		Emotional exhaustion		Depersonalization		Personal accomplishment
Variables	n	%	$\bar{\mathrm{x}}$±s	p	$\bar{\mathrm{x}}$±s	p	$\bar{\mathrm{x}}$±s	p	$\bar{\mathrm{x}}$±s	p	$\bar{\mathrm{x}}$±s	p
Sex
Male	316	45.1	45.64 ± 12.59	p = 0.265	65.79 ± 17.18	p = 0.986	27.43 ± 13.02	p = 0.075	8.84 ± 6.66	p = 0.382	29.52 ± 9.51	p = 0.002
Female	384	54.9	44.70 ± 9.79		65.81 ± 14.77		29.13 ± 12.14		9.26 ± 5.92		27.43 ± 8.06
Major
Clinical medicine	550	78.6	45.21 ± 11.09	p = 0.393	66.69 ± 16.31	p = 0.017	29.19 ± 12.60	p = 0.004	9.43 ± 6.43	p = 0.013	28.07 ± 8.77	p = 0.211
Chinese medicine	91	13.0	43.86 ± 12.83		62.12 ± 14.34		25.16 ± 13.18		7.66 ± 5.96		29.30 ± 9.36
Clinical Stomatology	59	8.4	46.31 ± 8.54		63.22 ± 13.18		25.61 ± 10.00		7.85 ± 4.62		29.76 ± 8.09
Residency year
Year 1	294	42.0	45.29 ± 11.42	p = 0.395	66.30 ± 16.40	p = 0.303	29.18 ± 13.08	p = 0.107	9.35 ± 6.50	p = 0.540	27.77 ± 9.04	p = 0.305
Year 2	222	31.7	44.34 ± 10.59		66.43 ± 14.09		28.64 ± 11.55		8.98 ± 5.98		28.81 ± 8.50
Year 3	184	26.3	45.80 ± 11.34		64.25 ± 17.07		26.72 ± 12.81		8.72 ± 6.23		28.81 ± 8.75
Total	700	/	45.12 ± 11.14	/	65.80 ± 15.89	/	28.36 ± 12.56	/	9.07 ± 6.27	/	28.37 ± 8.80	/

Linear regression models were conducted to address the effect of sense of school belonging on burnout (see Table 2). After adjusting for sex, major, and year of residency, higher level of sense of school belonging was associated with lower overall burnout (B = −0.722, 95%CI= [−0.814,-0.631]), and consistent patterns were found in three dimensions. In particular, belonging was associated with lower emotional exhaustion (B = −0.690, 95%CI= [−0.756,-0.625]), lower depersonalization (B = −0.279, 95%CI= [−0.315,-0.242]), and higher personal accomplishment (B = 0.246, 95%CI= [0.191,0.302]). Interestingly, Chinese Medicine major were also found to have a protective effect across all dimensions of burnout, and females were found to report lower level of personal accomplishment (B = −1.988, 95%CI = [−3.232,-0.744]).

Table 2. Linear regression predicting burnout (N = 700).

Variables	Burnout_Total		Emotional exhaustion		Depersonalization		Personal accomplishment
	$\mathit{\beta }$	95%CI	$\mathit{\beta }$	95%CI	$\mathit{\beta }$	95%CI	$\mathit{\beta }$	95%CI
No interaction variable
(Constant)	98.988***	[93.270,104.706]	57.350***	[53.254,61.446]	21.525***	[19.257,23.793]	20.113***	[16.642,23.584]
Sex	−0.307	[−2.356,1.74ss1]	1.382	[−0.086,2.849]	0.299	[−0.514,1.112]	−1.988**	[−3.232,-0.744]
Residency year (Year 1)	1.554	[−0.967,4.075]	1.956*	[0.151,3.762]	0.434	[−0.566,1.434]	−0.837	[−2.367,0.693]
Residency year (Year 2)	0.552	[−2.140,3.245]	0.390	[−1.539,2.319]	−0.380	[−1.448,0.688]	0.542	[−1.093,2.177]
Major (Clinical Stomatology)	−2.647	[−6.332,1.038]	−3.020*	[−5.660,-0.380]	−1.355	[−2.817,0.107]	1.728	[−0.509,3.965]
Major (Chinese medicine)	−5.517***	[−8.584,-2.449]	−5.190***	[−7.387,-2.993]	−2.273***	[−3.489,-1.056]	1.946*	[0.084,3.808]
Sense of school belonging	−0.722***	[−0.814,-0.631]	−0.690***	[−0.756,-0.625]	−0.279***	[−0.315,-0.242]	0.246***	[0.191,0.302]

*p < 0.05; **p < 0.001; ***p < 0.001.

We further examined the interaction effects between burnout and sex, year of residency and major, respectively (see Table 3). The results showed that no significant interaction was found in predicting overall burnout. When regressing on emotional exhaustion, the main effects of sense of school belonging (B = −0.492, 95%CI = [−0.692,-0.293]) and sex (B = 7.656, 95%CI = [1.508,13.805]) were found, qualified by a significant interaction effect (B = −0.139, 95%CI = [−0.271,-0.007]). With simple effect analysis, it showed that among both male and female, sense of school belonging was associated with lower emotional exhaustion (for male: B= −0.492, p < 0.001; for female: B = −0.631, p < 0.001), and this was more pronounced among females (see Figure 1).

Figure 1. Simple effect analysis across sexes (N=700).

Table 3. Linear regression including moderators predicting burnout (N=700).

Variables	Burnout_Total		Emotional exhaustion		Depersonalization		Personal accomplishment
	$\mathit{\beta }$	95%CI	$\mathit{\beta }$	95%CI	$\mathit{\beta }$	95%CI	$\mathit{\beta }$	95%CI
Interaction variable: Sex
(Constant)	92.384***	[79.287,105.481]	48.501***	[39.139,57.962]	17.195***	[12.007,22.382]	26.689***	[18.750,34.628]
Residency year(Year 1)	1.426	[−1.104,3.957]	1.786	[−0.023,3.595]	0.351	[−0.652,1.353]	−0.710	[−2.244,0.824]
Residency year(Year 2)	0.463	[−2.234,3.160]	0.270	[−1.657,2.198]	−0.438	[−1.507,0.630]	0.631	[−1.004,2.266]
Major(Clinical Stomatology)	−2.712	[−6.398,0.974]	−3.107*	[−5.742,-0.472]	−1.398	[−2.858,0.062]	1.793	[−0.442,4.027]
Major(Chinese medicine)	−5.497***	[−8.564,-2.430]	−5.164***	[−7.357,-2.972]	−2.260***	[−3.475,-1.045]	1.927*	[0.068,3.786]
Sense of school belonging	−0.575***	[−0.854,-0.296]	−0.492***	[−0.692,-0.293]	−0.182**	[−0.292,-0.071]	0.099	[−0.070,0.268]
Sex	4.375	[−4.227,12.977]	7.656*	[1.508,13.805]	3.369	[−0.038,6.776]	−6.651*	[−11.865,-1.436]
Sense of school belonging*Sex	−0.104	[−0.289,0.081]	−0.139*	[−0.271,-0.007]	−0.068	[−0.141,0.005]	0.103	[−0.009,0.216]
Interaction variable: Residency year
(Constant)	100.413***	[91.682,109.144]	55.423***	[49.170,61.675]	19.730***	[16.274,23.185]	25.261***	[19.984,30.537]
Major(Clinical Stomatology)	−2.598	[−6.292,1.096]	−3.063*	[−5.708,-0.418]	−1.311	[−2.773,0.151]	1.776	[−0.457,4.008]
Major(Chinese medicine)	−5.547***	[−8.622,-2.471]	−5.171***	[−7.373,-2.968]	−2.328***	[−3.546,-1.111]	1.953*	[0.094,3.811]
Sex	−0.289	[−2.347,1.769]	1.349	[−0.125,2.822]	0.239	[−0.575,1.054]	−1.877**	[−3.121,-0.633]
Sense of school belonging	−0.754***	[−0.929,-0.579]	−0.647***	[−0.772,-0.522]	−0.237	[−0.307,-0.168]	0.130*	[0.024,0.23]
Residency year(Year 1)	0.477	[−10.015,10.968]	3.930	[−3.583,11.443]	4.105	[−0.047,8.257]	−7.559*	[−13.899,-1.218]
Residency year(Year 2)	−2.800	[−14.160,8.560]	4.199	[−3.936,12.333]	0.602	[−3.894,5.098]	−7.600*	[−14.465,-0.735]
Sense of school belonging*Residency year(Year 1)	0.023	[−0.200,0.247]	−0.043	[−0.203,0.117]	−0.081	[−0.169,0.008]	0.147*	[0.012,0.282]
Sense of school belonging*Residency year(Year 2)	0.075	[−0.170,0.319]	−0.084	[−0.260,0.091]	−0.021	[−0.118,0.076]	0.180*	[0.032,0.328]
Interaction variable: Major
(Constant)	100.388***	[94.276,106.499]	57.775***	[53.389,62.160]	22.082***	[19.657,24.507]	20.531***	[16.818,24.244]
Sex	−0.406	[−2.459,1.648]	1.367	[−0.106,2.841]	0.272	[−0.543,1.087]	−2.045	[−3.293,-0.798]
Residency year(Year 1)	1.643	[−0.879,4.164]	1.977*	[0.167,3.787]	0.464	[−0.537,1.465]	−0.798	[−2.331,0.734]
Residency year(Year 2)	0.485	[−2.210,3.180]	0.384	[−1.550,2.318]	−0.395	[−1.464,0.675]	0.496	[−1.142,2.133]
Sense of school belonging	−0.750***	[−0.854,-0.647]	−0.699***	[−0.773,-0.625]	−0.290***	[−0.331,-0.249]	0.239***	[0.176,0.302]
Major(Clinical Stomatology)	2.245	[−17.830,22.320]	−3.309	[−17.714,11.097]	−0.899	[−8.866,7.069]	6.452	[−5.744,18.649]
Major(Chinese medicine)	−13.929*	[−25.101,-2.758]	−7.425	[−15.441,0.592]	−5.351*	[−9.785,-0.917]	−1.154	[−7.941,5.634]
Sense of school belonging*Major(Clinical Stomatology)	−0.105	[−0.532,0.322]	0.006	[−0.300,0.313]	−0.010	[−0.179,0.160]	−0.102	[−0.361,0.157]
Sense of school belonging*Major(Chinese medicine)	0.191	[−0.053,0.434]	0.051	[−0.124,0.225]	0.070	[−0.027,0.166]	0.070	[−0.078,0.218]

*p < 0.05; **p < 0.001; ***p < 0.001.

Significant interaction effects were also found between sense of school belonging and residency year (Using the third year as the reference group, belonging * first year: B = 0.147, 95%CI= [0.012,0.282]; belonging * second year: B = 0.180, 95%CI= [0.032,0.328]) in predicting personal accomplishment. With simple effect analysis, it was found that the sense of school belonging was associated with high personal accomplishment across years of residency (for 1^st year: B = 0.274, p < 0.001; for 2^nd year: B = 0.310, p < 0.001; for 3^rd year: B = 0.124, p = 0.030), suggesting the effect was more salient in among 1^st year and 2^nd year residents (see Figure 2). No significant interaction effect was found between sense of school belonging and major when predicting burnout.

Figure 2. Simple effects analysis across residency years (N=700).

Discussion

The current study has revealed that psychological burnout, especially the emotional exhaustion and reduced personal accomplishment, is a prevalent and serious threat to the medical graduate’ wellbeing during residency training. Meanwhile, higher level of sense of school belonging may serve as a protective factor in reducing burnout. With moderation analysis, it was found that residents who are female and in the early years of residency could be benefited more from school belonging. The findings provided critical insights for developing support service to help medical graduates adapt better to the standardized residency training.

In line with the existing literature, our findings suggested that psychological burnout could be a prevalent issue among medical residents. In the previous review on Chinese medical students [7], the prevalence of burnout is approximately 50%, which was lower than the prevalence of burnout reported in the current study. According to Frajerman et al., (2019) [9], previous reviews on the burnout rate among medical students and residents usually found a broad range that could be due to the different versions of measurements and cutoff values. Therefore, it may not be appropriate to directly compare the prevalence across studies. Within the current study, it was also found that the prevalence of burnout is higher among those in clinical medicine and stomatology, which is probably related with the heavier workload in the specialties in western medical settings [26]. As mentioned in introduction, the three majors have no significant differences in graduate education programs, nevertheless, their professional training and knowledge could cast an impact on well-being. It is possible that students from Chinese medicine program, residents may adopt the skills inspired by traditional Chinese medicine to better cope with stress and maintain well-being, such as Qigong [27] and Chinese traditional massage [28]. The findings have provided insights for developing intervention programs for residents majored in clinical medicine and stomatology, such that stress coping training should be provided with adopting traditional Chinese medicine exercise. In addition, compared with males, females showed lower personal accomplishment and the effect of school belonging is more salient. In line with this, a previous study on pediatric residents [29] also found females are at higher risk of burnout. Another study on female endocrinologists reported that lacking personal accomplishment was associated with shorter sleep duration [30]. The findings suggested that more attention should be paid to female residents, with a closer look at lifestyle and psychosocial factors to tailor intervention strategies. At organizational level, positive feedback and recognition for personal achievement should be emphasized for female residents in organizational culture [31], to build personal accomplishment and reduce burnout.

Our findings also showed that sense of school belonging has a protective effect buffering against resident’s burnout. In mainland, China, since the residents have no clinical training or working experiences before entering residency, they may be more attached to the ‘student’ identity rather than ‘physician’ identity. Although they spend at least of 33 months on residency training, the support from their graduate school is still a critical source of psychological capital. Note that the benefit of school belonging is more salient among those in early years of residency, suggesting that early interventions may bring merits in preventing burnout in later stage. For example, emphasizing group identity and establishing social connection via campus orientations and student associations activities may have significant impact at early stage.

As more attention has been paid to well-being promotion in graduate medical education (GME), it is advocated that both environmentally focused intervention and the individual-focused intervention should be developed [32,33]. Our findings indicated that boosting resident’s sense of school belonging may be a starting point of both environmentally focused and individual focused interventions. Bronfenbrenner’s (1979) Ecological Model for Human Development could be viewed as a theoretical framework (micro-, meso-, exo-, and macro-systems) for developing school belonging [34]. For example, good relationships between students and the staffs, positive teaching and learning climate, and inclusive school culture were factors from different systems that could all be helpful for cultivating school belonging.

Strengths and limitations

The main strength of the current study is the extension of existing literature on describing medical graduate’s burnout during residency training, with clarifying the effect of and potential moderators in school belonging. By identifying the vulnerable residents for burnout, the current study has provided empirical evidence that enhancing school belonging could bring merits for resident’s well-being and reduce burnout, particularly for female, those at early stage of residency, and majored in clinical medicine and stomatology. However, a few limitations should be acknowledged as well. First, using convenient sampling method to recruit participants from a single city in mainland, China has reduced the generalizability of the findings. The residency training setting could be a critical factor affecting resident’s burnout [35], though the settings are standardized in mainland, other regions in Chinese society and overseas may have different situations. Cross-cultural research could be conducted to address the differences in diverse residency settings. Second, the cross-sectional design does not allow for tracking resident’s trajectory of burnout, and other contextual factors (e.g., the outburst of COVID-19) could also be a confounding factor in explaining the burnout differences between years of residency. Therefore, we plan to conduct a follow-up on the burnout and related psychosocial factors among the first- and second-year residents in their final year. Last, the present study has only captured the association between sense of school belonging and burnout, intervention studies are guaranteed to examine how to increase sense of belonging and reduce burnout effectively.

Conclusions

The current study has provided empirical evidence for advancing our understanding about the impact of the residency training program that has been implemented nation-wide since 2020. Burnout is a prevalent issue among the residents and effective interventions at institutional levels are necessary. Given that medical school is the most important social group and micro-system for the residents, building sense of school belonging in this period is the key to reduce burnout even when they are located at different hospitals. Theoretical frameworks and intervention strategies to enhance school belongings were discussed above. Policy makers, mentors at graduate school and staffs at hospitals should make joint efforts in cultivating residents’ social connections and sense of belonging in the 3-year residency training.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The work was supported by the -2022 Project of online course construction and teaching for national medical and pharmaceutical postgraduates [BYXC2022-02-0310]; 2020 Guangdong Province degree and graduate education reform project [2020JGXM012]; 2023 Jinan university ”Golden course” projects [JG2024065]; Jinan University’s 19th Batch of “Innovation Project” in Educational Technology.