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Medical education and training
Original research
Burnout among medical residents in Haiti: a mixed-methods study
  1. Ludentz Dorcélus1,
  2. Vernet Etienne1,
  3. Emmanuel Mathieu1,
  4. Kesnel Dorestant2,
  5. Ornella Saintérant1
  1. 1Hôpital Universitaire de Mirebalais, Mirebalais, Haïti
  2. 2Hôpital Saint-Nicolas de Saint-Marc, Saint-Marc, Haïti
  1. Correspondence to Dr Ludentz Dorcélus; ldorc06{at}gmail.com

Abstract

Objectives To investigate the prevalence and risk factors associated with burnout among residents and to explain their experiences with burnout.

Design Mixed-methods convergent parallel study with an explanatory follow-up.

Settings One tertiary hospital in Mirebalais and one community hospital in Saint-Marc.

Participants Of the 127 registered residents in both settings, 26 were excluded because they were on leave. Therefore, 101 were asked to participate. We received responses from 98 residents (response rate 97.02%).

Interventions Data collection took part in two stages: quantitative data collection was first made over a 2-week period in July 2023 using a questionnaire which included the Maslach Burnout Inventory. We simultaneously conducted a qualitative analysis based on three questions around which stress factors were related to work, personal fulfilment and social issues in the questionnaire. Second, following preliminary data results, one focus group was held with the seven chief residents to bring an in-depth understanding of the quantitative data analysis from the study questionnaire.

Primary and secondary outcomes Sociodemographic and clinical factors linked to burnout for quantitative data. The themes explored for qualitative data were stress factors related to work, personal fulfilment and social issues. One focus group held with the chief residents explained, based on preliminary results, the main causes of burnout among medical residents, influencing factors, coping strategies and perspectives.

Results Five major findings emerged from the quantitative data, including the following: (a) burnout prevalence was 79.59%; (b) 43% of the residents estimated working more than 80 hours/week; (c) the group with the highest burnout rates were the second-year postgraduate residents (p=0.01); (d) paediatrics and family medicine residents had the highest mean score of emotional exhaustion (p=0.01); (e) general surgery/orthopaedics and paediatrics had the highest mean score of depersonalisation (p<0.01). For the qualitative data, five categories were linked to burnout: the residents’ quality of life, their feelings of ineffectiveness, their regrets for choosing to do residency in Haiti, the hospital’s admission policy and social factors.

Conclusions Burnout prevalence was significantly high. The medical education department needs to implement initiatives that improve patient healthcare, boost the residents’ morale and comply with accreditation standards. A cohort study or quality improvement project investigating the impact of interventions might also be suitable, or a study at different times of the academic year and in a less volatile period of time in Haiti might provide a more complete picture of the onset of this syndrome.

  • MEDICAL EDUCATION & TRAINING
  • Occupational Stress
  • OCCUPATIONAL & INDUSTRIAL MEDICINE

Data availability statement

Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available. Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2024-087847

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This was a mixed-methods convergent parallel study with an explanatory follow-up which was conducted in two teaching hospitals in Haiti: Mirebalais University Hospital and Saint-Nicolas Hospital.

    • For quantitative data, the study questionnaire included a validated tool considered as the gold standard method to evaluate burnout, the Maslach Burnout Inventory.

    • For qualitative data, the study questionnaire included three themes around which stress factors related to work, personal fulfilment and social issues were perceived to be linked to burnout, and one focus group was held with the residents to provide an in-depth understanding of the main causes of burnout among medical residents, influencing factors, coping strategies and perspectives.

    • Data collection occurred towards the end of the academic year.

    • Residents were exposed to the term burnout since their first year, potentially causing an information bias.

    Introduction

    No one is exempt from sources of stress in the workplace, resulting from the negative interaction between work conditions, performance demands and personal expectations, regardless of their professional occupation.1 In the medical field, residents typically face an exceptional period of stress during their learning process, exposing them to burnout.2 3 Understanding the scope of the problem of stress and burnout and its sources would help alleviate this syndrome and improve the residents’ experience in residency.

    Derived from the broader term stress, burnout is described as a syndrome caused by stress factors related to workload, working conditions, lack of social support, economic difficulties, handling difficult patients and other emotional concerns characterised by emotional, physical and mental fatigue.3–5 The concept of burnout has been well documented in the literature. With response rates varying from as low as 19.9%6 to as high as 94.7%,7 some studies, either cross-sectional or prospective, have approached the subject in one residency programme. In one study investigating burnout and specialty-choice regret in oncology residents, the burnout prevalence was found to be 44%.8 In another study, emergency medicine residents expressed an overall 65% rate of burnout, being higher among married residents. Poor work satisfaction and lack of autonomy were linked to burnout.9 A national prevalence study in the USA in 2017 revealed that 60% of general surgery residents experienced burnout.10 In Saudi Arabia, 70% of paediatrics residents experienced burnout.11 Other studies investigated the overall prevalence of burnout among many residency programmes in the same setting. A study conducted in Holland found lower degrees of burnout in general surgery and obstetrics-gynaecology residents.12 A national prospective study in the USA in 2018 surveyed 3588 residents with a 76.4% response rate and found 45.2% burnout levels and 14.1% career-choice regret. The specialties more statistically linked to burnout were urology, neurology and emergency medicine.13 Therefore, no definite pattern of burnout across residency programmes and its associated sources or factors has been established in the literature. This leads us to believe that burnout rates and causes vary according to the differences in residency programmes, and each institution should conduct its own evaluation to truly understand burnout within their residency programmes.

    There are seven teaching hospitals that support residency programmes across four cities in Haiti: Port-au-Prince, Mirebalais, Cap-Haïtien and Saint-Marc. Prior to the 2010 earthquake in Haiti, Zanmi Lasante engaged solely in providing healthcare services at their hospitals and clinics. Following the earthquake, Zanmi Lasante recognised critical issues that resulted from the earthquake: a loss of healthcare professionals and decreased quality and quantity of medical education options. As a result, Partners In Health/Zanmi Lasante responded to the national need for quality residency training and built a teaching hospital in Mirebalais, opening one residency programme at their hospital in Saint-Marc in 2012, followed by seven residency programmes in Mirebalais in 2013. In 2019, Mirebalais University Hospital obtained institutional accreditation from the international accreditation body ACGME-I and programme accreditation for its family medicine and internal medicine residency programmes in 2023. This significant step in standardising postgraduate medical education in Haiti requires intentional and regular monitoring of the balance between training, healthcare provision and residents’ well-being. This has been particularly difficult in the Haitian context, due to increased socio-political and economic instability, resulting in countless strikes in the tertiary hospitals in Port-au-Prince. Hospital closings have led to an influx of patients from Port-au-Prince coming to either Saint-Marc or Mirebalais for healthcare. Combined with the residents’ personal concerns about nationwide insecurity and how it impacts their daily lives and those of their family and friends, this situation increases the risk of burnout syndrome. The potential consequences could be significant: medical errors, misconduct, subpar learning, substance abuse, depression and suicidal ideation.14 15

    To our knowledge, no study has been conducted in Haiti about factors related to resident burnout symptoms and specialty-choice regret in Haiti. Hence, the objective of this study was to present the risk factors associated with burnout among residents at Zanmi Lasante and provide an explanation of their experiences with burnout.

    Methods

    Setting and participants

    This was a mixed-methods convergent parallel study with an explanatory follow-up which was conducted at Mirebalais University Hospital (Mirebalais, Haïti) and Saint-Nicolas Hospital (Saint-Marc, Haïti) over a period of 2 weeks in July 2023, during the 11th of 13 rotation blocks in the academic year.

    Inclusion/exclusion criteria

    All the residents were invited to participate, except those on medical or annual leave during the data collection period.

    Instruments

    Data collection took part in two stages. First, after obtaining signed consent, the residents completed the study questionnaire. For quantitative data, we were looking for basic demographic and academic data. Questions about the residents’ assessment of their interpersonal relationships, performance and specialty-choice regret, through a Likert scale, were asked. It also contained the Maslach Burnout Inventory (MBI) questionnaire, a 22-question survey to assess for burnout. It evaluates three parameters: emotional exhaustion, depersonalisation and personal accomplishment, each of which accounts for burnout severity through frequency of symptoms by a Likert scale. A license to use the MBI was purchased along with a French-translated version. We simultaneously collected qualitative data with three questions embedded in the study questionnaire. These questions, adapted from a previous study in Qatar,7 explored stress factors related to work, personal fulfilment and social issues that residents perceived to be linked to burnout. Respondents selected relevant stressors from a predefined checklist (providing quantitative data) and had the opportunity to elaborate on their selections in open-text responses (providing qualitative data). Second, following preliminary data results, one focus group was conducted with the seven chief residents (the orthopaedics programme was only 1 year old and therefore did not yet have a chief resident) by one of the investigators to give more insight on the key findings of our preliminary results. An interview guide (online supplemental file 1) was designed, and the session was audio-recorded for transcription and analysis. Chief residents were selected for the focus group due to their leadership roles and their unique position as intermediaries between programme directors and residents, providing valuable institutional and systemic insights into burnout.

    Outcomes measured

    The presence of burnout was identified in any resident whose MBI yielded a significant score for emotional exhaustion and/or depersonalisation, that is, an emotional exhaustion score ≥27 and/or a depersonalisation score ≥10.16 17 Psychometric analyses demonstrated that this score has high reliability and validity as a burnout evaluation tool, supporting its popular use.18 Additional analysis was conducted for variables of age, sex, marital status, parental status, postgraduate year level, specialty, number of working hours per week, lack of autonomy, workload, personal satisfaction, time to eat meals in a day and interpersonal relations. We also conducted a qualitative analysis based on open-ended questions from the questionnaire to bring an in-depth understanding of quantitative data analysis from the MBI. The themes explored were stress factors related to work, personal fulfilment and social issues. The key variables explored during the focus group discussion were as follows: the main causes of burnout among medical residents, the influencing factors, coping strategies and perspectives.

    Data analysis

    The analysis of quantitative data was conducted using Epi Info (version 7.2.2.6), a software developed by the Centers for Disease Control and Prevention (CDC, 2011; https://www.cdc.gov/epiinfo/). Quantitative data were expressed as mean±SD. Categorical variables were compared using χ2 square or Fisher’s exact test when appropriate, and quantitative data were analysed using t-test and Kruskal-Wallis. A p value<0.05 was considered statistically significant.

    For the qualitative component, stress factors related to work, personal fulfilment and social issues represented our principal themes. We adopted a constructivist paradigm. After data collection, we reviewed each of the residents’ responses in the questionnaire that helped us identify subthemes to construct our analytical framework. Our analytical framework was structured hierarchically into primary themes and secondary themes as specifications, aiming to break down the information into dimensions represented by categories. This allowed us to distinguish factual elements from interpretative elements, thereby minimising uncontrolled interpretations. Additionally, the qualitative data were processed through content analysis, ensuring that the information was analysed in adherence to the forms of verbatim expressions. These verbatim excerpts were categorised, while thematic analysis of the focus group provided validation of the verbatim, enabling a deeper understanding of its meaning. Finally, codes with similar meanings were grouped into the same category, further subdivided into subcategories and dimensions, to highlight the characteristics and significance of residents’ burnout experiences.

    Ethical considerations

    Zanmi Lasante’s Institutional Review Board approval, valid for 1 year, was obtained (application number: ZLIRB06052023) on 20 June 2023, and it declared this study in compliance with the highest ethical standards for human subject research. Since the participants were the residents, hence a vulnerable group in this study, the study questionnaire was anonymous. The informed consent form stated that mental health personnel were available to assist them should they feel the need. Participation in this study was not compensated.

    Patient and public involvement statement

    Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    Results

    The eight residency programmes for the academic year 2022–2023 contained 127 residents. The 26 residents on leave during the study period were excluded from participation, two refused to participate and one was off-site and unreachable. Therefore, our sample population was 98 residents out of 101 eligible with a response rate of 97.02%. The average age of the residents was 30.4 (±2.2) years. The majority of them, 80% (79/98), were single. Only 8.25% (8/98) reported having one child or more. Nearly 43% (43/98) of residents estimated working more than 80 hours per week. We identified 79.59% (79/98) of the residents expressing burnout (table 1).

    View this table:
    Table 1

    Demographic and clinical characteristics of the residents

    The main sources of stress for the residents related to work were patient overload (79.59%) and the work environment (60.2%). Those related to social issues were the country’s current situation (88.78%) and a lack of leisure (73.47%). Those related to well-being and personal fulfilment were the need for study time (79.59%) and concerns about achieving their goals (72.45%) (table 2).

    View this table:
    Table 2

    Sources of stress of the residents

    Specialties showing the highest mean emotional exhaustion scores, with a significant difference (p=0.01), were paediatrics 36 (±8.8), family medicine 34.6 (±9.4) and general surgery/orthopaedics 34.4 (±12.8). Mean depersonalisation scores were high in surgery/orthopaedics 12.1 (±5.5) and paediatrics 11.4 (±6.8) (p<0.01). No statistical difference was noted in mean personal accomplishment scores between the specialties (table 3).

    View this table:
    Table 3

    Mean (±SD) Maslach Burnout Inventory score variations by specialty

    Having fewer children on average was associated with the presence of burnout (p=0.01). Second- and third-year residents expressed more burnout, 95.9% and 82.9%, respectively (p=0.01). No statistically significant associations were found for age, sex, parental status, specialty and hours of work/week (table 4). Residents who felt overwhelmed, based on their level of residency, had more burnout (p=0.04). The degree of satisfaction with clinical or academic performance was associated with burnout (p=0.01). No statistically significant associations were found for lack of autonomy, relationship with peers/attendings, time to eat meals in a day and specialty-choice regret (table 5). Considering the sources of stress, the lack of leisure (p=0.01) and working hours (p=0.02) were linked to burnout.

    View this table:
    Table 4

    Bivariate analysis on demographic and clinical characteristics of the residents

    View this table:
    Table 5

    Bivariate analysis on the residents’ assessment on their interpersonal relationships, performance and specialty-choice regret

    For the qualitative component of our study, we conducted a thematic analysis based on the open-ended answers by the residents expressing burnout, which was further confirmed in the focus group. Five major burnout-impacted categories were found from the data: their quality of life, the hospital’s admission policy, feelings of ineffectiveness, regrets for choosing to do a residency in Haiti and social factors.

    The quality of life at the medical residents’ house is linked to a lack of basic services, self-care activities and commodities. Work overload emerged as a fundamental factor that exerted the greatest influence on burnout among residents. The physical and mental dimensions of overworking extended to the point of impacting a decline in academic performance, as expressed by residents when one asserted, “Work overload affects us physically, and the academic demands that cannot be met affect us mentally.” Underlying an excessive influx of hospital visits per day, characterised by ‘an extreme quantity of patients’, work overload was also a corollary that generated a challenging work environment that even became threatening when patients and caregivers became impatient in seeking service. This situation was stressful and insecure for the residents, and they felt compelled to act, especially when, as one resident stated, “… We receive threats and too many patients and parents at the same time. Sometimes we are forced to act as security guards when the ward is overcrowded…”

    Due to a challenging work environment, the residents were left conflicted with a perceived inefficiency. Feeling neglected and lamenting the lack of favourable responses from superiors to their concerns, they believed that “…our superiors do not pay enough attention to these problems.” Furthermore, work overload significantly impacted the protected time for residents to engage in medical knowledge, research and self-care activities, resulting in delays in meeting their academic requirements: “Stress is related to a lack of personal time to catch up with our studies.”

    Residents felt pressured and overwhelmed. Their inability to react created a constant sense of frustration, leading to low self-esteem. In their quest for personal answers, residents questioned this constant exposure to stress in relation to the institution’s policy of not turning away patients, even when the hospital’s capacity is exceeded. They suggested that “The hospital’s policy of not refusing patients, even when the hospital’s capacity is exceeded and the conditions are not ideal, and the demand for productivity from attendings bring constant pressure and frustrations.” Residents felt that patients and their families held them personally responsible for poor service. While they were expected to provide quality work, constant physical and psychological pressure took its toll. A sense of guilt was felt, with a recurring feeling of inefficiency due to tasks left incomplete. They reached the point that “I feel like I'm doing something useful, but sometimes, with the various limitations, it’s the opposite. I feel like I’m not up to it.”

    Although the residents had developed a coping mechanism by anticipating the end of residency, the residents questioned their very choice to engage in a residency programme in Haiti. The residents felt “blamed for everything. I'm constantly disrespected, and I can't react.” This was strongly expressed by the statement: “I’m literally imploding …” Factors influencing burnout were not, however, solely related to work overload. They were also strongly connected to the overall insecurity in the country: kidnappings, the impossibility of travelling and the residents’ reduced ability to see their families. Residents were thus filled with worry about their future after residency, believing that “The country’s situation troubles me, and I constantly wonder if I made the right choice by specialising in the country.”

    The residents reported typical burnout factors, including work overload, a stressful and threatening work environment in the context of fragile interpersonal and professional relationships and, above all, a deteriorating situation in the country. Burnout is a familiar term to them. “The risk of developing burnout varies depending on the residents’ ability to manage stress. Residency is not easy anywhere.” They expressed a worrisome lack of confidence in the system’s ability to address these problems to the extent that they conceal their burnout. They felt that the process of complaint management was not well-defined. Unsurprisingly, residents feared that reporting burnout could result in a formal diagnosis of burnout, “There is, therefore, a fear of diagnosis among us, so we just want to finish (the residency program) as quickly as possible…”

    Discussion

    The specialties showing the highest rates of burnout were paediatrics, general surgery/orthopaedics and internal medicine. When analysing the three parameters of the MBI, all specialties showed significantly elevated average scores of emotional exhaustion except for anaesthesiology. Average scores of depersonalisation were significantly higher in surgery/orthopaedics and paediatrics, but average scores of personal accomplishment did not show statistical differences.

    According to this study published in Kenya,19 female residents had a higher risk of burnout than males, which contrasts with our findings where no significant gender difference was observed. One possible explanation for gender differences in burnout risk is the greater work-life conflict among female healthcare workers due to childcare responsibilities. As shown in this study in Pakistan,20 burnout had a more significant impact on residents with children, potentially due to the increased emotional investment and empathy required for both professional and parental roles. Parent residents are less cynical and more empathetic, showing fewer depressive symptoms and greater life satisfaction. However, it is unclear whether resident parents tend to show more empathy or if empathetic residents tend to have more children.21

    Age was another variable not linked to burnout based on our results and those of this study published in Iran,22 but this study suggested that younger residents may benefit from greater adaptability in managing burnout.23 No specialty stood out as particularly prone to inducing burnout, as the responses varied across studies. However, surgical specialties tended to be more recurrently associated with burnout, with surgery and obstetrics-gynaecology leading in some studies,24 25 along with urology.13 Though this was not the focus of our study, it would be interesting to stratify how work environment or workload affects residents in different programmes.

    Marital status did not play a role in the occurrence of burnout in our study. Being married can provide a source of support for a resident,26 while a single resident may be more focused and dedicated to their work.27 Second- and third-year residents were found to have significantly higher rates of burnout. First-year residents typically work under supervision most of the time, and fourth- or fifth-year residents are often called on to mentor younger ones, which could explain our results. For 3-year programmes, third-year residents are likely burdened by increasing workload demands. Our focus group discussions emphasised that each level of residency comes with its own stressors, and they cumulate after each academic year. Nonetheless, it is worth remembering that our focus group exclusively included only senior residents. Other studies have shown a link between burnout and junior residents, implicating a lack of mentorship or the use of coping strategies.21

    Our study did not confirm a link between the number of working hours and burnout, and this relationship is not consistently found in the literature.22 However, the feeling of being overwhelmed did show a link. Some studies found that strict regulation of working hours did not guarantee an improvement in burnout symptoms,28 29 especially as it could lead to suboptimal learning quality or prolonged formative time.30 In our case and as per the definition of burnout, burnout appeared to be more related to workload and working conditions than the actual number of hours. Long working hours, working conditions and ineffective hospital systems were also found to be linked to burnout.19

    Our qualitative data showed that the residents felt targeted by the patients and their supervisors due to the high demand of productivity in an overcrowded setting. The lack of understanding they feel, coupled with a perceived unclear pathway for burnout management, contributed to their stress. Based on our data, the overall state of insecurity in the country most likely is the main culprit. This aligns with the findings in these two studies in Libya31 and Lebanon32 where the COVID-19 pandemic increased burnout levels in healthcare workers. This cross-sectional exploratory study in Ukraine showed that continuous traumatic stress led to moral distress and impacted various aspects of professional quality of life.33 According to the Pan American Health Organization, as of November 2024, only 41% of healthcare facilities in Port-au-Prince were fully functional,34 severely limiting access to healthcare in the population. This leads to overcrowding in the remaining functional institutions, even in Haiti’s neighbour country, which has seen a surge of Haitian women seeking perinatal care.35 Coupled with pre-existing institutional problems highlighted by the residents, it is likely that the problems leading to burnout are interconnected.

    In a study published on burnout evaluation in oncology residents,8 burnout was statistically linked to specialty regret and the desire to leave medicine, citing reasons such as the number of deaths and the feeling of being fallible. In our study, most residents were satisfied with their specialty choice, although they expressed feelings of academic or clinical inefficiency and a lack of autonomy. These deficiencies were correlated with burnout9 and could even lead to negative behaviours regarding the quality of care.36 Burnout symptoms have been found to correlate with specialty regret,13 and our study found the same. The desire to pursue postgraduate studies existed, but it was difficult for our residents to envision the future of their careers within Haiti due to the current environment, further reinforcing the impact of external factors on burnout.

    Based on our qualitative data, we can identify certain consequences to this syndrome. As highlighted by the residents describing their working environment as threatful and fearing an uncertain future in a troubled Haiti, physician emigration (‘brain drain’) is inevitable.37 There is a negative relationship with hope for a future with social and financial stability and academic burnout levels in medical students.38 Finding how burnout objectively affected academic performances was beyond the scope of our article, but many residents significantly were not satisfied with their academic performance, due to time restraints and physical and/or emotional fatigue. One cross-sectional study showed that there is a positive correlation between burnout, impostor syndrome and low self-esteem, despite not directly impacting academic performance.39 Furthermore, residents’ lack of trust in the healthcare system exacerbated their burnout. It has been reported in a survey that 81% of junior doctors in Australia40 feared personal repercussions for reporting incidents like bullying, discrimination and harassment due to lack of confidence in institutional protections.

    The cross-sectional, site-bound nature of this study provided a snapshot of the problem at a specific and unique time and place in Haiti. Therefore, this study cannot be generalised to other teaching hospitals in Haiti nor conditions in the future. Burnout, while ubiquitous, varies from person to person, influenced by their values, experiences and work environment. It can be argued that the socio-political context at the time of data collection favoured the occurrence of burnout syndrome, suggesting a time-bound bias. Residents were exposed to the term burnout since their first year, potentially causing an information bias. No methods to control confounding factors were considered. However, since burnout has a subjective expression, we believe that a mixed-methods approach using a combination of a validated survey tool and focus groups was the most appropriate way to address it in a study. A cohort study or quality improvement project investigating the impact of interventions might also be suitable, or a study at different times of the academic year and in a less volatile period of time in Haiti might provide a more complete picture of the onset of this syndrome.

    Conclusion

    The prevalence of burnout within this academic institution was found to be significant. Burnout was not only related to internal institutional issues but also to the overall socio-political situation in the country. Qualitative data explained that the factors related to burnout could be interconnected and complex. Given these findings, it is evident that burnout determinants in one setting cannot be extrapolated to others. To mitigate burnout, medical education leadership must implement targeted interventions, including the establishment of wellness committees, stricter workload regulations, enhanced staff training on burnout recognition, structured pathways for burnout management and regular meetings with residents to address stress-related concerns. Future studies should assess the impact of these interventions through quality improvement projects or cohort studies conducted across different time periods and hospital settings. By addressing both institutional and systemic issues, it may be possible to improve residents’ well-being and, ultimately, patient care outcomes.

    Data availability statement

    Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available. Data are available upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants. Zanmi Lasante’s Institutional Review Board (IRB) approval was obtained (application number: ZLIRB06052023) on 20 June 2023. Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    We extend our heartfelt appreciation to Ingrid Moïse, Alexandre Emmanuel and Mary Clisbee for their invaluable contributions. We also acknowledge the support and cooperation of the various programme directors who gave the medical residents free time to participate.

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    Footnotes

    • Contributors LD is the principal investigator and made substantial contributions to the concept of the manuscript, quantitative data analysis, drafting and final approval of the manuscript and agreed to be accountable for all aspects of the manuscript. VE is the co-principal investigator and made substantial contributions to the concept of the manuscript, qualitative data analysis, drafting and final approval of the manuscript and agreed to be accountable for all aspects of the manuscript. EM is the co-investigator and made substantial contributions to the concept of the manuscript, qualitative data analysis and interpretation, drafting and final approval of the manuscript and agreed to be accountable for all aspects of the manuscript. KD is the co-investigator and made substantial contributions to the concept of the manuscript, drafting and final approval of the manuscript and agreed to be accountable for all aspects of the manuscript. OS is the co-investigator and also serves as the senior author and made substantial contributions to the concept of the manuscript, drafting and final approval of the manuscript and agreed to be accountable for all aspects of the manuscript. The guarantor is LD. Non-author contributors are Ingrid Moïse and Alexandre Emmanuel who have participated in data collection and Mary Clisbee who has made contributions to the writing style and revising the final manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.