To the Editor: 

We read with great interest the article by Johnson et al¹ in the March 2018 issue of The Journal of the American Osteopathic Association. The authors performed an observational study to examine the factors of the Medical Education Hassles Scale-R to identify subscales that would be useful to categorize hassles for research and assessment purposes. They identified 7 subscales: (1) Academic and Time Pressures, (2) Financial, (3) Social, (4) External Influences, (5) Day-to-Day Functioning, (6) Relationships With Immediate Family, and (7) Health. The authors should be congratulated for performing a well-designed study on an important topic (ie, well-being) in graduate medical education and physician practice.^2,3 The need to identify specific areas for intervention is an innovative concept that has not been appropriately explored.^4,5 

Although the study¹ was well conducted, some elements of the study need to be clarified by the authors. First, the assessment instrument used 101 individual questions, which represents a long length of participation that can induce response fatigue in participants. Current instruments evaluating burnout have been validated using only 2 questions.⁶ Second, the authors did not examine the degree to which program leadership contributes to burnout. It is possible that program leadership wellness and support can be protective to student burnout. Third, other factors leading to trainees’ burnout (eg, working hours, control over professional life) may also have affected the study results and need to be further explored. 

We would welcome some comments from Johnson et al¹ to address these issues and thus further substantiate the findings of this important study.