Response

We thank Castellini et al for a refreshing new perspective on the individual factors relating to burnout during psychiatric training. ^{Reference Castellini, Tarchi, Cassioli, Ricca, Abbate-Daga and Aguglia1} The authors soundly emphasise the importance of supportive supervision throughout psychiatric training to foster better well-being and career development for trainees. The narrow focus of this research, however, treads a fine line regarding the stigmatisation of burnout. Observing burnout from an internal lens risks creating a narrative wherein individuals are implied to be weak and unsuited to the demands of residency and can perhaps result in attribution of blame to said individuals. As such, we believe further discussion could have included external factors that have an even greater effect on burnout development, for example, workplace-related factors such as work demands and poor work environment, ^{Reference Zhou, Panagioti, Esmail, Agius, Van Tongeren and Bower2} and perhaps the impact of COVID-19. In the UK, we have evidence that the number of doctors at risk of burnout has doubled since pre-pandemic levels in 2019. ³

We also wonder what the impact of different working cultures and varied expectations of trainees of different grades and specialties might have on clinical supervision attendance and questionnaire completion. For example, a trainee in general medicine may face different daily expectations (e.g. participation in or leading ward rounds, independence in clinical decision-making and levels of risk), outcomes for progression in training (e.g. exam completion and portfolio requirements) or reported well-being and satisfaction with training, compared with another specialty. Further, differences in working environment and culture may influence responses to questioning on burnout. Perhaps those in specialties in which burnout is seen as an individual failure are less likely to report honestly on burnout symptoms.

Similarly, we consider that variations in working culture across countries could influence regional definitions of burnout. This may limit the wider applications of such work. Selection bias may be introduced, as those who pursue a career in psychiatry may already be more psychologically minded and reflective. There may also be attrition bias in that individuals from other specialties who complete the questionnaire may be at lower risk of burnout through having more time and mental headspace to do so. We also offer an alternative outlook on the impact of adverse childhood experience on emotional development. Early life stressors can foster greater resilience and reduce sensitivity to subsequent stressors in later life. ^{Reference Liu4}

Finally, it would be enlightening to understand the basic structure of Italian psychiatry training to support our interpretation of the results here in the UK. This may help us to better understand why there may be differences in burnout levels between years 1 and 2 of psychiatry training, if perhaps there are training requirements such as exams and/or portfolio tasks that are to be undertaken in these years.