Residency: Training for Burnout

Don’t talk to me about adjusting. I don’t want to become adjusted to a bad system.

-Paraphrase of remark by Barbara McAneny, President-Elect, AMA, 2017

There is much current hand-wringing about physician burnout. We now have task forces, committees, surveys, and learned articles. We don’t have Congressional investigations, but that’s coming, as sure as taxes. And yet, we all know the source of our frustration. It’s our toxic work environment. There’s only so much we can do to adapt to 12-minute clinic visits, excessive paperwork, intrusive oversight, and execrable technology. The word “execrable,” by the way, stems from the Latin word for “putting under a curse.” Right on.

But what about our residents? Those wonderful young folks, who are helping us today, and will be putting us out to pasture tomorrow? Are they going to bring fresh blood into the system, and re-invigorate American medicine? We’re training them to be our successors, to be sure. Are we training them to be our salvation?

Well, no. In fact, we aren’t even training them to tolerate the system we’ve got. Perhaps that’s why so many students and residents are all up for single-payer medicine. Compared with what they have to live with, even Canada looks better and better. Or so they think. But I digress.

Let us begin with students. There are at least four problems. First, medical school has always been high pressure. Tragically, my own medical school class had a suicide within two weeks. Medical students still kill themselves.¹ Second, medical students are high achievers, driven by their parents and themselves to succeed. Even small failures can be devastating. Third, we don’t let up. Grade point average. Three USMLE exams. Residency match. Abusive residents. Grumpy faculty. And fourth, money, money, money. The average student graduates with $200,000 debt. They’ve acquired a mortgage, but they don’t have a house to live in.

And then, they get to be residents. At least, they’re now doctors. OK, residency has always been challenging. But I recall vividly, looking back on my intern year and commenting that I’d rather do that for four years than be a medical student again. Remember, this was in the day of 110-hour weeks. It was still highly rewarding, no matter how much work it was. Since 2003, residents have been limited to 80-hour work weeks. With less frequent call! Still rewarding, but much more livable, eh? Well … sort of.

The 80-hour work week has indeed solved some problems. Residents have fewer nights on call, and get more sleep. Some of them even have a social life. Back in the day, there were programs in which residents were on call, at home, or in the hospital, all the time. Every other night was considered pretty reasonable. No longer. Even every third night call, although “legal,” will exceed the 80-hour limit. The most demanding surgical programs are every fourth night, with some exceptions. However, the lighter call schedule means fewer residents to cover the service each night. When a resident is on call, he or she works the whole night. Then, there is the dreaded hand-off. Residents not on call must leave their patients under someone else’s care. Handing patients off to another resident for the night or the weekend introduces its own stresses, on both physicians. Also, it affects patient care. In surgical programs, fewer nights on call may mean fewer operations and less experience. Residents often reach the end of the program feeling they need more training. Before the work hour limits, 25% of general surgery graduates took post-residency fellowships. Now, 75% do so.

Residents share the same sort of harassment that plagues all physicians. The electronic health record is still execrable (hey, when I find a good word, I use it). In multihospital programs, residents may have to learn three or four execrable EHRs (see?). Oversight is still intrusive. Residents have to limit their work hours, and they frequently have to do so by compromising patient care. Or else they just lie on their timesheets. Did I mention that? Yes, residents have to fill out timesheets. Every week. In detail. In some places, they have to “card” in and out of the hospital. Sounds like we’re telling them that they’re really factory workers.

Like a factory worker, a resident might be fired. From a faculty standpoint, it’s very hard to fire residents. But from a resident’s standpoint, the risk is always there. It’s a terrible threat, because the consequences are devastating. Even a 1% possibility is demoralizing and stressful.

And examinations. Everyone has to take yearly “in-training” examinations. These are supposed to be for “evaluation.” Except that if scores are too low, a resident may be kicked out of the program. All of this leads up to the very high-stakes Board exam(s) at the end of training. You thought exams were over with that M.D.? Think again.

Many residents take further fellowships. That means applications, interviews, competitive matches. Maybe moving the family to another city. That’s if the resident is foolish enough, or brave enough, to start a family. Consider. You’re $200 grand in debt, you’re working 80 hours a week, you’re making $10–$15 an hour, and your employment status is year-to-year. Who wouldn’t want to get married and start a family? Did you fall in love with another resident? Then the two of you can be $400 grand in debt when you start out! And remember, the interest accumulates.

Of course, residents are supposed to be “resilient.” Now, resilience is a very good quality in a healthy personality. The sort of individual who gets through college and medical school usually has that quality in spades. But even the stoutest rubber band will break if it’s stretched far enough. And we do a whole lot of stretching. If the resident seeks mental health services, will that affect their later career? Licensing? Employment? Better to tough it out.

Burnout among medical residents is not a terribly well-studied problem. There have been a few studies. A Dutch review from 2007 found 19 articles in the literature, of which five were of moderately good quality. The reported rate of burnout symptoms ranged from 18% to 82%.² In a 2002 survey of 415 American internal medicine residencies, Collier et al. found depression symptoms in 35% of residents, with indicators such as dehumanization and cynicism in still others.³ Goebert et al., in a study of residents and students at six centers, found depressive symptoms in 21% of residents.⁴ A French survey of general surgery residents published in 2017 indicated a 52% rate of burnout symptoms.⁵ Yes, burnout is a problem in Europe, as well as in the U.S. We can conclude that both medical and surgical residents are subject to burnout, perhaps about as much as physicians in general. Putting it more harshly, our training programs are failing to protect residents from burnout and depression.

There have been a fair number of articles from individual centers promoting this or that coping strategy. Most of these papers say their strategy works. Or appears to work. In general, if a program recognizes and tries to deal with the problem, the residents will benefit. However, there is little consensus on best practices. The truth is, if we don’t know how to manage burnout in practicing physicians, then we probably don’t know how to manage stress in residents.

We’re still training competent residents. We are not, as has been suggested, training future workers in the medical factory. But we are getting somewhat closer to that than we may find comfortable. One thing is certain. Our current medical students and residents will be the core of the profession in the next 10 to 15 years. The more we can keep them happy and mentally healthy, the better our profession will become. And right now, we’re not doing that very well. Among nearly all specialties, we need to begin a serious conversation on how we can stop burning out our residents even before they get into practice.

Biography

Charles W. Van Way, III, MD, FACS, FCCP, FCCM, MSMA member since 1989, Missouri/AMA Delegate, and Missouri Medicine Contributing Editor, is Emeritus Professor of Surgery, University of Missouri - Kansas City.

Contact: cvanway@kc.rr.com

Reprinted with permission, Kansas City Medicine.