Opinion Burnout and residency: Focus on growth at work instead of time off, DO writes Less work does not necessarily imply more life and does not necessarily create happiness. Nov. 19, 2018Monday Lisa Owens, DO Contact lowens Facebook Twitter LinkedIn Email Topics DO & student voices Editor’s note: This is an opinion piece; the views expressed are the author’s own and do not necessarily represent the views of The DO or the AOA. The No. 1 concern of today’s residents, both for their residency and first job, is work/life balance, primarily the issues of schedules and call hours, according to the Medscape 2018 Residents Lifestyle and Happiness Report. The inference from the survey is that resident physicians attribute their symptoms of burnout to the amount of time they are expected to be at work or on call. Yet there are no standard definitions of burnout and universal tools to measure it are also lacking. Residents face multiple challenges: bearing witness to people’s pain and suffering, delivering bad news and managing ethical questions, as well as a work schedule that can be unpredictable and physically difficult at times. Residency is a time of self-discovery However, residency is when you learn how to handle these challenges. It is a time of self-discovery, when the importance of community with colleagues develops. It is the last opportunity in a physician’s career for organized, structured learning with supervision and feedback. It’s where you learn to be a doctor. I entered the pediatric residency program at Baylor College of Medicine in 1990. This was pre-duty hour restriction and we worked a lot. We residents would, of course, have our “gripe sessions,” but we were all in it together and that seemed to lessen the load. In return for time spent at work, we saw everything. How a disease process started, the generation of a differential diagnosis, the middle and end of a course of illness, as well as an immense variety of diagnoses. We learned triage and prioritization, as well as how to manage distractions. We also interacted with families, nurses, consultants, attendings, and most importantly, one another. I completed a neonatology fellowship at Baylor College of Medicine in 1996. When I took my first job with a private practice in a mid-sized city, I realized how my residency experience–the excellent faculty members, large patient volumes and variety of diseases–was invaluable to my ability to practice medicine. After 20 years in private practice, I returned to Baylor as a faculty member. Residency is temporary As a resident, in the moment, you’ll likely find the long hours and patient care responsibilities daunting. But when you look back, you’ll see how much you grew and learned. Residency is replete with indispensible learning opportunities, which build a solid foundation of knowledge that benefits physicians for their entire careers. Only 12% of the Medscape survey responders said educational and professional growth opportunities would help them avoid burnout, which suggests that residency is no longer considered a time of great personal and professional growth, but a battle for time off. The search for the first post-graduate job fares no better. Again, the opportunity for professional development, a supportive organization and potential for advancement take a back seat to work hours and money. A sacred and special job Experts use the term work/life integration rather than balance because there cannot be an actual balance. Less work does not necessarily imply more life and does not necessarily create happiness. Things shown to improve job satisfaction include finding meaning in your work and working for organizations that are value-oriented, have adequate resources and promote autonomy. Whether you work 30 hours per week or 60 hours per week, if you feel powerless and your work holds no meaning, the time away from work may not compensate. Being a physician, being allowed into people’s lives in their greatest time of need, is a sacred and special job that comes with the opportunity to form profound human connections with both your patients and colleagues. Don’t lose sight of the unique position where medical training has placed you. Take advantage of all residency has to offer on your journey of medical training. After graduation, evaluate potential work positions in terms of engagement and meaning along with compensation and work hours. Further reading: What’s it really like to live like a resident? 5 facets of physician burnout Doctor burnout: Two brand-new JAMA studies raise more concerns More in Training 6 states in 12 months: A guide to life on the road during fourth year Fourth year is what you make it. Rachel Pray, OMS IV, shares how she embraced travel and adventure as much as possible during her fourth year. Being a DO in a heavily MD residency program: What surprised me I was incredibly nervous to join a large MD-dominant internal medicine residency, but I was pleasantly surprised by how much my osteopathic training helped me excel. Previous articleMed student leaders reach out to those in need in San Diego Next articleAOA past president receives a US senator's tribute
6 states in 12 months: A guide to life on the road during fourth year Fourth year is what you make it. Rachel Pray, OMS IV, shares how she embraced travel and adventure as much as possible during her fourth year.
Being a DO in a heavily MD residency program: What surprised me I was incredibly nervous to join a large MD-dominant internal medicine residency, but I was pleasantly surprised by how much my osteopathic training helped me excel.
I tell my residents, “You can ‘work for the man’ anywhere but, in the end you buy your lifestyle.” Each of us buys our lifestyle with a different currency-time, relationships, geography, patient care and administrative duties and money. the author is correct in the statement that a work-life balance is not truly achievable in human existence. however, we each must set priorities and constantly re-evaluate them in order to find the sweet spot that brings each of us joy. Unfortunately, we as physicians are being relegated to just another “provider” in this thing we call “healthcare”. Given the enormity of the present iteration of the delivery of healthcare in this country, we as physicians have almost no choice. We have allowed others to encroach on the historical areas of medicine, especially in the primary care specialties, because there is either too much work to do that does not directly involve patient care or the volume of patients that need to be seen is overwhelming. With a continued and rising predicted physician shortage, I believe that answer is not more physician extenders but more physicians. There needs to be a top down re-evaluation of how we teach, train and finance the education of our future physician colleagues. This at present appears to be a task for a skilled cat herder, what with all the different special interest groups to please. Gone are the days when we can “just take care of people.” I would love to be part of a return to those days, if possible. Nov. 29, 2018, at 8:20 am Reply
I wholeheartedly agree with the concepts of this article piece. I don’t think the sole focus of efforts to combat burnout should be reduced work hours only. I think reducing burnout would include promoting physician autonomy, physicians having a large say in their own healthcare ecosystem whether it is private practice (with colleagues, payors, etc) or in large healthcare systems or hospitals. I think physicians feel burnout in part, many times, because we feel like were being replaced with less trained people calling the shots. We’re being undercut from our profession. Nov. 29, 2018, at 8:30 am Reply
I think we need to focus on a number of issues to include the EHR, organizational supports, work-processes, autonomy, prior-authorizations, etc. Also, I think we have sufficient evidence that burnout is occurring. Physicians have the highest suicide rate (40/100,000) and physicians are leaving the profession which is creating a shortage. So, whether we have the best tools to measure burnout, is sort of a moot question. You’d have to be blind not to see it. That being said, we should continue to refine our measurement tools for burnout. Now, referring to work hours. Owens is recommending a “keep your head down,” approach coupled with a “make the best of it” approach. This continues the cycle of abuse. Also, I would define temporary as weeks to months, not years. Moreover, many people have multiple residencies and fellowships – so for some GME is a lifestyle. All of the benefits Owens cites from long work hours can also be experienced by working in staggered shifts (like night float) without requiring 24-hour shifts. 24-hour shifts have short and long-term health effects. Just because some physicians are workaholics doesn’t mean the rest of us should have to be their enablers. In fact, I think the conversation has to shift toward treating physicians who suffer from workaholism, who are clearly addicted, in denial and suffering from cognitive dissonance. “It’s the work hours, stupid,” would be an appropriate mantra. Nov. 29, 2018, at 12:22 pm Reply
Eric, My point was that a reduction in resident duty hours has not solved this problem. As in medicine, a correct diagnosis usually leads to the proper treatment, a better definition of burn out is needed before the solution can be found. Lisa Owens Dec. 22, 2018, at 12:48 pm Reply
No, I’m not using the descriptor [Human] to differentiate human vs. veterinary doctors but rather to indicate that I am first a human. I’m a living human being who happens to have pursued the physician profession. While this article presents a valuable perspective with several valid points, there is one glaring omission which is bothersome, intentional or not. There isn’t any mention of the proverbial “big elephant in the room” – the issue of physician suicides, which can be considered a public health crisis. More than 400 physicians end their life by suicide every year in the U.S. alone. Of course, we can’t have a genuine conversation about physician burnout without at least mentioning mental health, stress, or depression, right? Apparently, this issue wasn’t deemed important enough to mention by the author in this article. The article also implies that the issue of so-called burnout largely depends on a physician’s outlook, decisions, and actions. It fails to recognize the often toxic environment & attitudes that exist in medicine. Coincidence? Maybe. Stigma? Likely. Ignorance? I hope not. The status quo will remain until our profession and its leadership start prioritizing physician wellbeing, including mental health. To make meaningful changes, our profession must unequivocally recognize that physician burnout is not a personal flaw but largely driven by the broken culture in our healthcare & educational systems. “Physician experience” is integral to value-based care! Nov. 29, 2018, at 12:27 pm Reply
The sentiment of this article is right in the sense that a simple answer to burnout isn’t just more time off and, finding value in your work would help. However, unfortunately, many trainees lose sight of the value of their work when medical education frequently consists of pointing out errors, flaws, and inadequacies in one’s knowledge (ie pimping) despite many trainees working countless hours to learn his/her field. It’s impossible to feel appreciated by others, peers or superiors, and to be expected to maintain own self worth when you think you have worked hard just to feel belittled again. I think PART of the solution to resident burnout needs to be focused on altering the method of teaching and medical education to emphasize the growth of the trainee (as you have suggested) and highlight the strengths rather than pointing to the weaknesses. Pimping, as we all know, can be effective teaching and opportunity for growth, however nore likely than not it’s done in a derogatory manner. I think we would find a shift in trainee wellness even if just more faculty state appreciation for their trainees. Nov. 29, 2018, at 12:39 pm Reply
Satire. How many hours were spent charting in the old days? Residency has turned into 60-80 hours of charting; 10 hours chasing and waiting for social workers, PT, other ancillary staff; 10 hours of actual training, seeing patients, returning pages, talking to consult physicans, etc. Nov. 29, 2018, at 1:06 pm Reply
Funny to read of “burnout” in the same sentence as “residents”. Been at this with 30 years visible on the horizon. Old enough to remember when yes, we focused mainly on sick people, not old enough to retire, yet. The “B” word -Burnout- was never mentioned, let alone mentioned concerning residents. Doctors shuffled down the halls and didn’t look forward to retirement unless almost physically unable to practice. Now colleagues young and old can’t wait to find the “exit” with all the changes (hardships) thrust upon our shoulders. However, make no mistake, the constraints we find ourselves in are the very shackles we ourselves forged. For we, and those before us, allowed the feds and big business to pat us on the hand and say, “There, there, you just take care of your patients, let us worry about the messy rules and business for you.” Can you imagine lawyers allowing this? Any successful company allowing an outside unrelated entity to call the shots? There is a saying in Hollywood that goes something like, “It is the screenwriters who are the most valuable contributor, and they must never find out.” The only question is who will be the champion to lead us to bring medicine back to medicine? Nov. 29, 2018, at 5:13 pm Reply
You state reducing hours does not reduce burnout. Yet the Mayo clinic article you link to actually says exactly this: “Physicians are nearly twice as likely to be dissatisfied with work-life integration as US workers in other fields. This problem is likely, in part, explained by differences in work hours. Approximately 45% of physicians work more than 60 hours per week compared with less than 10% of US workers in other fields… Evidence suggests that reducing professional work hours can help individual physicians recover from burnout.” I think argument only holds true if you’re single and have no relationships outside of your job but I’d wager this does not apply to most people. Nov. 30, 2018, at 9:34 am Reply
DrProsaic, Thanks for your comments, but you are incorrect to assume that physicians are at the top of the hours scale. Attorney partnership tracks, stock brokers, CEOs, even realtors routinely have 100 hour weeks. “Burnout” is unique to physicians; other professions aren’t encountering these issues. Medicine needs to define burn out before a solution can be found. Dec. 22, 2018, at 12:44 pm Reply
Can you elaborate Oz? And what your background is? I dont think its tone deaf at all. Nov. 30, 2018, at 9:37 am Reply
More physicians feel burnout these days as compared to the past – in my opinion – despite no reduction in work hours or responsibilities (and possibly a decrease in work hours) – because nowadays were being replaced by less trained people, we have less autonomy, and we have less control with regard to work environments. Dec. 7, 2018, at 12:09 pm Reply
Med school is hard. That is pretty well known by the general public. If you aren’t up for hard work don’t go to medical school. Making medical easy because somebody isn’t up for the challenge is not the answer. Certain residencies are hard and long. If you are not up for this pick a specialty with easier training, there are plenty to choose from. Watering down the training is not the answer. Don’t want to work nights or take call? Just be honest with the groups you interview with before signing a contract. The workaholics will make more money, you will have more time. Mount Everest is very difficult and dangerous to climb. If you don’t want to commit to that nobody will judge. Nobody is going to build an escalator to the top either. When people accept life on life’s terms life is more doable. Dec. 20, 2018, at 9:04 am Reply
I was a resident in a malignant program for two years. I saw a lot of residents that could definitely be labeled as “burned out,” and I would count myself among them. I can tell you from my experience that work hours was not the only problem, but I can also tell you that the idea that we worked less hours than residents 20-30 years ago is ludicrous. Our time sheets may have regularly shown our work hours as less than 80 per week, but only because we were encouraged, and often intimidated, to falsify those time sheets. The culture of the program was that you should always be the first to arrive and the last to leave. If a resident was seen leaving the hospital by an attending (even well into the evening hours when hand-off to the night team had already occurred), that resident was shamed for weeks and passed over for opportunities. Because of this, the average real work hours per week was over 100 for myself and many of my colleagues. You aren’t getting the real picture from those surveys because residents are scared to speak out. Simply having a “rule” that work hours should be restricted is not enough. It is the culture that has to change. This article was written in the tone of that culture, which is why I think it has invoked such a strong response. To say that we should “find the good,” and “get through it” is ignoring all of the evidence of the situation. If that is the only answer we have, then we will continue to see rising levels of burnout and suicide. Dec. 20, 2018, at 9:44 am Reply