Medical education

Burnout prevention should be taught in residency

In many ways, the transition from resident to attending amplifies the bad behaviors that we learned in residency to cope with stress.

Editor’s note: This story was originally published by KevinMD.com and has been edited for The DO. It has been reposted here with permission. 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.

I was not at all prepared for my transition from being a resident to an attending. Now that there are work hour restrictions and constant oversight during training, graduating residents seldom get a preview of what it feels like to be at the top of the decision tree.

‘A very terrifying change’

I am an ob-gyn, so for me, this meant that I went from being on call with a handful of other residents and several attendings to being the only physician covering the obstetric and gynecologic patients. I am very lucky to be working in a supportive environment with plenty of people to call, but this was still a very terrifying change for me.

In many ways, the transition from resident to attending amplifies the bad behaviors that we learned in residency to cope with stress. I would respond to stress by eating chocolate, drinking wine and binge-watching reality TV.

I was told by my friends and colleagues that my feelings of inadequacy never really go away, but that I would get better at dealing with them. Not long into the start of my career, I was overwhelmed, anxious, and looking for a way out of medicine.

Increased responsibility, increased anxiety

The journey from medical student to attending is an interesting one. The things that we used to get excited about as students become the biggest burdens when we’re attendings.

I remember happily anticipating my first call shift as a third-year medical student. I was so excited to learn from all the ER admissions and getting to be more involved with patient care in the middle of the night. As an attending, I do not look forward to being on call, and pages from the ER are not something I particularly enjoy.

As our responsibility for the patients increases, our anxiety naturally follows. It would be beneficial to have a way to counteract that anxiety so that we can continue to enjoy our careers for at least as long as we trained for them.

The problem with residency

Burnout has become pervasive in health care. There are books, blogs, podcasts, and physician coaches all trying to decrease the rate of burnout. I can’t help but wonder if the solution for burnout, like that for so many other things, lies in the prevention of it altogether.

Residency is a stressful several years, and it includes poor sleep habits, eating at all hours of the day and night, limited time to exercise and downtime that often involves large amounts of alcohol. When faced with the anxiety of being an attending, we lean on our residency habits to help us through.

This leads to a deterioration in our health and our emotional well-being. It is a cycle that continues and often leads to physician burnout or to the abandonment of medical careers entirely.

Preparing residents to become attendings

It’s time to incorporate strategies to prevent physician burnout into residency programs. We need to teach our young physicians how to appropriately cope with stress. We need to be focusing on mindfulness and metacognition. We need to be preparing residents for life as attendings without sacrificing safety.

Medicine is not going to get easier. Insurance companies are not going to start reimbursing at a better rate. Electronic health records aren’t going anywhere and will never be perfect. It’s time that we take control of our own happiness and teach young physicians how to do the same.

Related reading:

Doctor burnout costs the US $4.6 billion annually, study finds

5 facets of physician burnout

8 comments

  1. I don’t disagree with teaching burnout prevention. I think that during residency is too late. As a burnout statistic myself (early retirement in the month I turned 60–the soonest I could do it) I speak from experience having taken multiple courses to try and prevent/manage burnout. I believe a physician’s specialty choice contributes to his/her burnout, so this issue should be addressed early in medical school, maybe even sooner as an undergraduate. All medical students should be given a Myers-Briggs Personality Inventory. This can be done during the Neuro/Psych training module. Students should understand their personality type as a contributing factor to how they “energize” and avoid the fatigue associated with burnout. An “introvert” will not do well seeing 20+ patients per day; an “intuitive” would have a more difficult time in the OR where practicality/details (“sending”) are the norm. So much of the literature is missing this aspect of burnout, either focusing on physicians already in practice, or discussing young physician’s regret that they chose medicine as a career. Need to go back before students pick their specialty to make sure it matches with their personality type.

    1. I agree with everything you said! The earlier that we can learn about our personalities and tendencies, the better equipped we are to managing them. There is certainly a lot of work to be done in this area.

  2. In a large recent survey on physician “burnout” physicians identified paperwork and bureaucratic tasks as the largest contributors to “burnout”. Interventions like mindfulness training and metacognition can be helpful in bolstering physician well-being but seem to have only modest effect on reducing “burn-out” over the long-term.
    The last paragraph of the article is somewhat fatalistic in stating that the systems that contribute most to physician “burnout” are unlikely to change and that physicians should “take control of our own happiness.” Physician “burnout” is not caused by lack of individual resiliency. With the years of sacrifice, delayed gratification, and grit that are required to complete medical training it is difficult to conceive of a more resilient group than physicians.

    The American Psychiatric Association Ad-hoc Workgroup on Well-being and Burnout suggest that “Burnout is best addressed as a systemic problem with systemic interventions directed at changes in the workplace. These interventions include those targeting workflow, autonomy, isolation, communication and teamwork.” Physicians do need to “take control of our own happiness” by challenging the institutions and systems that are impeding physicians from providing our patients with high quality care.

    1. Agree with you totally from beginning to end!!! I don’t agree with the article about victim-blaming or how to prepare the victim to take the abuse with pleasure, and encourage them to stay longer than in the abusive relationship, and then lie to future victims that “no this is not abuse and it’s normal to feel used, to feel disrespected, to feel incompetent”—even though in reality you’re the best among your college class, even though you’re the most optimistic, the most charming, the most outgoing person all your life prior to the abuse!!! Listen to the lies long enough and doctors will start to believe it. Facts: There is a way out, there are better options, there are other jobs or gigs, there are Direct Patient Care, there are many many ways to help society that don’t involve self sacrifice or burning at the stake, and that it’s ok to walk away AFTER you already set boundaries w the “partner” but he/she continued to be abusive to you. RUN away if they are killing you or you feel like dying; it is NOT your fault to feel helpless; it is because you are in too deep, or too close to the situation to realize you are used and abused and you are blamed for their greed!!!!!!!

  3. Don’t blame the victim and don’t tell the victim to be stronger or to accept/welcome the abuse and to continue to stay in the abusive relationship saying “just cope with it or prepare for it”! It is NOT right to prepare future wide-eyed-innocent victims with PTSD and self help books and sessions that would waste more of their precious time and energy!!!! Physician “burnout” is NOT caused by lack of individual resiliency nor because they are NOT good enough of strong enough for the rape/beating!!! The solution is for the previously-abused to stand up/speak up, speak out, and fight and expose the lies, and expose the EVILS of:
    bureaucracy that say “nurses NOT having to answer to doctors” and has the option to NOT do their job and dump work back on doctors; “doctors have to please and bow down to admin”; putting doctors at the bottom of the decision making tree in hospitals or in clinics; frivolous suing that should be severely punished (if found to be frivolous the family should pay for all the damages to doctors’ time and money and career retrospectively); insurance NOT paying for what deemed as a need by doctors yet vs “a want” by nonmedical businessman; customer-service mentality of medicine on employment contract instead of “do no harm” i.e. doing what is “unpopular” by saying “no” to patients’ demands of dangerous drugs and procedures, etc.

  4. Very well said. As a private practice internist I continually struggle to try to keep up with the expectations of my PHO, my ACO, each insurance company, the state licensing board, the AOA, the ACOI, CMEs, OCC (are you kidding), and all of the other carnival games. Even writing this and thinking about it somewhat burns me out.

    Staying late to help out a patient: fills me up

    Performing a peer to peer: burns me out

    Reviewing a case with a colleague: fills me up

    Printing out hundreds of pages from an electronic a chart for an insurance audit: burns me up

    Calling a patient that is admitted to the hospital: fills me up

    Not being able to perform rapid influence of testing and a Blue Care Network patient: burns me out

    Providing free care to a patient who lost their insurance: fills me up

    Filling out forms so that a patient can get shoes from their podiatrist: burns me out

    Opening up a spot in the day to get a new patient in: fills me up

    25 modifier: burns me out

    Seeing a patient outside of the office that appreciates our services: fills me up

  5. I appreciate the comments. Burnout is a difficult topic and certainly our experiences will shape our opinions of what causes burnout.

    There is no victim blaming intended in this article. I am referring to the several internal factors that put physicians at risk of burnout (imposter syndrome, lack of awareness of internal dialogue etc). This is in contrast to the external and systems factors that are causing physician burnout. Things like EHR, lack of control over schedules, wRVUs, and unacceptable demands from insurance companies certainly contribute (or are entirely responsible for) burnout for some physicians.

    My take home message here is that physicians are not taught anything about the power of our minds. Most of us know nothing about metacognition, visualization or confirmation bias. Many physicians struggle with Imposter Syndrome and some don’t even know what this is, except that they feel like a “fraud”.

    There is not a “one size fits all” solution for physician burnout. I simply suggest that we do better for our young physicians when it comes to preparing them for a long career in medicine.

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