Tait Shanafelt, MD, program director of the Physician Well-Being program at Mayo Clinic, is here to answer your questions and provide tips on how to avoid burnout.
Let’s start with our first question.
Dr. Shanafelt, do most institutions have any safeguards against burnout?
Unfortunately, most institutions do not have effective safeguards. Although nearly all institutions have resources for those with distress who step forward and ask for help, few have effective measures to help physicians in training monitor their well-being (in anonymous way) and link them to early interventions to provide support before distress compounds. Few institutions have effective approaches to promote resilience and well-being. Many institutions have implemented some type of wellness program in response to the ACGME requirements. Although well intentioned, most of those that do exist are not evidence based.
So what can residents who are under distress do to seek help?
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First, it's important to recognize this is a common problem. Studies demonstrate that a majority of residents experience burnout at some point during their training. Accordingly, burnout is not a sign of weakness and does not imply a individual is "not cut out to be a physician". Those in distress should see help so that they can deal with distress before it gets worse. Most residency program offices provide resources for those in distress and that can be a good place to start. Sometimes resident are concerned that those resources are not confidential. If that is the case, you can contact the employee assistance program at your medical center which typically has resources to mental health and other confidential resources outside your medical center.
Providing confidential (as opposed to anonymous) support resources is critical. Providing at least some anonymous resources, however, does increase psychologic safety and may make it easier for residents to begin exploring what options to assist them are available.
You mention few institutions have effective measures to deal with burnout, even though it is extremely common. Why is this and what measures can/should be taken to address it? What are the barriers?
Recent national studies we conducted in collaboration with the AMA evaluating the prevalence of burnout among residents of all specialties found a burnout prevalence of ~60% (http://www.ncbi.nlm.nih.gov/pubmed/24290109). In a separate study in which we studied nearly all internal medicine residents in the U.S. (n>19,000), over half had symptoms of burnout with the highest rates during the intern year (http://www.ncbi.nlm.nih.gov/pubmed/21900135).
Residents, have any questions for Dr. Shanafelt? Feel free to submit them now.
We recently reported on an online initiative developed by the AMA called STEPS Forward designed specifically to curb burnout.
This is a good initiative by the AMA and provides some initial resources for residents to explore. Most residents with significant distress will need to follow-up with someone in person whether it be someone in their program office, at their medical center, or even a trusted family member or personal friend.
Many of these tasks are particularly difficult during residency because of the long work hours and the limited control residents have over their calendar. I think identifying one consistent activity outside of work that is just for you and making sure it happens every week is critical. When I was a resident, I had a standing “Sunday night BBQ” with 2-3 friends that occurred every week unless I was on call. The food, music, and fellowship were the respite in my week that helped me stay connected with my life and identify outside of medicine.
Should residents discuss burnout with their attending?
Residents should consider discussing burnout with someone within their training program who they trust. Most the time, this will not be their current attending. It is more likely to be their program director or someone within the residency office designated to be a support resource for residents. If a resident has an established relationship with faculty member or attending who they trust (but who is not evaluating them on a current rotation), that individual may be an appropriate individual to discuss things with.
Integrating personal and professional life is one of the biggest challenges for physicians and this challenge persists after the completion of training (http://www.ncbi.nlm.nih.gov/pubmed/22911330). This is partly driven by the high number of hours but by the fact that many physicians prioritize their professional responsibilities over their personal responsibilities. This often creates a circumstance where a physician trying to live up to personal responsibilities has to "swim against the current." Ultimately, there are not simple answers here. Progress is not made simply by "surviving until the completion of training" (http://www.ncbi.nlm.nih.gov/pubmed/25049326) Typically, progress is made when an individual identifies the conflicts between personal and professional and determines the trade-offs they need to make to meet the obligations that are most important to them. This always comes at a cost. Your time, talent and energy are limited resources. You cannot be the perfect parent and the world's best surgeon. Once you acknowledge that, you can begin to make the tough choices of what "excellent" (but not perfection) looks like in both spheres.
The best approach would be to first connect with that individual directly to ask how they are doing. Most training programs are small enough that people know each other well. A sincere inquiry from a colleague about how you are doing and providing support can be very helpful. Asking the colleague if they have taken advantage of the resources provided to them or if they have someone they can talk to about the challenges they are facing also is sometimes a helpful nudge that encourages them to get the help they need. I think the only time it is imperative you go to the program director without their permission is if you see a patient safety issue evolving. If a resident has an alcohol or substance issue (or is using those approaches to cope with their distress) or if their distress is so severe they are making mistakes, you then have a duty to protect the patients.
Good comment Ario. This relates to the meaning in work dimension which is one of the biggest driver of satisfaction/burnout among physicians. Most physicians went into medicine to be a healer, a teacher/educator, and/or an expert making discoveries that improve the care of patients. Increasingly, physicians feel that their connections with patients (which is a cornerstone of that meaning) are being lost/eroded. Many factors contribute to this -- clerical work, electronic health records, and electronic ordering. So called "team based care" can be a double edged sword depending on how it is implemented. In its best manifestations, it can relieve the physician of clerical burden and allow them to focus their time and energy on the aspects of care that require their expertise. In its worst manifestations, it destroys continuity of care the relationships physicians have with patients that are a key to satisfaction and are why many of us went into medicine. You cannot provide the best medical care to your patients if you don't have time to get to know them and how their individual circumstances an preferences influence what is the best decision for their care.
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The link for the AMA module on physician resiliency can be found below:
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Thanks for joining us today and thank you to Dr. Shanafelt for co-hosting with us.