Post-apocalyptic portrayals of medical school. Depressive symptoms in 43.2 percent of resident physicians. 34.1 percent of medical students experience burnout by third year, and that percentage increases during residency, ranging from 41 percent to 74 percent by specialty.
We lose hundreds of doctors each year to suicide, at a rate that is twice as high as the national average. Burnout increases the risk that a physician will make a mistake, which is a risk we cannot afford in an industry that already harms 1.5 million patients with medication errors every year. In order to eradicate the burnout epidemic facing the health care profession, three urgent needs must be met: root-cause oriented research, evidence-based interventions, and physician buy-in to the seriousness of this issue.
Many studies have demonstrated that large numbers of residents and medical students experience burnout. We should now go beyond tallying numbers and instead delve into the underlying reasons that cause burnout in health care professionals. 20 years ago, researchers identified six factors that affect burnout: workload, individual agency, adequate reward for work, community spirit, fairness, and personal values aligning with workplace values.
Medical education researchers should build upon this pre-existing burnout research to understand how those factors manifest themselves in the health care setting. As a part of this effort, there should also be more interdisciplinary research teams investigating the causes and solutions for this epidemic. As medical professionals who are not trained in social psychology, we should draw upon the knowledge that other disciplines have to offer. By pooling resources and sharing expertise, we will be able to find real solutions to the problem of burnout.
In addition to interdisciplinary research, any interventions for burnout should be based on scholarly evidence. Decades of literature indicate that burnout is primarily caused by social and organizational influences. So why then, do we continue to propose interventions that target individuals only? Programs that teach residents coping skills and stress management techniques are not enough to prevent burnout.
Instead, our goal should also be to change the environment in which medical students and residents are taught. Residency and medical school should not be a walk in the park, but the stress that students feel should challenge and motivate them, rather than induce exhaustion and depression. The ACGME’s Clinical Learning Environment Review (CLER) already assesses fatigue and burnout management practices at institutions. They should take this one step further, and include in their rubric whether institutions are addressing the fundamental, structural causes of burnout. Although CLER site visits are too transient to participate in drafting new policy or implementing structural reform, they provide longitudinal, independent oversight that may be necessary to solve the problem of burnout.
Physician buy-in is absolutely necessary to change the culture of burnout in health care. Solving burnout would be challenging without administrative support, but impossible without physicians and nurses on board. An intransigent hospital CEO could slow down any proposed reforms, but committed physicians and nurses would still be able to implement smaller-scale reforms in their own departments.
If, however, orders came down from above that health care providers did not support, one can imagine those providers following the letter of the law while maintaining a social environment that ran counter to the intended reforms. Although this situation is unlikely to occur, there are still far too many voices in the literature and the media questioning the severity of burnout and arguing that this generation of doctors is “softer” than its forebears. In order to promote physician backing of residency and workplace structural reform, national medical organizations should take the lead in expanding awareness of burnout. The AMA is already at the forefront of this initiative by offering CME credits for completing online educational modules.
Finally, we should carefully watch institutions that have implemented reforms and learn from their challenges and successes. Stanford has introduced several initiatives to strengthen the sense of community among its surgical residents, as well as a time-banking program to help ED physicians manage their lives outside of medicine.
Vanderbilt has created a student wellness program that offers numerous opportunities for students to escape from the oftentimes overwhelming environment of medical school.
The Mayo Clinic has incorporated the humanities into the fundamental structure of their curriculum in order to address fatigue and low motivation among its residents.
Each of these reforms are specific to a unique curriculum and workflow, but the lessons learned in realizing them may be abstracted to many different institutions. Departure from the status quo is never comfortable, but the structure of medical education must change if we want to decrease burnout and its tragic consequences.
Tyler Cooke is a medical student.
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