Most physicians recall the rigors of their residency training through a mixed lens. In prior generations, a single-duty shift could stretch to 36 or more consecutive hours, but the exhaustion was buoyed by the camaraderie of sleepless on-call nights in the hospital. Despite the exhaustion, resident well-being received scant attention. Beginning with the 1984 Libby Zion case, and later the Accreditation Council on Graduate Medical Education (ACGME) duty hour restrictions in 2003, resident work hours are under increased scrutiny. Despite the recent limitations in work hours, rates of resident burnout have not decreased.
The explanation for this contradiction is likely multifactorial. Many of the same factors that influence attending physician burnout (such as third-party regulations, financial pressures, loss of autonomy, and the electronic medical record) may also be affecting our residents. But perhaps other factors are in play as well. Based on published work in the social sciences, it is plausible that the very regulations that were instituted to “protect” the resident physician are, in fact, having the unintended consequence of contributing to burnout.
To better understand the inverse relationship between burnout and work hours, it is helpful to understand the current state of GME training. One concern expressed is that residents no longer take “ownership” of their patients. How then do we instill that responsibility of patient ownership into our current trainees? Assume for a moment that we can condense this challenge into a mathematical equation:
Autonomous decision making + Continuity of care = patient ownership
If a resident makes patient care decisions and then follows the patient’s clinical course to see the outcomes of those decisions, it would follow that the resident would feel a strong connection with that episode of clinical care. In other words, they would feel ownership of the clinical outcome. To further extrapolate, taking more responsibility for patient care will lead to the fulfillment of a sense of purpose.
Patient ownership = Purpose
Repetition in training is important. Although it may be difficult for a resident to attain the “10,000 hours” of deliberate practice required to attain mastery over the course of a residency, repeated clinical experiences will lead a learner further along the pathway to mastery.
Purpose x 10n = Mastery
So, in summary:
Autonomy + Continuity = Ownership
Ownership = Purpose
Purpose x 10n = Mastery
Understanding human motivation is critical in linking the process of residency training to burnout. Daniel Pink, in his book, Drive: The Surprising Truth About What Motivates Us, delineated three tiers of motivation. The first two tiers comprise basic instinctual motivations and the pursuit of external rewards. The third tier, however, drills down to the intrinsic motivators that allow individuals to find true fulfillment.
Pink’s third tier identifies three areas critical to meeting those intrinsic motivations: autonomy, mastery, and purpose. Having control over your time, who you work with, and what you do every day provides a satisfying degree of autonomy.
Attaining mastery is not easy, yet the pathway to mastery is in itself the reward. It is the path to mastery, not the destination that is fulfilling. Finally, purpose provides individuals the satisfaction of engaging in something bigger than themselves. So how do these motivations factor into resident burnout? The key is remembering Pink’s three key “nutrients” for fulfilling intrinsic motivation (autonomy, mastery, purpose) and how those factor into our equations.
Resident motivations are likely unchanged from generation to generation and center largely on the positive societal benefit of curing their patients’ ills. Increasing supervision of residents in training — due to a combination of payer requirements, financial pressures, and accrediting body regulations — has compromised their sense of autonomy.
With the loss of autonomy, residents are getting fewer opportunities to make independent clinical decisions. Duty hours restrictions have decreased the number of hours worked and have also led to increased transitions in care. Therefore, there are fewer instances in which a single resident physician will longitudinally observe the entire clinical course of a patient’s disease process.
Less autonomy, coupled with fragmented patient care, has the downstream effect of decreasing patient ownership. If one does not feel as intimately connected to patients and their outcomes, then the sense of purpose erodes, depersonalization occurs, and the pathway to mastery is hampered. Thus, the three keys to the fulfillment of intrinsic motivation (autonomy, mastery, and purpose) may have been impeded by well-intended policy changes.
So how should the GME community address resident burnout? The answer is not to unleash inexperienced resident physicians on unsuspecting patients. But measures do exist which can improve the sense of autonomy, mastery, and purpose that motivate all of us, including residents in training.
Many residency review committees (RRC) delineate a minimum number of cases for graduation in key categories of surgeries. Once residents have met that minimum number and demonstrated sufficient proficiency, allowing indirect supervision of surgical cases may increase the trainee’s sense of autonomy. The development of an additional category of “Autonomous Resident Surgeon” could provide program directors with a metric to follow this type of clinical experience. With repeated opportunities, the cumulative experience should lead to more proficiency and eventually closer towards a level of mastery with a resultant increase in feelings of personal accomplishment.
While all residents work hard, the reality is that different specialties have different time demands. A “one-size-fits-all” duty hours restriction definition may lead to some unnecessary transitions in care. Allowing RRCs some latitude to tailor reasonable duty hours restrictions that more accurately match their specialty’s workflow may allow resident physicians to observe patients for longer periods of time and see both the natural clinical course of some disease processes, as well as to see the outcomes of their clinical decision making.
Residency training was never intended to produce masterful, experienced physicians after only three to five years of supervised training. Yet, some well-intended regulations may have the unintended consequence of contributing to resident burnout. Using principles from popular social science, the GME community may be able to develop measures to balance resident clinical experience with well-being better.
William O. Collins is an otolaryngologist.
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