Is burnout inevitable during medical training?

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Medical training in the United States is a long and tedious process. It begins in college, when one must complete the mandatory prerequisite curriculum and take a medical entrance exam; your score on which is directly compared to other applicants, immediately labeling you as a competitive candidate or not. The process of applying requires the completion of multiple comprehensive applications, the compilation of countless hours of research, clinical experience, letters of recommendation, and most importantly an associated fee at each step.

As acceptance into a medical program is becoming increasingly difficult, most applicants apply diffusely across the nation, amassing a substantial payment upon submission of the applications. The fees grow exponentially from here, as one travels from state to state for interviews; typically a two-day process, involving a flight, hotel booking, transportation to and from various locations, and other associated traveling expenses.

Fast forward six months.

Upon acceptance into a program, one undertakes endless hours of study each day and night, irrelevant of sickness, holiday or special occasion, to complete the two-year medical curriculum. Typically, medical colleges charge roughly $40,000 per year for tuition alone, and all schools require four years for completion.  The debt, and its associated interest, piles up quick. The final two years of medical training includes rotations at affiliated hospitals.

In my third year, I completed all of the required core rotations including internal medicine, family medicine, surgery, psychiatry, pediatrics and obstetrics/gynecology. It was at this time, as a 23 year old, I was exposed to the cruelty medical students and residents face throughout their training. It was at this time, I faced the negative and critical criticism — often unwarranted — dished out by attending physicians and hospital staff onto students.

Most of these students, myself included, were without any prior clinical experience except for what was provided in the comfortable and safe pseudo-clinical environment created by our respective schools of training. Many rotations required 20+ hour shifts, thoroughly exhausting the body and mind, then required extensive critical thinking in matters relating to life or death of a complete stranger entrusting their life in our hands. Our efforts weren’t applauded, but dismissed. Our failures were plastered across our face and projected for the world to see.

This may not be the experience of all students throughout their training. Some students, my colleagues, included, went to different hospitals and loved going to and leaving work each day, growing more competent and confident with each shift, and consequently making my experience infinitely more painful to endure. Regardless, it takes a great deal of perseverance to complete medical training. Most students do so with the hope that residency will provide the light atop the darkness of the pit of misery we are thrust into as students. I chose to complete my four-year emergency medicine residency training at the same hospital I had the experience of rotating through as a medical student.

As an intern (first year of residency), you rotate among various departments completing general medical training. Regulations have been placed capping intern hours at 16 hours per shift and, on average, 80 hours per week. However, inaccurate documentation of hours, and the inclusion of an intermittent vacation can offset these hours and adjust the average to below the capped amount. Medicine rotation requires 8 to 12 hour days, every single day of the month, except three 24-hour periods off; which often begin at the tail end of a night shift until the following morning (not providing a single calendar day away from the hospital).

The emergency department is the least malignant environment, by a substantial degree. However, it still demands 12-hour shifts — most of which is spent frantically running around, providing care to multiple sick patients and responding to traumas — with the added difficulty of constantly switching between day and night shifts. As a resident (following completion of internship), the hour regulations are lifted. ICU shifts include 24+ hour days, sometimes without any sleep or at best, an hour or two of interrupted sleep, while bearing the responsibility of the care provided to the most critical patients.

The patient load, increasing resident responsibility, extended work hours, and lack of personal time provide a net unhealthy environment for a resident. Less focus is provided on a resident’s mental and physical health, leading to an increasing number of physicians feeling burned out, and ultimately losing their passion for medicine and for life (an increasing number of physicians have lost their lives to suicide in recent years).

Why not quit? Quitting is not a simple solution. Lack of marketable skills and hundreds of thousands of debt as a consequence of a lifetime pursuit of a career in medicine acts as a shackle, restraining you to the chosen path.    

The past year has been particularly challenging. I feel thoroughly exhausted prior to the completion of my second year of residency, with two years still to go. I find myself in a difficult position. I enjoy learning, and caring for the sick and dying and the healthy alike. Yet, the current system is effectively deterring my passion for medicine. The further I get into training, the more tired I become and the less eager I am to spend the very limited time off devoted to studying. I feel compelled to read, research, and to strengthen my foundation of clinical knowledge to implement into my practice for the betterment of my patients, yet at the expense of less time spent doing what I love — sports, outdoor adventures, traveling, cooking — with my loved ones. The more I realize this constraint on my personal life the more bitter I become with the decision I have made to become a physician.

Perhaps the way I feel is biased by my experience at the hospital where I train.  Perhaps I have chosen the wrong specialty. Perhaps I am not mentally or physically capable of the rigors of a medical residency. Perhaps burnout is inevitable.

Alex Jabourian is an emergency medicine resident.

Image credit: Shutterstock.com

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