Blair Ford, MD
In recent years, there has been a growing awareness of stress and burnout during residency, issues that have wide-ranging consequences for resident well-being, patient care, and training programs. The objectives of this discussion are:
- to define burnout
- to describe the signs of burnout in residents
- to review the potential causes for burnout during residency training
- to suggest coping strategies and resources for burnout in residents
Definition
Burnout, a term coined by Freudenberger in 1974, is a syndrome consisting of: (i) emotional depletion due to occupational demands; (ii) depersonalization, a sense of distance from the work; and (iii) a feeling of low personal accomplishment and self-worth. Freudenberger characterized the syndrome as an “extinction of motivation” manifesting in a variety of physical and behavioral signs, including poor attention span, insomnia, irritability, cynicism, aggression, impatience, social isolation, and boredom, among others [1,2]. Burnout can occur in any occupational setting, but is especially likely when a high level of responsibility is experienced by workers who have little control over their situation [3].
Burnout is considered a psychological construct, and is not listed as a psychiatric illness in the DSM-IV-TR. It may share some features or co-exist with depression but the two are regarded as distinct problems [3,4]. The Maslach Burnout Inventory, a 22-item questionnaire, is the most widely used tool for measuring burnout, and includes subscales for emotional exhaustion, depersonalization and self-worth [5,6].
Recognizing burnout in residents
In recent years, there has been an increasing interest in identifying and ameliorating burnout during graduate medical education [3,7,8,9]. To date, the literature on burnout is relatively young, consisting mainly of single-institution surveys and bivariate analyses. The prevalence of burnout is unknown, but has been estimated to vary between about 15 and 75%, according to numerous reports [3]. Among residents, signs of burnout may include a loss of compassion for patients, families and colleagues, indifference to performance, a decline in workplace civility, and a loss of enthusiasm for learning. The potential consequences of unrecognized burnout among resident physicians include self-neglect, social isolation, alcohol dependence and substance abuse, depression, and even suicide.
The relationship between burnout and depression is unclear, in part because surveys have not reported the relative time of onset. In some individuals, burnout may trigger a depressive episode [10] while conversely, a depressed resident may be prone to stress reactions in the face of a heavy workload [3]. Residents with burnout are impaired in their ability to care for patients, and there is a reciprocal association between perceived medical errors and resident distress [11].
Causes of burnout in residency training
Contributors to burnout include the long-recognized pressures of residency: the intensity of the work, the emotional demands of patient care, prolonged exposure to sickness and death, long hours of duty, and the challenges of mastering a rapidly expanding knowledge base. External sources of stress, such as financial concerns, uncertainty about the future, competing lifestyle demands, the pressure of relationships and raising a family, may all weigh heavily upon a young physician in training. Modern residents carry increasing debt burdens, and this correlates with self-reports of depressive symptoms, heightened cynicism, and the perceived need to moonlight for financial survival [12].
A resident’s personal characteristics may also increase the susceptibility to burnout: it has long been argued that highly driven individuals with compulsive, perfectionistic tendencies may be especially prone to workplace exhaustion. One study recorded an association between burnout and antisocial, passive-aggressive, avoidant and dependent personality styles, but the effect may relate primarily to the social support network of such individuals [3].
Is burnout an ailment of the modern medical workplace, or simply a problem that was always present but not fully recognized? As Ludmerer has written, graduate medical education has always subjected young physicians to long hours and prolonged emotional stress. For much of the last century, house officers lived a monastic existence, housed in cramped hospital quarters, eating poor quality food. And yet, the grueling lives of these residents contained many sources of support that are no longer key components of the modern residency, including a deep and personal connection to the hospital, close integration with the faculty, a supportive hospital family milieu, and abundant camaraderie [13].
In recent decades, Ludmerer argues, residency has become more intense for modern house officers than their forebears as a result of advances in medical technology, the explosion in medical information, and the accelerated pace of the modern hospital. At the same time, there has been a decline in institutional support, and erosion of a sense of community within academic faculties [13].
Some researchers have noted a connection between long work hours and a lack of professionalism among residents [12]. While prolonged work hours are not new in residency training, they are an obvious contributor to mental exhaustion and burnout [14]. The case of Libby Zion, a young patient who died several hours after being admitted to a hospital in 1984, brought into sharp public focus the grueling work of the house officer, linking mental exhaustion with resident work hours, and igniting the current systems of regulation and surveillance that are pervasive in graduate medical education.
Nonetheless, the relationship between work hours and burnout is not clearly established; and it remains uncertain that limiting work hours by itself is an adequate means of preventing resident burnout. Studies measuring quality of life in residency have shown trends towards decreased emotional exhaustion and improved motivation after implementing mandatory work hour limits [15]. While more rigorous studies are needed, work hour restriction appears to contribute to decreased rates of depression and emotional exhaustion, a reduction in motor vehicle accidents, and more time to read and be with family [15,16]. Methods to reduce resident work hours, including the use of short duty shifts, sign-outs, cross-coverage systems, night floats and physician extenders, have sometimes been the target of criticism by educators concerned about diluting the rigor and continuity of training, and by the potential for creating errors of miscommunication [17].
The residency experience differs from specialty to specialty, and burnout has not been specifically studied in neurology residents. Internship is considered to be the year of greatest hardship during residency training, representing a time of peak exhaustion and frustration among trainees [18]. Arguably, neurology trainees experience the equivalent of a two-year internship, as the medical internship itself is followed by a PGY-2 year that is typically freighted with ward service, neurocritical care, in-house call duty and night float shifts, similar to the internship year.
The educational content of the neurology training experience, with its prolonged hospital-based exposure to patients suffering from devastating neurological deficits and incurable diseases, may predispose trainees to burnout. In one survey of practicing physicians, higher burnout specialities were those dealing with chronically ill, dying, or incurable patients [19].
Approaches to the resident with burnout
Published treatment approaches to burnout among physicians include workshops, assistance programs, self-care interventions, support groups, didactic sessions, and stress management training [3,20]. These interventions have rarely been studied systemically, however, and the literature remains inconclusive. Stress management workshops may be helpful in providing coping advice but it appears that modifying the depersonalization element of burnout is a difficult challenge [3].
Program directors and faculty are well-advised to look for signs of burnout in their residents; and to enquire and intervene in a supportive manner. Given the inherent stresses of residency training, early detection of burnout coupled with effective, timely interventions could promote benefits in terms of resident well-being, the educational mission, and patient care.
Institutional factors that may help to prevent burnout are already in place at many training programs, and include faculty role models, an advisor/mentorship system, efforts to enhance resident camaraderie, social events, support groups for residents, and a balanced schedule that allows emotional recovery after intense clinical rotations [21].
For the resident showing signs of burnout, supportive counseling, a reduction or change in work duties, psychiatric evaluation and intervention, and even a leave of absence may all be indicated. Despite the paucity of randomized, controlled studies for preventing and treating burnout in graduate medical education, the vast popular literature on the syndrome contains advice that appears helpful and reasoned, including an emphasis on adequate rest, nutrition, exercise and especially social support [22].
Conclusions
In summary, burnout is a common syndrome among residents, characterized by emotional depletion, detachment from their clinical work, and poor self-esteem. Burnout can have a deleterious effect on a resident’s ability to care for patients and to learn. Since its inception, residency training has always placed enormous emotional and physical demands on young physicians, subjecting them to prolonged exposure to illness and sleep deprivation. The literature on resident burnout is relatively new, and there is a clear need for more systematic study of the problem. While many strategies exist for reducing resident stress, including the reduction of work hours, the importance of a supportive social network cannot be overstated. To date, the recognition of work-related stress among American physicians in training has not become the focus of occupational standards, but the growing awareness of the importance and impact of burnout is a promising sign.
References
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