Residency burnout

Mr. B is a 64-year-old truck driver with a 250 pack-year history of smoking. He presented to the hospital with non-massive hemoptysis, and his work-up demonstrated metastatic squamous cell carcinoma, of lung primary. Despite multiple attempts by his physicians to discuss his prognosis, Mr. B remained steadfast that he would “beat” his lung cancer. Despite a seven-day course of radiation, the tumor rapidly expanded over three weeks in the hospital, eventually obstructing his right mainstem bronchus, and he became more and more hypoxic. Still, he was unwilling to discuss his wishes for end-of-life care. During work rounds one day, one resident caring for him said to another, “Man, Mr. B’s lung cancer is really ruining my life.” Less than a year into my training, I’m struck by the changes that I already see in myself and my co-residents. In fact, it’s hard to escape the idea that residency actually detracts from our humanity. And it’s not just me: there’s evidence that residency lessens our sensitivity, alters our behavior and perhaps even changes our personalities We’re more likely than our attendings to heavily copy-and-paste when using electronic notes (1), and a full third of us report “aversion to patients” (2). The psychology literature calls it burnout, and anywhere between 50 and 75 percent of residents develop it during training (3,4). Since most of us were not so terribly cynical before we started training, and we (hopefully) will adjust our attitudes by the time we reach PGY-8 or so, there must be something about being a house officer that temporarily (again, hopefully) causes our poor attitude. The ACGME has acted in recent years to limit duty hours, suggesting that they might chalk up the temporary insanity that accompanies residency to long hours and lack of sleep. But the evidence linking work hours and burnout is decidedly mixed. While two studies have demonstrated a linkage between hours worked and negative attitudes toward patients (5,6), others have failed to do so (7-9). One recent prospective survey of residents at five institutions failed to demonstrate any association between burnout and duty hours (3). Even if long hours and lack of sleep do play a role, there are certainly other factors at work. I have my own hypothesis, based entirely on anecdote and likely completely un-testable: house officers burn out because  of the impotency inherent in the position, and because we have no idea how to deal with that feeling. Mr. B’s case is illustrative. His case was hopeless from his initial presentation with Stage IV lung cancer. Further complicating matters, his wife had been diagnosed with Stage IV breast cancer 15 years ago and survived. He thought he had months — years, even — to deal with his illness. Watching his progressive hypoxia, we residents knew he might only have days or weeks. As residents, we were carrying out (and dealing with the side effects of) a treatment plan — local radiation — designed by someone else. As a physician-scientist, I could not help but wonder whether there was any evidence base for what we were doing. (The answer: There is no evidence per se for local radiation in Stage IV non-small cell lung cancer — though there is evidence of a survival benefit with “definitive local treatment” (10).) Then, on hospital day 14, Mr. B and his wife called a house officer to his room to “talk about what was going on.” Mr. B opened the conversation by saying, “I’m not even sure you guys are right that I have cancer; maybe there’s nothing wrong with me at all.” We already knew at that point that the best possible outcome — a cure — was never going to happen. The second-best outcome — home with a few months of relative good health — also seemed unlikely. Plan C — home with hospice — did not look promising. Even the fourth-best outcome — death in the hospital, but with patient and family coming to terms with the situation prior to a protracted ICU course — looked unlikely. Instead, his rapidly approaching death would be a nightmare — marked by ventilators, pressors, ethics committees, and conversations that start with “what would he want if he could tell us right now?” As house officers, we were Mr. B’s primary care takers, and it was up to us to make the best of his bad situation.  We were the ones who saw him every morning, and who came by his room when he complained of shortness of breath, nausea, and pain. We were the ones who spoke with his family, and were tasked with helping them understand his prognosis. But despite our best efforts, we could neither help him come to terms with his illness nor offer effective treatment. We were impotent. Perhaps a more experienced physician would have the confidence to know he did his best. Maybe a more experienced physician has accepted that sometimes it is not possible to reach a patient or a family. But as interns, we can’t escape self doubt. Did I do it right? Could I have done it differently? Is this my fault? Compounding the problem, there is never time to confront those feelings, so we push them away. In our words to each other, it is always the patient’s fault, never ours. We mask our impotence with bravado, and our despair with jokes made at our patients’ expense. I could not find any published evidence that promised we residents would become less cynical and more sensitive once our time in training ended, or any step-by-step guidelines for how to learn. But I see evidence of that transformation every day. Almost all of my attendings (including, and perhaps especially, those physician-scientists who only see patients part-time) are compassionate toward patients and seem to delight in taking care of them. These senior physicians remind me and my classmates of the reasons we chose to become physicians in the first place, and inspire hope that impotence and burnout will soon just be memories. Alexander Fanaroff, MD Duke University Medical Center PGY-1, Medicine

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