April 1, 2014
Volume 78, Number 4
Residents’ Review: Burnout in Residents
Amanda Michele Chan, M.S., D.O.
Have you ever felt burned out at work? Emotionally depleted? Cynical about or detached from your patients? Stressed and overwhelmed?1 These feelings of burnout are common in residents, so if you answered “yes,” you’re not alone. This problem is very real for many of us. The early-morning didactic sessions, 24-hour workdays and the weeks without a day off – we practice challenging tasks repetitively in hopes to one day achieve attending status. We set high individual standards and, once those have been accomplished, we reset to higher ones. The daily grind is a familiar concept that makes residents susceptible to breakdown and burnout. We see it in the workplace every day.
The House of God, by Stephen Bergman, M.D., Ph.D.,2 provides an often humorous yet overall somber reference to the effects of burnout. The repetitively badgered interns work endless shifts and are expected to perform daunting tasks in an overcrowded hospital. They characteristically exert their frustrations through various means of psychological expression: lewd behaviors, alcoholism, addictions and anger, but also through exercise, conversation and acceptance. Dr. Wayne Potts, a timid Southern gentleman, is belittled and abraded by higher authorities due to his mistakes. When his patient, “The Yellow Man,” dies, he blames himself. This burden, in addition to other factors, adds to his already guilty and overwhelmed conscience, and he eventually commits suicide. After this, in the latter half of the book, the importance of community is stressed as the interns make decisions about their future careers in medicine as a team. The burnout of intern year remains an affliction in their lives but contributes to judicious and astute life choices.
A state of exhaustion characterized by cynicism concerning the importance of one’s occupation is the definition of occupational burnout.1,3 According to the Maslach Burnout Inventory,1 burnout is characterized by three categories: emotional exhaustion, depersonalization and a low sense of professional accomplishment. It has been postulated that burnout originates in medical school and is caused by various factors, including academic pressure, sleep deprivation, student abuse and “hidden curriculum” of cynicism.4 Studies suggest psychological distress is associated with residents with high educational debt and avoidant or passive-aggressive personality traits. Variables contributing to resident burnout include stressful demands, lack of control and a lack of sense of community.5
Detrimental health consequences, including drug and alcohol addiction, medical errors, marital and family disruption, and suicidal ideation, have all been related to burnout. Anesthesiology residents are particularly susceptible to drug addiction due to an increased access to narcotics and drugs of abuse. From 1991 to 2001, 80 percent of anesthesia residencies have dealt with residents under the influence of drugs. Of those residents, only 46 percent successfully completed an anesthesia residency.6
Additional studies have revealed that work overload, insufficient incentive, decreased control and conflicting values further exacerbate this condition.5 In Medscape’s current survey, 42 percent of anesthesiologists were burned out. As the fourth highest specialty experiencing burnout, anesthesiologists tied with internists, general surgeons and OB/GYNs.7 Similarly among U.S. anesthesiology trainees, a recent study in Anesthesia and Analgesia found a high risk of burnout in 41 percent of respondents. Burnout was associated with the female gender, greater than 70-hour workweeks and greater than five drinks per week.8 To decrease these negative repercussions, residency programs are refocusing standards to balance quality of life and work priorities.
Burnout is a relatively new construct of interest, first looked into in the 1980s due to controversial and monumental issues raised in the 1984 Libby Zion case. Libby Zion died at 18 years of age as a result of an iatrogenically-induced Serotonin Syndrome.9 Ultimately, her death was caused by a drug interaction between phenelzine, an antidepressant she had been taking, and meperidine, which had been administered to her by resident physicians. The case addressed judgment issues and a lack of supervision of physicians-in-training. In the years that followed and in the example set by New York State, the ACGME and AOA instituted work-hour maximums of 80 hours per week and limited shifts to 24 consecutive hours for residents.10 Since these duty-hour regulation models were enforced, residents have had increased alertness and well-being and decreased burnout.11 Identifying causal factors and implementing standards or programs that can target burnout prevention are vital to improving intern resident training.
Although only more recently the subject of study, burnout in residency has been evident for decades. A certain degree of stress and responsibility are inherent to our involvement in medicine. Extended work hours, educational debt and passive-aggressive traits contribute to a resident’s emotional debilitation, decreased satisfaction in achievements and cynicism. Anesthesiology residents are particularly susceptible to psychological distress, which can lead to destructive work habits and a neglect of duties. With available access to pharmaceuticals, anesthesia residents also have increased opportunities for drug abuse. Significant stress-coping practices, emphasis on coworker communication and stress management workshops may play a role in decreasing burnout.5 Prospective studies are required to evaluate resident burnout and reform the current work environment. As a community, acknowledgement and recognition of burnout and related long-term adverse effects is the first step to working toward the overall well-being of resident physicians.
Amanda Michele Chan, M.S., D.O. is a PGY-2 anesthesia resident, Doctors Hospital, Ohio Health, Columbus.
1. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.
2. Shem S. The House of God. New York: Berkeley Books, Penguin Group; 2010.
3. Garza JA, Schneider KM, Promecene P, Monga M. Burnout in residency: a statewide study. South Med J. 2004;97(12):1171-1173.
4. Ishak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;1(2):236-242.
5. Thomas NK. Resident burnout. JAMA. 2004;292(23):2880-2889.
6. Collins GB, McAllister MS, Jensen M, Gooden TA. Chemical dependency treatment outcomes of residents in anesthesiology: results of a survey. Anesth Analg. 2005;101(5):1457-1462.
7. Peckham C. Anesthesiologist lifestyle report 2013. Medscape Multispecialty website. http://www.medscape.com/features/slideshow/lifestyle/2013/anesthesiology. Accessed October 30, 2013.
8. De Oliveira GS, Chang R, Fitzgerald PC, et al. The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesth Analg. 2013;117(1):182-93.
9. Boyer E. The serotonin syndrome. N Engl J Med. 2005;352(11):1112-1120.
10. Kramer M. Sleep loss in resident physicians: the cause of medical errors? Front Neurol. October 20, 2010;1:128.
11. Fletcher K, Reed D, Arora VM. Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules. J Gen Intern Med. 2011;26(8):907-919.