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Perspectives

Fostering Meaning in Residency to Curb the Epidemic of Resident Burnout: Recommendations From Four Chief Medical Residents

Berg, David D. MD; Divakaran, Sanjay MD; Stern, Robert M. MD; Warner, Lindsay N. MD

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doi: 10.1097/ACM.0000000000002869
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Abstract

In the medicine departments of most U.S. teaching hospitals, a small group of residents return after graduation to serve as chief medical residents for 1 year. The first chief medical resident at our hospital was Dr. Francis Weld Peabody, who famously wrote that “the secret of the care of the patient is in caring for the patient.”1 When we started our year as chief residents in the Department of Medicine at Brigham and Women’s Hospital in June 2017, we expected to be planning educational conferences, attending on the general medicine service, and coordinating resident schedules. Our training and the experiences shared by our predecessors had prepared us well to meet these expectations. We were less prepared for the distressed emails and text messages from residents, the frequent discussions with mental health professionals, and the magnitude of burnout among residents.

Perhaps we should not have been surprised. In 2018, 2 large studies of residents documented high rates of burnout. In the iCOMPARE duty hours trial, Desai et al found that 70% of medicine interns, regardless of whether they were assigned to a more or less flexible intern schedule, reported moderate or high scores in the domains of emotional exhaustion and depersonalization on the Maslach Burnout Inventory.2 Dyrbye et al reported similar findings: In a prospective cohort study of burnout and career choice regret among residents across medical and surgical specialties, 45% of residents reported symptoms of burnout.3 Internal data collected within our residency program are in line with these larger studies: Nearly 50% of our residents met criteria for burnout and 16% met criteria for overt depression in 2017.

These high rates of resident burnout have significant implications for patient care. Compared with residents who do not meet criteria for burnout, residents who experience burnout are more likely to report providing suboptimal patient care, to describe suboptimal attitudes toward patients, and to perceive themselves as committing medical errors.4,5 Residents are not alone in this regard. A meta-analysis of 47 studies including 42,473 physicians found that burnout among physicians was associated with twofold increased odds of unsafe patient care, unprofessional behaviors, and decreased patient satisfaction.6 High rates of resident burnout also have critical personal implications for residents. Burnout among medical trainees is significantly associated with an increased risk of alcohol abuse or dependence, suicidal ideation, and career choice regret.3,7,8

To date, much of the literature addressing burnout in residency has centered on elucidating and tackling the many individual contributors to burnout. However, addressing these contributors one by one may miss the forest for the trees. To truly alter the resident experience of emotional exhaustion and depersonalization, we believe residency programs and hospitals must shift their focus from addressing burnout to fostering meaning within residency.

Borrowing from the field of positive psychology, we define meaning as a sense of “belong[ing] to and [being] in the service of something larger than ourselves.”9 Based on our experiences as chief medical residents, we believe that it is through finding meaning that residents achieve purpose and professional satisfaction in their work. This is also supported within the medical literature. For example, Shanafelt et al reported that academic physicians who devote at least 20% of their time to the aspect of work they find most meaningful experience burnout at half the rate of those who do not.10 Similarly, Levin et al showed that neurology residents and fellows who find meaning in their work have a lower risk of burnout.11

On the basis of data from physician surveys12,13 and our own conversations with residents, we believe that 4 important elements for fostering meaning within residency are patient care, intellectual engagement, respect, and community. Patient care, intellectual engagement, and community provide residents with a focus that is larger than themselves, while respect is necessary for a resident’s sense of belonging. For residency programs and teaching hospitals to foster meaning among trainees, they must actively prioritize and cultivate each of these elements. In this article, we therefore offer recommendations from our own experiences and from the medical literature for each of these elements (summarized in Table 1).

Table 1
Table 1:
Four Elements That Promote Meaning for Residents and Recommendations for Addressing Each Element

Fostering Meaning in Residency: Four Key Elements

Patient care

The joy, privilege, and challenge of caring for patients are what drew most residents to the field of medicine and what sustain many physicians throughout their careers.10,12 Moreover, the opportunity to take care of patients provides residents with a sense of service to something larger than themselves. Yet we observed that direct care of the patient constitutes a surprisingly small portion of the day for residents. The iCOMPARE study found that an internal medicine resident devotes a maximum of 13% of his or her shift to direct patient care.2 In real time, this amounts to a resident spending less than 15 minutes per day with each patient on service.14 This lack of time for direct patient care limits opportunities for building relationships with patients. In a recent meeting of the resident and fellow members of the Accreditation Council for Graduate Medical Education’s (ACGME’s) Council of Review Committee Residents, freeing up residents to have more time to directly engage in meaningful contact with patients was a predominant theme.15

There are many reasons why residents are pulled away from the bedside. From our experience, 2 of the most pervasive are the high patient censuses on teaching services—interns in our program regularly carry lists of 10 patients (the current ACGME-mandated upper limit)—and unrelenting indirect patient care work. Across the country, internal medicine residents spend two-thirds of their day on indirect patient care tasks.2

To cultivate meaning in residency training, we need to bring residents back to the bedside. Doing so would require residency programs and teaching hospitals to commit to sensible patient censuses for interns and ensure that housestaff services are not treated as “pop-off valves” during times of high patient volume. Programs and hospitals should also find creative means to transfer some indirect patient care tasks, including clerical work and data entry, from residents to other team members. Successful pilot programs at our hospital have included introducing a transitions-of-care pharmacist, who assists residents with medication reconciliations, prior authorizations, and patient education, and a care progression facilitator, who is responsible for arranging inpatient and outpatient procedures and office visits. These 2 simple but effective interventions have allowed our residents to spend more time on direct patient care and on building meaningful relationships with their patients.

Intellectual engagement

Residency training is, at its core, an educational experience. Residents work long hours at lower annual salaries than their peer group of graduate professionals in exchange for the educational value of their training. This education occurs through formal conferences and experiential learning in clinical settings; both are vital to a trainee’s development. In describing an “environment that enhances meaning in daily work,” Hipp et al emphasized the importance of “a learning environment conducive to developing clinical mastery and progressive autonomy.”15

Educational experiences on the wards, in clinics, and in didactic sessions are all critical for preparing and empowering trainees to take on the graduated responsibilities that make residency feel meaningful. Examples of didactic sessions include case-based morning reports and topical noon conferences that complement patient care–based learning. This formal educational curriculum is only valuable, however, if residents can participate. While on inpatient rotations, our residents often leave early from or do not attend teaching conferences because of the pressure to move patients quickly through the hospital. Our program is not unique in this regard: Internal medicine residents across the country spend only 7.3% of their inpatient shifts on educational activities (defined as teaching rounds in the presence of patients and educational conferences).2

For residents to benefit the most from their training, it is important for programs to prioritize intellectual engagement. This would require residencies to commit to protected educational time during which residents can engage in learning without feeling pressure to return pages, call consults, or write discharge summaries. There are many novel approaches to accomplishing this, including introducing a text paging system through the electronic health record,16 clustering the educational curriculum into one morning or afternoon session per week, or asking attending physicians to serve as responding clinicians during certain core educational activities. These actions would not only promote conference attendance but also signal to trainees that program directors and hospitals value their intellectual and personal growth—and are invested in helping them develop meaningful careers.

Respect

Respectful behavior is a core element of professionalism. Of equal importance is an internalized sense that one is respected and valued by one’s colleagues and patients. This sense of being respected allows trainees from diverse backgrounds to engage in their profession with dignity. Unfortunately, disrespectful behavior is prevalent in teaching hospitals and academic environments.17 Both overt disrespect and unconscious biases can erode residents’ sense of belonging and, consequently, their ability to find meaning in their work.

As chief medical residents, we witnessed how unconscious gender and racial biases had a particularly negative impact on female and minority residents. As an example, a white coat is a symbol of our profession, but it is an insufficient identifier for many female and minority trainees. Unconscious biases among patients and medical staff lead to frequent misidentification of these residents as nonphysician members of the care team, which may compound the sense of isolation and imposter syndrome that many trainees already experience. This, in turn, can lead to depersonalization and worsening of burnout. To address this often-implicit bias, residents in our program created large identification badges that clearly identified residents as the “Doctor.” This small but highly visible act helped decrease misidentification and enhance respect for trainees.

Conversations on gender and racial bias within our residency program also brought to light the absence of a formal, accessible mechanism through which sexual harassment and racial discrimination could be reported and investigated. Our program is similar to those in other residencies and higher education institutions in which numerous barriers exist to reporting and addressing harassment and discrimination.18 Programs must actively confront gender and racial bias, which are often insidious in nature. Beyond simple interventions to help create a culture of respect and inclusion, such as the “Doctor” badges described above, programs and teaching hospitals must commit to formal, transparent, and closed-loop mechanisms for reporting and investigating harassment.19

Community

Residency is an emotionally charged experience for residents. For the first time in their professional lives, residents must not only confront but also assume responsibility in situations fraught with existential stresses such as loss, grief, and personal error.20 This leaves many trainees vulnerable to social isolation, which, in the workplace, is tied to impaired task completion, compromised judgment, and, perhaps most important, an erosion of meaning.21

Most of us who have been residents can still recall moments when we felt frightened, embarrassed, and alone. Many of us also remember moments when our coresidents supported us through difficult experiences, which helped build enduring personal bonds. Residency programs play an important role in this community building by creating the time and space for strong resident connections to develop.22 In our program, this includes organizing social events for residents, such as class dinners and holiday parties, as well as offering research and elective pathways that bring together residents with common career goals. Since some residents are more introverted and may not find connections through traditional social gatherings, peer discussion groups can provide another valuable forum for building community.23 For example, our program’s long-standing, facilitated small-group series during internship known as the “humanistic curriculum” provides a space for reflection and bonding with peers. When we were chief residents, the small-group series was expanded to include upper-level residents, and this was widely viewed as a successful approach to building community within the residency.

Another opportunity to help trainees feel like they are part of something larger than themselves is to build connections across residency programs within the same teaching hospital. Specific strategies may include organizing and supporting interdisciplinary events for residents, forming a housestaff council with representatives from each program, and providing free late-night meals for all residents working overnight. These latter 2 strategies were implemented in Brigham and Women’s Hospital in 2018 and have been well received by residents. By focusing on personal connections between colleagues, residency programs and teaching hospitals can foster the sense of community that helps trainees find meaning in their daily work.

Conclusions

As we discovered during our year as chief medical residents, emotional exhaustion and depersonalization are commonplace during residency and have negative implications for patients and residents. Nevertheless, we remain optimistic. On the basis of our experience and the literature, we believe that if residency programs and teaching hospitals invest in the elements of residency that provide the most meaning—patient care, intellectual engagement, respect, and community—the epidemic of resident burnout can be curbed.

Acknowledgments:

The authors would like to thank Dr. Joel T. Katz and Dr. Joseph Loscalzo for their mentorship and review of the manuscript.

References

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