ARTICLE IN BRIEF
A new survey finds burnout is pervasive among neurology residents and less so among neurology fellows. Residency program directors and neurology residents share their perspectives on the causes of burnout — and how they address them.
Nearly three-quarters of neurology residents and more than half (55 percent) of neurology fellows report experiencing at least one symptom of burnout, according to the findings of a survey published in the June 30 online edition of Neurology.
Burnout involves one or more components: emotional exhaustion, feelings of cynicism and detachment (depersonalization), and a sense of ineffectiveness at work (low personal accomplishment), the study authors said.
For residents, greater satisfaction with work-life balance, meaning in work, and older age were associated with lower risk of burnout, while greater satisfaction with work-life balance and effective support staff were associated with lower risk of burnout among neurology fellows. [For more details about the participants, see “Characteristics of Respondents.”]
Study author Kerry H. Levin, MD, FAAN, chair of neurology at the Cleveland Clinic and chair of the AAN Resident Burnout Subcommittee, said the field of medicine is much more aware of professional burnout, and can now study the issue in a systematic way, spawning activities to try to understand and prevent it.
Practicing neurologists have one of the highest burnout rates and one of the lowest levels of satisfaction with work-life balance among all medical specialties, he said. But he noted that other specialties have also shown an increase in burnout.
In the current survey, he said: “I thought it was interesting, and not previously reported, that fellows do better than residents. Fellows had a closer burnout rate to practicing neurologists than residents did.”
Another surprise in the report was that trainees living in the Midwest were more likely to report career satisfaction than those in the Northeast, even though personal and professional characteristics in those two geographical areas were not significantly different, he said.
The study, which was co-authored by 11 neurologists, surveyed 938 United States AAN-member neurology residents and fellows using standardized measures of burnout, career satisfaction, and well-being from January 19 to March 21, 2016.
Of the 354 residents and fellows who responded, 73 percent of residents and 55 percent of fellows had at least one symptom of burnout; residents had higher scores for depersonalization than fellows.
The findings, the survey authors said, suggest the need for organizational changes. Among changes, they said neurology training curricula could be redesigned to focus on more meaningful internal medicine experiences in the preliminary year of training (for adult neurology residents), including emphasizing professional development; teaching coping skills; and reducing clerical burdens. Alternating less intense with more intense clinical rotations in earlier years of training could decrease depersonalization, they wrote.
FINDINGS ‘NOT SURPRISING’
Neurology residents and residency program directors who reviewed the survey findings for Neurology Today said the results were not surprising. They said most residency programs were trying to address the situation by limiting night hours and creating more avenues for residents to talk about their concerns.
As director of the neurology residency program at Thomas Jefferson University Hospital in Philadelphia, Christopher Skidmore, MD, assistant professor of neurology and vice chair for clinical affairs, supervises 27 residents. He said he plans to start using some of the questionnaires used in the resident study to help screen for burnout, particularly at the beginning of the residency when stress is at its highest.
Dr. Skidmore said the residency program at the hospital continues to change to address student needs. For example, instead of simply starting on the hospital floor on July 1, all residents have a 10-day boot camp in the lecture hall. The residents review emergency scenarios, are taught how to do a neurological exam, and learn how to dictate and write a consultation note. Not only does the refresher help, but it also gives the incoming residents a chance to bond together and to meet the members of the neurology department.
But he said that there's a limit to what program administrators can do.
“I want to be a friend and a colleague but I should not be someone's doctor,” he said. To that end, a dedicated team of counselors is available free of charge for residents and fellows, he said, adding that if it's clear that a trainee needs help he will refer the person to these services.
Jennifer A. Vermilion, MD, who is starting her fellowship at the University of Rochester, said that she felt fortunate that her residency program put a value on having an outside life. The intensity of the work is good for training, she said, but can be exhausting.
She said she knows several residents who left during residency. “People are talking about burnout and that's all well and good to put a spotlight on it, but it's an overlying systems issue: The patient demand that's out there, the way hospitals are set up, and the intensity and complexity of the patients that come in — it's all draining,” Dr. Vermilion said. “Even when programs are trying to make changes to offer better training and better lives, there's a lot that isn't being done like increasing funding or hiring more staff to help pick up some of that load.”
For example, hiring more mid-level providers and teams would help with the burden that comes with high patient volume due to an aging population, and the complexity of the patients, she said.
Kristen A. Lindgren, MD, PhD, just finished her residency at Newtown-Wellesley Hospital, and is now an attending physician in child neurology. She said that often older physicians and attending physicians would comment on how their residencies were harder.
“The increasing burden on doctors to be available constantly to both patients and the hospital, whether through email, the patient portal, or phone, could definitely have an impact on one's quality of life,” Dr. Lindgren said, noting that she has been paged in the middle of the night, for example, from patients looking to renew their medication for attention deficit-hyperactivity disorder.
As a first-year intern, she said she worked 16-hour shifts, but that felt to her like she was in the hospital all the time, because it resulted in being on day or night shifts many days in a row. She preferred the 28-hour shifts because she could schedule downtime post-call.
“It's not seeing the patients that causes the burnout,” she said, “it's all the [things to do] after work.” For example, she said, ordering an MRI would entail significant time clicking through multiple computer screens to find the right diagnosis so insurance would cover the cost, instead of simply placing an order.
When the program added a neurology nurse practitioner to the inpatient team to see some of the post-call patients, that helped, she said. That meant they all had 18 patients a day instead of 25; the nurse practitioner also helped with administrative duties, such as writing notes and ordering tests.
Erica Schuyler, MD, the neurology residency director for the University of Connecticut and the incoming chair of the AAN Consortium of Neurology Program Directors, said today's residents face a heavier workload and expectations as teaching hospitals get busier and residents are working with increasingly sick patients.
“I believe that for resident physicians, long days are expected. But it's so important that they can disconnect when they are done with a shift or when they have a day or weekend off,” said Dr. Schuyler. “When they are off, they need to get some rest and use that time for self-care and for connecting with the world outside of work.”
She said it's important not to push residents to the point where they lose their empathy toward patients and are so tired that they can't feel good about what they're doing.
“It's really a question of ‘How do we find that balance?’ because while we know this isn't a 40-hour work week, we really need to figure out how much is too much,” she said.
For Luca Bartolini, MD, an epilepsy fellow at the National Institute of Neurological Disorders and Stroke, the study highlighted the need for family support as well as general program support.
“Your significant other and children can give you the motivation and emotional support needed to cope with long days and nights at work more than anything else; even if the partner is a doctor (like in my case) and works as much as you do, the simple fact that you feel understood and loved makes your day easier,” said Dr. Bartolini. “Your partner can also give you the support needed to deal with life events outside of work (hardship, loss in the family, etc.), when as a trainee sometimes you can't take days off without prior notice.”
For example, he said, it would be helpful to have access to extended daycare hours either inside or close to the hospital, particularly with “resident-friendly” rates, as well as access to gym facilities. Dr. Bartolini also said that social opportunities to bond with other residents and faculty members might help as well, particularly with those who have children.
At Jefferson University, Dr. Skidmore said that they do hold some social events, and residents are encouraged to take advantage of living in Philadelphia.
The program is also discussing incorporating a mindfulness program, already in place in the medical school, into the residency program. However, some residents worried that these events would turn into more required hours. “It's great to offer yoga classes, but after a long day at work I'd rather be home with my family and friends,” said Dr. Lindgren. Perhaps if time was specifically allocated for those activities, or if faculty or senior residents covered for junior residents during those times, people would be more apt to take part.
“If these options are going to impact my already limited personal time, I'm not likely to participate,” she said.
The study authors noted that the persistently high burnout rate did not indicate a striking impact from work-hour limitations, and high burnout among residents was evident years after the implementation of duty-hour restrictions. The report noted that a study of European residents reported burnout despite a 48-hour work restriction.
But Dr. Bartolini said he found that hard to believe. “The more you work, the more likely you are to feel burnout,” he said. “Now that I'm a fellow, I work much less than I did as a resident, and it's much easier to cope with the stress. That's human nature; we're not programmed to work 100 hours a week.”
Dr. Levin, of the Cleveland Clinic, noted that many neurology residents start by doing a year of internal medicine, and they may not find some of that particularly meaningful. The AAN Resident Burnout Task Force will offer recommendations for making the curriculum more meaningful, he said.
An example would be elimination of less relevant rotations. The study authors also suggested that emotional exhaustion might be decreased by alternating high intensity inpatient rotations with less intense rotations during the early years of residency training.
Dr. Skidmore agreed. “The residents are seeing people with gastrointestinal bleeding, heart attacks, and pneumonia, and while they're going through that process it might be hard to see the forest through the trees,” he said. “We need to remind them that while some of it may not be directly applicable to neurology, the learning process will be, and we need to help them remember why they were so engaged and why they wanted to be a neurologist.”
BURNOUT AND WELLNESS: How do you individually or as part of a practice or institution address feelings of emotional exhaustion, cynicism and detachment (depersonalization), and the sense of ineffectiveness at work? For a new column on wellness, we'd like to feature strategies, programs, and solutions incorporated in practice. Send your ideas to [email protected].
CHARACTERISTICS OF RESPONDENTS
- Survey responders worked a mean of 64.6 hours per week with approximately 76.9 percent an average of 59.7 hours a week
- Residents worked more hours on average (67.5 hours) than fellows (59.1 hours; p<0001) and spent a larger proportion of their time in direct patient care (82.5 percent vs 67.3 percent; p<0.001), and devoted less time to research (4.11 percent vs. 19.3 percent; p<0.001).
- Residents spent more nights per week on call than fellows (1.39 vs. 1.18; p=0.003).