Reflections on physician burnout by a burned-out transitional year resident
I have been thinking of submitting this piece for peer-review publication. Burnout in medicine is near and dear to my heart, and I hope my story, experiences, and thoughts may be able to help others. If you are an attending physician or retired professor and would like to supervise this, please let me know. I appreciate any and all feedback! - Casey
Introduction
I am writing this essay as a current transitional year intern with many more years of residency training and practice ahead of me. Throughout this past year, I have felt multiple symptoms of burnout, such as energy depletion, increased mental distance, and an overall lack of career fulfillment. Please know that my thoughts and opinions expressed in this essay do not reflect the thoughts and opinions of my employer or affiliated persons, nor do they reflect the quality of my education and the learning environment in which I trained. I am overall very satisfied with the institution at which I worked throughout this year, and could not have asked for a better place to have completed my transitional year internship.
As my burnout has steadily increased during my National Board of Osteopathic Medical Examiners (NBOME) COMLEX Level 3 exam preparation, I wanted to step away from boards studying briefly and dive deeper into current research behind physician burnout. The purpose of this essay is to serve as a reflection on physician burnout and lengthy work hours, reducing workweek days or hours as a potential solution, and addressing my own fatigue. I hope this article serves to be a source of hope or motivation for other medical students, residents, and physicians to feel comfortable being open about their struggles with burnout so we may continue to help further improve each other individually and the healthcare system as a whole.
Employee Work Hours and “4 Day Week Global” Program
In 2022, Voglino et al. [1] published a systematic review of how reducing work hours could influence health outcomes, and they found positive relationships between reduced work hours and work-life quality, sleep, and stress. Although the authors found unclear differences between reduced workweek hours and improvement in general health outcomes (e.g., self-perceived health), this study suggests that reducing work hours while retaining salary could improve overall employee well-being. Last year, a coordinated 6-month international trial of a four-day workweek without pay loss for employees was led by the “4 Day Week Global” program. This nonprofit, international initiative was founded by Andrew Barnes and Charlotte Lockhart [2] and is associated with the University of Oxford in Oxford, England, and Boston College in Boston, Massachusetts. Most companies involved in the program reduced workweek hours from 40 over 5 days to 32 over four days, and did so by following the 100-80-100 model (workers receive 100% of pay for 80% of the time while maintaining 100% productivity) [3].
According to Liu, many workers who tested this four-day workweek model were extremely satisfied with the experience and reported that they would not go back to a five-day workweek [4]. As self-reported levels of employee performance rose, reports of burnout and fatigue decreased. Furthermore, workers involved in the survey reported better control over their schedules and fewer hours commuting. Some companies adjusted to the change in work hours by altering communication strategies, cutting down on meetings, and changing program work software. Above all, this pilot study returned positive results, and about 40% of companies involved plan to keep the 4-day workweek moving forward.
This “world’s largest” four-day workweek experiment yielded tremendous employee benefits: 71% reported feeling less burnout, 39% reported feeling less stressed, 48% were more satisfied at work, 60% endorsed better work-life balance, and 73% were overall more satisfied with their personal lives [5]. As fatigue decreased, employees admitted to sleeping more and having improved mental health as well.
These results are astonishing and the importance of preventing workplace fatigue is more important now than ever, especially for healthcare employees due to the worldwide impact of the COVID-19 pandemic [6-12]. Working long hours is highly prevalent among healthcare workers, particularly physicians. Some may say it is ingrained in the culture of medicine and being a physician, whether right or wrong [13]. Even though average weekly work hours for U.S. physicians declined by 7.6% (from 52.6 to 48.6 hours per week) from 2001 to 2021 [14], the COVID-19 pandemic increased rates of physician emotional exhaustion and depression, decreased rates of physician work-life satisfaction and professional fulfillment, and overall led nearly 63% of physicians experiencing burnout in 2021 [15][16].
Burnout and Its Relation to Work Hours
Now, what is burnout, and how do work hours come to play? According to the World Health Organization’s (WHO) 11th Revision of the International Classification of Diseases (ICD-11), burnout (or burn-out) is defined as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. Three dimensions characterize it: feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy” [17]. Although the WHO does not classify burnout as a medical condition, it is acknowledged as an “occupational phenomenon” meant to reflect the effects of workplace fatigue [17], which is impacted by prolonged work hours [18].
According to a 2021 retrospective study of 2,081 healthcare employees in Taiwan from 2016 to 2017, the odds ratio of work-related burnout when compared with a 40-hour workweek doubled when weekly hours exceeded 60, tripled when hours exceeded 74, and quadrupled when hours exceeded 84 [19]. Even though physicians (n=369) were less susceptible to burnout secondary to increased weekly work hours when compared to other healthcare workers (nurses, n=973; technicians, n=391; administrators, n=348), physicians faced the greatest estimated reduction in sleeping hours (25-73%) proportional to increased work hours [19]. While reducing work hours may drastically help with physician recovery from burnout, not all doctors find this option to be feasible, whether due to patient needs or administrative paperwork demands [20].
However, other doctors do think this option is feasible. For physicians who are able to negotiate 4-day workweeks, Dr. Jennifer Frank, a family medicine physician out of northeast Wisconsin, recommends it [21]. She states that the benefits of a 4-day workweek for physicians include: increased time for (1) personal health appointments and (2) family, (3) more schedule flexibility (i.e., can take Friday off one week and take Wednesday off the next week), and (4) possibly less money spent on extraneous costs such as commuting, landscaping, grocery delivery services, etc. But, the unfortunate reality is that not every physician is in the position to take on one-less day a week (or cut their weekly duty hours by 20%), and Frank does acknowledge this.
One such group of physicians is resident physicians (or “residents”). During residency training, which is a multi-year commitment for residents to experience elevated patient-care volume under licensed physician guidance as they develop competency en route to practicing individually, reducing work hours to less than 80 a week has not adversely affected patient care outcomes nor impacted meeting graduation requirement needs [22]. While many may argue that even fewer working hours among residents should be pursued (e.g., less than 56 or 48 hours a week), current literature regarding this is of poor quality or has conflicting results. Having said this, research suggests that first-year residents (or “interns”) should not work more than 16 consecutive hours given significant reductions in physician-reported medical errors, preventable adverse effects, and fatal medical events [23]. Although, according to a study by Landrigan et al. in 2020 [24], non-intern residents who do not work extended (i.e., 24-hour) intensive care unit (ICU) shifts may be more likely to make more serious patient care medical errors and may actually see more patients per shift as opposed to residents working 24-hour ICU shifts.
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Complexities Behind Physician Burnout: Is Reducing Working Hours the Answer?
Whatever the case may be, discussions on workweek hours, patient safety, and physician wellness is a more complex issue than one may think, especially since reducing physician workweek hours does not necessarily mean improved patient care or doctor wellbeing [25-27]. So, what can be done if reducing workweek hours may not be the complete answer? Dr. Vivek Murthy, Surgeon General of the US, wrote in the New England Journal of Medicine that individual physician and healthcare worker burnout are rooted in health system dysfunction and this, ultimately, is what must be addressed [28]. Ways that health systems can address this national (and, frankly, international) issue, according to Dr. Murthy, are as follows: (1) value and protect healthcare workers; (2) reducing administrative burdens; (3) increased access to mental health services; (4) increased public funding to improve the healthcare workforce and public health; (5) creating a culture that supports well-being.
This last point that Dr. Murthy makes is crucial. Although healthcare workers find that altruistic behaviors in their daily line of work may provide warmth and fulfillment [29], this is not always the case. Physicians and other healthcare workers should not be punished for reporting their mental health concerns or seeking help. Medicine is stressful, and many physicians (among other healthcare workers) are still reluctant to seek help when they need to (or even recognize symptoms of burnout) [30]. Unfortunately, stress and burnout may contribute to career dissatisfaction and ultimately physicians leaving medicine [31], which is dire to consider as the US is currently facing a projected shortage of between 37,800 and 124,000 physicians according to The Complexities of Physician Supply and Demand: Projections From 2019 to 2034 released by the Association of American Medical Colleges (AAMC) [32].
In light of this, is reducing workweek days or hours among physicians, thus, the answer to curbing rates of burnout and slowing down this projected shortage? The answer is: maybe. For physicians who are able to, it may not be a bad idea. Does this mean seeing fewer patients, whether directly or indirectly? Yes. Could this result in less financial gain? Potentially. However, when considering the risks and benefits of reducing workweek days or hours versus decreasing physician burnout, a slight pay-cut may be worth it if it results in enhanced career meaning and fulfillment [33], as well as improved patient care [34]. But if healthcare systems began adopting a “4 Day Week Global” 100-80-100 model, maybe healthcare employees would not need to sacrifice much pay after all for fewer workweek hours.
“Regardless of approaches taken”, as stated by West et al. [35], physician and other healthcare employee burnout is a “shared responsibility of both healthcare systems and individual physicians”. Perhaps physicians, then, need to be just as accountable for their own mental health and well-being as much as healthcare systems need. West et al. [35] provide an extensive list of self-practice solutions that physicians should consider exploring to mitigate individual burnout, including: mindfulness training, small-group engagement, intentional reflection on self-fulfillment and life priorities/values, positive/growth mindset and coping strategies, stress management, resiliency training, work delegation/prioritization, and transitioning from “full-time” to “part-time” status. Furthermore, learning how to say “no” is an important part of career development and may help limit unnecessary task burdens, especially among young professionals [36].
Whatever the case may be, reducing physician burnout is and ought to be a conversation that medical professionals and healthcare systems continue to have until adequate, reproducible, evidence-based reports of the contrary (i.e., resolved physician burnout levels) become true. Many physicians are happy with their careers. Some by living out the motto, “Do what you love[;] Love what you do”, as they not only improve the lives of patients, but develop young physicians into leaders, too [37]. Others by consciously recognize the communities, visible impact, connections, varieties of teaching, spiritual nature/calling, or sense of empowerment their work bring to themselves or others [38].
Personal Reflections on Burnout and My Final Thoughts
As for myself, I echo the above-aforementioned concerns by Dr. Murthy and appreciate the recommendations outlined by West et al. My intern year has been challenging on multiple fronts, and many times I was reminded of the teachings and stories mentioned in Dr. Samuel Shem’s House of God [39] while rounding on the wards. Grim realities that I did not consider as parts of my job as a physician before entering medicine hit me hard this past year. Not all patients get better at the end of the day, and social determinants of health [40] become as much a barrier to proper and efficient patient care for physicians as do understanding disease pathophysiologies, establishing definitive diagnoses, and applying evidence-based medical or surgical guidelines to treatment. Improper training in understanding these, although mandated in undergraduate medical education [41], often becomes a contributor to physician and resident burnout, especially as it pertains to spending more time “meticulously” charting patients’ medical records than actually spending personal time with them [42]. It surely has contributed to my own personal burnout, and navigating current transitional year Accreditation Council of Graduate Medical Education (ACGME) graduation requirements [43] has played a role as well.
So, in accordance with West et al., what have I personally done to address my own, individual burnout? Keeping with the overarching theme of time management and hours spent working, I have learned how to set appropriate boundaries between spending sufficient, meaningful time at work in my residency program, studying for boards, hanging out with my family and loved ones, and taking care of myself (e.g., sleeping, exercising). Coming to terms with that direct patient care (e.g., primary care) did not fulfill me professionally, while still wanting to help patients, physicians, residents, and medical students, I applied for pathology residency after gaining exposure in the field and finding great vocational meaning in it (i.e., finally loving what I do and doing what I love) [44-47].
Finally, I became more comfortable being open and vulnerable with my peers and co-workers regarding my thoughts and feelings. This year has not been all negative. In many ways, actually, this year has been among the best of my life. I am happily engaged and plan to start my own family in the next few years, I have developed many new great friendships and collegial relationships internationally, and I am now involved in meaningful research on how to use social media to promote accessible fellowship-level pathology education globally for free. Even though I was not able to help every patient I saw, I did the best I could to help out those whom I was able to, and for this, I am eternally grateful.
Medicine is a journey and a process. Although time may be against us as physicians and healthcare professionals, we need to continue taking appropriate steps toward ensuring adequate time to our patients, families, friends, loved ones, colleagues, and ourselves. However, this may look different for each individual. If it is reducing hours at work or finding other means for self-improvement, that is great. If it is addressing systemic barriers to efficient and adequate healthcare, that is great, too. Whatever the solution may be for each and every one of us, burnout among physicians and healthcare workers is a public health crisis [48] that still needs to be addressed.
References:
Gaurav Sharma, MD FCAP