November 12th, 2019

Can Minor Changes in a Program Affect Resident Burnout?

Dr. Daniel Orlovich

Dr. Orlovich is a Chief Resident of Wellness at Stanford University

“How did you like it there?” I ask, sitting down next to a new fellow (between bites of a plump sandwich, hoping there is no spinach in my teeth). 

I expect to hear the standard resident talking points — long hours, frequent call, and ballooning student loans. Instead, she surprises me. 

“Do you know how much they charged us to park there every month?”

I frequently text friends who are residents at her previous program. It is a program I respect — complex cases, the right amount of autonomy, meaningful research opportunities, and faculty dedicated to resident development. Things a resident wants in a program and things a quality program delivers.

She continues to list off things that could appear to be so inconsequential — lack of call rooms, cafeteria overcharging and closing early, and being called by her first name by staff in front of patients. I just met her, but I sense she isn’t whining or trying to win a pity award. Instead, she is opening up. Being vulnerable. Speaking trainee to trainee. I dab my mouth with the beige napkin and continue to listen. 

“Do you know how many cavities I have now?!” I perk up and shake my head in disbelief as I finally swallow that bite of sandwich. 

The more I think about these minor things and how they make some residents feel, the more the whole concept begins to make sense.

Minor Things

Most residents I’ve talked to will embrace the inherent challenges of residency. That means waking up early, staying late, and mastering the nuances of a field that proposes intellectual, emotional, physical, and moral challenges. Residency should be challenging. Residents know that it is temporary. But here is the sticking point: Residency shouldn’t have to be any more challenging than that. 

Minor things may be making residency unnecessarily more laborious and taxing than it has to be.

At times, I get the sense that the discussion about resident burnout is centered around large system-wide changes. Such sweeping changes merit careful consideration. However, do talks about the system overshadow and crowd out an additional issue — the minor things? 

Maybe improving resident burnout doesn’t require moving a mountain. Photo allowed with permission from Solving Resident Burnout.

I propose we consider these seemingly inconsequential and minor changes. This is in addition to, rather than instead of, larger changes. Things like getting quarters for laundry, going to the DMV, getting something notarized, picking up packages at the post office and, yes, going to the dentist. 

In isolation, one could view these minor changes as trivial. I can certainly see how it can be taken that way. To be clear, these minor annoyances are not more important than learning to become a physician. But here is the main message — taken in the right context, although the theme is clear: “Your input is valued and we are listening, you are a human being, and we respect you.”

So here is the key question: Are there minor ways in which programs can listen to what residents want and then deliver those things without radically changing the system? This means a residency program may already have allocated the time or money. These minor measures won’t fundamentally change the well-described barriers (culture, leadership, and financial incentives) to improving the system. Nor do these minor changes excuse us from having frank discussions and acknowledging ripe areas of opportunity. However, these tiny steps are a start. They may serve as a small foundation of trust and communication between programs and residents. They may herald a new way of approaching old problems. They may seem more real and tangible. And, they may even be easier to implement, since they offer a way to gradually make changes from within the system instead of retooling the entire system. 

A Recent Study

Are there any data to support using an existing framework to promote resident wellness in a minor way? Let’s look at a recent study of nearly 60 radiology residents (J Am Coll Radiol 2019; 16:221). These residents had 15 vacation days and 12 sick days. That means the program already had these days covered and funded. But here is where it got interesting — the program renamed 5 sick days and instead called them “wellness days.” Simple rebranding. These new “wellness days” could not be used on Mondays or Fridays to extend a vacation. What was the result?

  • The non-burnout group used more wellness days (71%) than did the burnout group (45%).
  • 86% of residents strongly agreed or agreed that “wellness days can help reduce or prevent burnout.”
  • 68% of residents strongly agreed or agreed that “wellness days have had a positive impact on experience as a resident.”

On the surface, these minor changes seem, well, minor. With a closer look, they reflect an expert understanding of the following: 

  • Listening to residents
  • Implementing cost-effective solutions
  • Working within an existing framework
  • Allowing residents the autonomy and freedom to engage in wellness activities of their choice

Take Home

We all know by now how bad resident burnout is. So minor solutions like the one above are reasons for hope and measured optimism.  Of course, minor solutions certainly won’t fix all the structural maladies plaguing our training system. Nor are minor changes ideal. But they are a practical step in the right direction. And it is a step that doesn’t require asking for money, going through 12 committees, or depending on large governing bodies to approve changes.

The main message is this:

  • Residents are on the front line — listen to them, because they may have creative solutions and insight.
  • Solutions don’t have to be expensive or require a dramatic overhaul — the framework may already exist.
  • These solutions may be considered “minor” but may be highly valued by residents and decrease resident burnout.
  • Residents know what makes them well — allow them to engage in activities of their choice. It is not a one-size-fits-all approach. 

And now I’d welcome and encourage your feedback. Would this work or not? Are there any other “minor” solutions that could be implemented?

The post and comments were prepared by the author in his personal capacity. The opinions, views, and thoughts expressed are the author’s own and do not necessarily reflect the author’s employer, fellow employees, organization, committee, or other group.

NEJM Resident 360

2 Responses to “Can Minor Changes in a Program Affect Resident Burnout?”

  1. Kathryn (Katie) Humes, MD says:

    Hi Dr. Orlovich,

    Really interesting article. I don’t think this particular solution would work for our system (I’m a chief resident at GW), but it’s an interesting take. I think it brings up one thing that I’ve heard from residents and full-fledged practicing docs–it’s about life day-to-day. Changes with true impact should be ones that make doing your job day in and day out more enjoyable, more efficient, or more fun. We have tried (over the last few years) to do small things and implement small changes (with the wonderful support of our program director) to take non-physician tasks off the residents’ plates. It amounts to one or two less small (and very annoying) things to do throughout the day that probably wasn’t even much of a time-suck, but was pretty clearly something that shouldn’t be their job. The feedback we have received is that they just feel more supported and listened to (even if their day isn’t cut shorter and the amount of work they are doing isn’t really changing). They feel like we are on their side.

    Thanks for your insights!
    Katie

    Kathryn Humes, MD
    Chief Resident, internal Medicine
    George Washington University Hospital

  2. Mohammad Kassem says:

    Great article. Interesting to see how programs have listened and made some changes. How does one attempt to change a new program culture that is resistant to most if not all changes from the residents under the guise of “education”?

    Unfortunately, many programs have the notion that residents are simply cheap labor to cover gaps in the schedule, and I completely agree with the article and previous comment, that small things could change the perception of how the program views the resident labor force.

Leave a Reply

Your email address will not be published. Required fields are marked *

Note: This is a moderated forum. By clicking on the "Submit Comment" button below, you agree to abide by the NEJM Journal Watch Terms of Use.

Our physician bloggers cannot respond to requests for personal medical advice, and recommend patients discuss health issues with their individual physicians.

Resident Bloggers

2019-2020 Chief Resident Panel

Prarthna Bhardwaj, MD, MBBS
Eric Bressman, MD
Allison Latimore, MD
Daniel Orlovich, MD, PharmD
Frances Ue, MD, MPH

Resident chiefs in hospital, internal, and family medicine

Learn more about Insights on Residency Training.