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

7 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

    • Daniel Orlovich, MD, PharmD says:

      Katie,

      Thanks for taking time to read and share what is going on at GW. Well done for making meaningful changes!

      I completely agree that it is about the day-to-day situation. And yes, I think while it may only be one to two tiny things the larger message it conveys is what resonates with residents. Namely, there can be a dialogue between the program and residents and that changes can occur.

      And you bring up a good point about not measuring the interventions in terms of hours worked but rather focusing on residents feeling supported and listened to. While there seems to always be a vigorous debate around the 80 hour work limit, I believe that other metrics may be just as meaningful. Resident burnout is more than just hours worked. What are we doing when we are there? What is the pace? Do we feel supported? Do we feel heard? How are we interacting with others?

      I’m interested in learning more about what you’ve done at GW. What were the hurdles you faced when taking non-physician tasks off the residents’ plates and how did you overcome them?

      PS – I appreciate the respect but please call me Daniel 🙂

  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.

    • Daniel Orlovich, MD, PharmD says:

      Mohammad,

      Thanks for reading and replying!

      You bring up a common point that a lot of residents have told me about residents being viewed as ‘cheap labor.’ Here is my personal opinion. Of course there are different ways of achieving changes in the culture. I am of the mind that a data driven, properly framed, cooperative, specific, and coordinated approach may be beneficial.

      By ‘data driven’ I mean certain metrics are gathered by residents. This will identify key themes, serve to focus the talking point, and streamlines the communication with the program. Ideally these would use gold standard metrics like the Well-Being Index by the Mayo Clinic of Stanford WellMD’s survey. As W. Edwards Deming said “Without data you’re just another person with an opinion”

      By ‘properly framed’ I mean recognizing what the program values and using the terms and priorities of the program. If it is ‘cheap labor’ as you have suggested then perhaps financial metrics would be most prioritized by the program. Obviously different programs have different values. This may help frame the issue from ‘your’ problem to ‘our’ problem. In a sense this is translating the message.

      By ‘cooperative’ I mean how can residents work with the program in good faith so that it becomes a ‘win-win’ for everyone involved.

      By ‘specific’ I mean that one to three minor and major solutions are proposed and selected by residents. Since residents are on the front line perhaps we also have access to what would help improve the situation. The minor solutions help refine this entire process, increase buy in, and strengthen the relationship. The major ones take more time, of course.

      By ‘coordinated’ I mean that residents have engaged with key stakeholders. This could be attendings in their department, different departments, different roles such as nurses, and even outside funding (industry, private donors). Residents only have so much time and energy, I know.

      Please let me know if I misunderstood your question. I’m happy to clarify if it is unclear at all 🙂

  3. Cheryl says:

    Thank you for your insight on tapping into the small things that can have a huge impact on resident wellness. Another area trainees should consider is EQ or Emotional Intelligence building. I was invited to a Clinical Wellness Grand Rounds on Wellness just last week and it blew my mind. The focus was on taking the time to be grateful, demonstrating kindness to your team and patients as well as taking a moment to consider the other side. While trainees go into programs knowing some of the challenges, it has become apparent trainees (maybe its twenty-first century trainees) have a sense of entitlement. This entitlement emerges in different forms such as juniors do not feel the senior residents know as much and thus seek information directly from leadership. Rather than complain why not exercise self-awareness, which lends to a sense of gratitude in turn ultimately emerging in to kindness to team members and patients.
    In healthcare, it takes an entire team including program leadership, coordinators and other ancillary services. Residents with a higher EQ tend to be thoughtful in their approach in handling matters (both clinical and non-clinical), ultimately resulting in less burnout.

    • Daniel Orlovich, MD, PharmD says:

      Cheryl, thanks for reading and committing!

      I agree with you about the merits of EQ. It is, like you mentioned, another tool that doesn’t cost much money and has the ability for a tremendous impact. I’m sure you’ve looked over Daniel Goleman’s book “Emotional Intelligence.”

      And I am glad you brought up the protective effects of EQ. It seems to be associated with less burnout, better performance, and improved well-being specifically for residents.
      – Talarico JF, Varon AJ, Banks SE, Berger JS, Pivalizza EG, Medina-Rivera G, Rimal J, Davidson M, Dai F, Qin L, Ball RD. Emotional intelligence and the relationship to resident performance: a multi-institutional study. Journal of clinical anesthesia. 2013 May 1;25(3):181-7.
      -Hollis RH, Theiss LM, Gullick AA, Richman JS, Morris MS, Grams JM, Porterfield JR, Chu DI. Emotional intelligence in surgery is associated with resident job satisfaction. Journal of Surgical Research. 2017 Mar 1;209:178-83.
      -Weng HC, Hung CM, Liu YT, Cheng YJ, Yen CY, Chang CC, Huang CK. Associations between emotional intelligence and doctor burnout, job satisfaction and patient satisfaction. Medical education. 2011 Aug;45(8):835-42.

      In regards to the complaining from juniors perhaps this could be used as a signal and opportunity to precisely define the problem and brainstorm solutions. In addition, perhaps programs could place importance on EQ when selecting for and training residents.

      • Cheryl says:

        Thank you for your response. Yes, I also agree about establishing criteria for EQ during resident selection and training. I recommended EQ 101 as well as leadership to one of the PDs as part of the plan of action. It also appears, the incorporation of what some may view as soft skills is new to clinical training and may present roadblocks, however; it is worth exploring further.

        I am in the process of completing a study but from a just as important member of the program team; the program administrator. I hope to share the data with you as well. In any team, any weak members may impede on the team’s growth.

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