February 18th, 2020

How Can Attendings Affect Resident Burnout?

Dr. Daniel Orlovich

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

A Sad Short Story

Harvard medical school. Stanford general surgery training. Northwestern vascular surgery fellowship. Suicide.

This devastating path, taken by a 33-year-old trainee in 2010, is not unique.

  • An estimated one physician commits suicide every single day in the U.S. alone (JAMA 2014; 312:1725).
  • A number of these lives are taken on the hospital premises, places where physicians feel deep emotional and psychological connections.
  • Residents are part of a field which has the highest suicide rate of any profession (CMAJ 2018; 190:E752).
  • Suicide remains the second-leading cause of resident death and the number one cause of male resident death in the U.S. (Acad Med 2017; 92:976).
  • In 2019, suicide is considered an occupational hazard of medical training.
  • Compared with other college graduates, we trainees are 1.6 times more likely to suffer from burnout and twice as likely to feel depersonalized.
  • We score lower in quality of life indexes on all sections — mental, physical, and emotional (Acad Med 2014; 89:443).
two surgeons in an operating room

Photo by Vidal Balielo Jr. from Pexels

Valiant attempts, ranging from reduced working hours to dedicated wellness programs, have been made to alleviate this reality. Such coordinated efforts to prevent both burnout and death frequently focus on individual coping mechanisms. While this strategy has merit, attempts to mitigate unnecessary stressors from our healthcare environment are equally important.

During the past few decades, we have witnessed major changes in training and practice across the U.S. medical system. While being a physician remains an incredible privilege and offers a truly meaningful connection, changes have occurred in the work environment. Notable changes include the electronic medical record, malpractice litigation, and the volume of patient turnover. For example, the average length of patient stay decreased from 14 days to 4.8 days from 1983 to 2009 (J Health Soc Behav 2012; 53:344). Advances in the field have allowed patients to be discharged on postoperative day 1, as opposed to 1 week later. The treatment modalities, imaging, and necessary paperwork have increased. Today, “care” includes extra core elements that go beyond patient contact, including charting, social work, and coordination. Rather than focusing on “hours worked,” it is illuminating to consider what trainees are actually doing and the pace at which it is being done. Interns might spend less than 10% of their time providing direct patient care (Acad Med 2016; 91:827). Once they’ve graduated, today’s medical trainees enter a field that has failed to keep pace with inflation: Compensation has fallen 7.1% from 1995 to 2004, whereas debt burden has risen 270% since 1986.

What Can an Attending Do?

One positive aspect that has not changed is the guidance and impact that an attending can have on a trainee. Traditionally, trainee burnout is framed between two groups: trainees and the system. Based on my experience, I believe that one of the most effective forces to directly benefit trainees, and to help keep burnout at bay, is a third element: the attending-trainee interaction.

Attendings wield significant influence and power, correcting us when we need guidance and praising us for a job well done. As trainees, we look up to them, we learn from them, we want to mold our careers based on their input. With one genuinely constructive comment or action, they can invigorate our day. But one flippant or misplaced remark or action can be disheartening. While large, coordinated efforts such as reducing hours or implementing retreats is a step in the right direction, I believe that simple, low key actions throughout the day serve as the cornerstone in combating trainee burnout. In addition, attendings may glean immense satisfaction from teaching and mentoring, while trainees gain fulfillment from learning. Thus, the entire medical ecosystem benefits.

Try This

From our trainee experience (myself and Dr. Dua, cited below), we propose five actions that might not only mitigate trainee burnout but also benefit the attending by providing a better trainee-attending relationship. These cost no money and minimal time.

  1. Use a trainee’s name during interactions. It may seem insignificant, but it makes us feel human, provides an instant connection, and allows us to more easily absorb the educational moment.
  2. Provide a quick debriefing at the end of rounds or a surgery, with both positive and constructive criticism. Guidance is one of the most important things attendings provide and what we, as trainees, seek above all. At times, when the environment is purely service (time constraints or patient severity), a few spent minutes highlighting fundamental learning points and communicating what was done well and what needs improvement is impactful and makes the trainee feel that educational goals were met.
  3. Acknowledging that some situations are less than ideal, although they cannot be instantaneously remedied, allows the trainee to be heard. Trainees, especially junior residents, spend a good time amount of time coordinating care with phone calls and paperwork. It can be inefficient, extremely time consuming, and anxiety provoking, primarily because it is sometimes at the expense of a high impact and more practical learning opportunity. Major system overhauls would be required to change the current situation, but the work still needs to be done. Acknowledgement of this situation by attendings provides a sense of solidarity, given that attendings also serve our patients in less than ideal system circumstances.
  4. Say “thank you” to acknowledge trainee input. While there is educational value in dictating a note, setting up a room, or writing a new consult note, a few words of appreciation can add worthiness and make trainees feel like contributing members of the team. No one wants to be praised for every little action. This is not a “participation trophy.” Rather, these tiny words shed light and make the path forward easier to see.
  5. Ask a trainee how things are going — not just professionally, but also personally. We all know that some of us spend more time with certain attendings than we spend with our own family. This presents an opportunity to form a genuine connection. Asking how or what a trainee is doing once again humanizes this unique relationship and reinforces the attending’s role as a mentor.

Let’s consider the idea that there exists an often underutilized, overlooked, and influential resource in the fight against burnout. Attendings serve as a vital part of trainee education. As young doctors, we are affected by how we are treated by the people who have the most influence. In our experience, five simple remedies can offer consequential change: using our name, providing immediate educational feedback, acknowledging and displaying solidarity in less than ideal circumstances, expressing thanks, and asking personal questions. The attending-trainee relationship is a special sacred one. We encourage attendings to help us fight burnout through support, encouragement, guidance and camaraderie.

Special thanks to Dr. Anahita Dua who contributed to the concept, writing, and editing of this article. 


NEJM Resident 360

9 Responses to “How Can Attendings Affect Resident Burnout?”

  1. Ed Paul, MD says:

    Hello and thanks for the article Dr. Orlovich. I have been a faculty member in Family Medicine residency education for 30 years, mostly as a Program Director. I do appreciate and abide by your 5 action steps to mitigate trainee burnout; I believe that this is practical advice and right on target.

    The worst scenario is a trainee hanging around in the hospital or clinic as just another white coat, not being recognized or feeling valued as part of the care team. Orienting the student or resident to the setting is important on day one – even for an early third year medical student.

    It is important to make each trainee recognize the potential value that they bring to a patient encounter. As an example with third year students, I always talk with them about taking the opportunity to develop their skills and to practice active listening, being curious, and to learn to express empathy with patients. This is something that is distinct from their understandably weak medical knowledge base at their level of training. I tell them that I do not want them worrying about passing their next shelf or step exam and that I expect them to be present and in the moment with my (their) patients. Ensuring that students and residents connect with patients brings meaning to them as professionals early in their career and is in itself anti-burnout.

    Another rule that I ask my faculty to follow is to commit to spending a minimum of 60 seconds with a trainee at the end of a clinic session or hospital day. One can cover a lot of ground face to face with someone in 60 seconds whether debriefing, offering feedback, saying thank you, or asking them how they’re doing as your article suggests. I don’t accept the usual excuse from faculty that “I don’t have the time”. We all can find 60 seconds once or twice a day to be present with the trainee.

    Thank you for your attention to this important and timely topic. Ed Paul Flagstaff, Arizona

    • Daniel Orlovich, MD, PharmD says:

      Hi Dr. Paul,

      Thank you for recognizing the practicality of the suggestions. While it is a luxury to consider ideal solutions I find that, as you certainly already know, we all practice in an imperfect and less than ideal environment.

      Your comments about making the trainee recognize the unique potential and value they may bring are key. Your description about ‘just another white coat’ perfectly encapsulates a feeling that trainees may experience. “If I didn’t show, couldn’t someone else could have done this?” is, unfortunately, a question I’ve heard that reflects your apt observation.

      And I agree completely that connecting with patients is anti-burnout. Medicine, to me, is a conduit to understanding and serving others. While there are many challenges throughout the day, I feel that this connection is special and privileged.

      I will have to incorporate the 60-second rule as well throughout the day.

      I admire your practical solutions and a unique perspective.

      I’m curious – what other challenges have you found to suggesting attendings spending 60 seconds with trainees?

      Again, thank you for the kind words and taking time out of your day to read my thoughts.

  2. Stephen Wood says:

    This is a well written commentary and brings to light some very important statistics on depression and suicide in medicine, particularly in trainees. There is a distinction here however in terminology that needs to be more clear. This article addresses what is more likely to be underlying depression rather than burnout. Burnout is defined as feelings of exhaustion, increased distance from one’s job and career and reduced professional activity. It is often preceded by moral injury. While there is a great deal of cross–over, there is a difference between burnout and depression. Certainly these recommendations can be helpful. Similarly, developing programs that teach mindfulness and resilience will help with burnout and to some degree depression. It must be recognized however, that depression and suicidality requires psychiatric care. Terminology matters and trainees that are demonstrating symptoms of depression and suicidality should be supported as suggested, but also referred to psychiatric care and other support services.

    • Daniel Orlovich, MD, PharmD says:

      Hi Dr. Wood,

      Thanks for taking the time to read and comment thoughtfully.

      I agree that depression and burnout are not, as you have pointed out, the same entity. To take it a step further I believe fatigue is not the same as burnout, either.

      And yes, I agree that those who are in need of urgent psychiatric interventions should seek immediate medical attention. It appears to me that some physicians may be resistant to having a formal diagnosis. So colloquially I’ve heard what you are describing as ‘beyond burnout.’ This implies to me that, again, burnout and depression are not the same things.

      I am of the mind that improving the workplace is important. To be clear burnout is not a trainee’s fault. With that being said, I do believe trainees are able to affect their day to day activities more quickly than a large healthcare entity. The healthcare organization still has a duty, of course.

      In addition, I feel that acknowledging the real drivers of burnout are important. Without proper ‘diagnosing’ we too often throw out one-size-fits-all solutions. Solutions, such as mindfulness and other well-proven techniques, are certainly helpful. I am encouraged by seeing the resident-led initiatives and openness of some programs to actively seek input from residents.

      Again, thank you for the thoughtful response. Happy to hear any additional thoughts you may have.

  3. Kyle Bradford Jones says:

    Thank you Dr. Orlovich! This is a very important topic. Your discussion about the negative impact of training on mental health is critical to further awareness and change. I have a book coming out in April about this very topic: Fallible: a memoir of a young physician’s struggle with mental illness (https://amzn.to/3c04Mrp). I hope it will continue the discussion even further. As an academic Family Physician, I try to implement your suggestions regularly. Please keep up your efforts!
    Kyle Bradford Jones, MD, FAAFP

    • Daniel Orlovich, MD, PharmD says:

      Thank you for recognizing this is an important topic in our field, Dr. Jones. I am looking forward to your book coming out. What particular angle do you take on the matter? And what message do you wish to impart on the reader? I will reach out to you. I’d love to have you speak on the issue on the Solving Resident Burnout podcast. I’m always looking for authentic takes from physicians addressing timely topics.

  4. Lea Monday says:

    Hi Dan, wow what a great practical article. Especially the part about acknowledging the often not fixable and terrible situations we find our patients in and how it requires so much extra time and paperwork from trainees. As a recent grad, I cannot express enough how extremely frustrating it was when attendings would suggest things be done (home health aids, ordering a motor wheelchair) yet had absolutely no appreciation for the complexity and hours long time commitment and often prolonged phone and fax follow up to the task, and also no knowledge what so ever if how to teach me to do these things (residents tend to learn this from other residents). The ultimate annoyance is an arrogant attending which prattles on about how younger docs don’t know how to do their own paracentesis (send to IR) or gram stains. Trust me I would much rather spend an hour on a procedure or in the lab rather than on the phone scheduling 3 follow up visits and fighting about a prior auth. A simple acknowledgement of the way these soul sucking activities detract from satisfaction and personalization would go a long way, even if doing nothing to solve the problems. This is SO spot on. Cheers from another PharmD,MD 🙂

    • Daniel Orlovich, MD, PharmD says:

      Dr. Monday,

      Thanks for taking the time to read and comment.

      And yes – you hit the nail on the head about a simple acknowledgment going a long way even if it doesn’t completely solve the problem. When I hear a supportive comment that acknowledges all the extra work required it definitely makes me feel that we’re all in this together. It is a messy system – we’re trying our best to navigate it for ourselves and for our patients.

      PS – That is great you’re an MD PharmD as well! Nothing like a package insert, pharmacokinetics, pharmacodynamics 🙂

  5. Ricarda Addington says:

    I agree with you

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