February 18th, 2020
How Can Attendings Affect Resident Burnout?
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).
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.
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.
- 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.
- 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.
- 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.
- 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.
- 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.