October 26th, 2020

Futility as a Cause of Burnout in Residency

Holland Kaplan, MD

Dr. Kaplan is a Chief Resident in Internal Medicine at Baylor College of Medicine in Houston, TX.

At the beginning of my residency training, one of our program leaders defined burnout as “work out of proportion to meaning.” In a sense, I think this also defines futility – performing a disproportionate amount of work compared with the results or meaning you are deriving from the work. The proposed causes of burnout in residency are broad – emotional exhaustion, depersonalization, lack of “resilience,” inordinate workload, sleep deprivation, and lack of time for leisure activities. However, the perception of futility also plays a significant role in burnout for residents. Below, I outline how feelings of futility contributed to my personal periods of burnout during residency.

In the ICU

I grappled for a long time with whether critical care was a good fit for me. I enjoyed the complex physiology, the consistent application of all areas of internal medicine, and the opportunity to help patients and their families through extreme illness and sometimes death. But I noticed as I completed my ICU rotations that I routinely started experiencing burnout and severe emotional exhaustion about 2 weeks into these rotations. Having experienced burnout of various durations in different settings throughout residency, I wondered what the precise cause of my burnout was in the ICU environment. Several years ago, I wrote about an experience I had as a second-year resident in performing CPR on an unfortunate elderly patient with multiple untreatable medical conditions. For this patient, CPR was never going to be helpful. I argued that my patient with severe anemia, heart failure, and metastatic cancer, had he been resuscitated, would still have had severe anemia, heart failure, and metastatic cancer. A portion of my ICU experiences centered on what I felt were futile efforts at resuscitation of patients who would never benefit from CPR. I reasoned that surgeons have the option to withhold interventions that have a low likelihood of success; why are we in medicine forced to perform a procedure (CPR) that in many instances has a success rate so low that a surgeon would never operate with those same odds? My disgust with performing CPR on patients in which it was futile reached the point that I rushed to run codes for fear of otherwise having to perform chest compressions. I spent many sleepless nights during and after ICU rotations grimacing at the thought of an elder’s osteoporotic ribs snapping beneath my hands like twigs in a futile effort to revive them. This perception of intense futility led me to burnout on all of my ICU rotations and ultimately turned me away from a career in critical care. Thankfully, many satisfying and rewarding aspects of critical care draw residents to this field, including the ability to see fast turnaround in very sick patients and interesting and complex pathophysiology. But the emotional aspects can truly contribute to feelings of futility and burnout.

On the inpatient wards and in the clinic

I remember inpatient wards and certain experiences in clinic during intern year being particularly rife with feelings of futility. The emotional distress on the wards and the clinic focused more often on the inability to provide patients with the care I felt they needed and deserved, but were unable to obtain, due to insurance or other systemic limitations. However, in these settings, a unique fuel for these feelings of futility centered less on emotional distress. I remember feeling inundated with endless documentation, phone calls for prior authorization requests, trying to meet unknown requirements to get patients to subspecialty appointments, and struggling to get help from ancillary services like physical therapy and social work to discharge patients to a safe living environment. I recall spending 60 minutes on the phone with an insurance company to ask them to approve an SGLT-2 inhibitor for my clinic patient, only to have them tell me they had to try two other oral diabetes medications first. I remember endless wait times with the appointment scheduling line for our health system, only to be told that the creatinine on the lab from last week was not recent enough for the patient to get a CT scan with contrast; I would need a more recent creatinine value. These experiences are not unique, physicians both in practice and in training report a significant administrative burden in the inpatient and outpatient settings that contribute to burnout. The feelings of futility regarding the time spent on an objective compared to the outcome achieved (or not achieved) was a major cause of burnout for me.

Combating burnout

So, how can residency programs alleviate burnout in their residents? This question is worthy of its own blog post, and I think the answer differs based on the cause of the burnout. However, with futility as a common thread among multiple causes of burnout, I think emphasizing and celebrating the things trainees are doing that are making a difference for their patients is critical. For a resident who just performed 30 minutes of chest compressions on a patient who was never going to survive, it makes a difference to say “Hey, I know those chest compressions were rough, but I think the way you called the code at the end and asked for a moment of silence was really meaningful for the family and for the patient’s memory.” Or for a battle-worn resident who has just gotten off a long call with an insurance company, a supervising physician could make an impact by saying, “I know those calls can be frustrating, but look at the improved glucose control you’ve achieved on this patient since meeting him. We’ll try these other meds first, and next time we’ll know the requirements for this insurance company.” Whether you’re a colleague or a supervisor for a burned-out resident, never underestimate the power of a few encouraging words in the face of feelings of overwhelming futility.

Sources:

Mian A et al. Medical student and resident burnout: A review of causes, effects, and prevention. J Fam Med Disease Prev 2018; 4:1510094. (https://doi.org/10.23937/2469-5793/1510094)

Ishak WW et al. Burnout during residency training: A literature review. J Grad Med Educ 2009 Dec; 1:236. (https://doi.org/10.4300/jgme-d-09-00054.1)

 

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7 Responses to “Futility as a Cause of Burnout in Residency”

  1. Olga Barkay says:

    So right and so sad. Why are we obliged to perform invasive procedures on those unfortunate patients with incurable diseases only to prolong their suffering?
    I know, the answers are so complex. Ethics, religion, fear of being sued. Even politics…
    But what about those insurance companies that only care for money? Why do they pay for hospitalisation in ICU for patients who when survived continue to be such a financial burden? While “saving” on modern medications for people who still work and support their families. What an absurd!

  2. Really great article. You put down in words exactly many of the frustrations I experienced in my residency, and in my current job as a hospitalist. Often, just thinking about those experiences can cause my stomach to get upset. Until we can have more control over these issues, I think the burn out will continue to plague us. I hope things will improve in the future.

  3. Klaus T Meinhof says:

    Couldn’t agree more but will add that while we can’t fix the paperwork issues (hoping for policy makers to one day rise to that challenge), we CAN avoid futile efforts in many patients by communicating better (= more openly and in language that people understand). There’s no magic solution and there will always be families with magical thinking, but by framing a conversation in a way where you can sincerely assure a family that you are doing everything that is medically reasonable can go a long way. For that you have to build trust first and that is the hard part – it takes time. But having a better connection with families will also prevent YOU from burning out.

  4. Sneha Shah, MD says:

    Holland, you’ve so eloquently described how many of us feel. These are similar reasons for which I, too, was turned away from critical care medicine.

    Something I wonder about: in our attempt to rid medicine of “patriarchy,” has the pendulum swung too far toward autonomy? Of course, we must allow patients to make their own medical decisions but perhaps Internal Medicine can start viewing things like Code Status, offering feeding tubes, and certain treatment plans as procedures which are not offered to those who would never benefit from it.

  5. Delphine Hansen says:

    What a great article Dr Kaplan. I’m a fourth year medical student at McGill University. While Clerkship can be all kind of amazing things, like finally being on the wards, seing real patients and doing true actions rather than simulations, it is also the first encounter with bureaucratic delays and administrative endless forms. I often felt a certain unease with how much this was getting in the way of optimal care for patients and you’ve put the words on the feelings I couldn’t name.

    I really enjoyed how you finished your article with potential solutions, something as small as simply acknowledging and encouraging residents and colleagues when they hit this futility feeling. I will keep that in mind.

  6. Vivek Sant, MD says:

    Holland – great post summarizing feelings of futility leading to burnout. This parallels the world of surgery – long hours and hard work don’t cause moral injury as much as the feeling that the work you are doing is devoid of meaning, or futile in the care of a patient.

  7. David Chen, MD says:

    Thank you for sharing such a beautiful reflection. I just finished a month in the ICU, and I felt the same emotions as you. About half of my census at any given time were terminally ill folks whom we were artificially keeping alive out of the wishes of family. One patient with COVID ARDS coded twice two days apart before his family would make him DNR, and the most draining part of the experience was the daily conversations with the family about the futility and even “brutality” of doing chest compressions on him, when we knew with reasonable confidence that a code was imminent. And speaking of confidence, perhaps even more difficult was the feeling that through our prognostication we are sentencing people to death… Sometimes hope can breed a type of toxicity in the face of reality, one that leads to disappointment and futility.

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