I am now one and a half years in, about halfway through my postgraduate medical training. Admittedly, at times I wonder if I should soldier forth. I question my path not because I dislike patient care or relish self-pity. But any rational actor in today’s medical industrial complex wonders, at times, whether the labor is sensible and the effort sustainable.
In fact, since graduating from medical school nearly 2 years ago, my five best friends have all elected to forgo further clinical training. Today’s trainees have exposure to alternate career paths in tech, consulting, and policy. Contrast this with the bureaucratic, burdensome, and burned-out world of clinical practice, and this “MD drop out” trend makes sense. A recent article described the rise of online communities of dissatisfied and disaffected doctors, such as Drop Out Club and Physicians Nonclinical Career Hunters, looking to change careers. This is alarming, given an impending shortage of physicians in the United States.
Leaders of medical education and provider systems agree that this nationwide phenomenon of physician burnout is adversely impacting our already troubled health care system. Many physician leaders blame bureaucrats and administrators for saddling us with more paperwork. Bob Wachter argues that endless quantification and comparison of the measurable aspects of care delivery are eroding physician autonomy and compromising the art of medicine. Abraham Verghese bemoans the time we spend treating the “iPatient” in the EMR at the expense of the real patient in the hospital bed. A group of leading hospital CEOs contend that “the spike in reported burnout is directly attributable to loss of control over work, increased performance measurement (quality, cost, and patient experience), the increasing complexity of medical care, the implementation of electronic health records, and profound inefficiencies in the practice environment, all of which have altered work flows and patient interactions.”
These trends undoubtedly contribute to physician burnout. Yet the common thread here is pointing the finger outward — at administrators, policymakers, and “the system” — before examining our own complicity. As I navigate through training, it has become glaringly evident to me that the way we train primes us for burnout.
The literature cites six key ingredients of burnout: high job demands in conjunction with a lack of control; disconnect between individual values and that of the organization or system; insufficient rewards such that one feels taken for granted, undervalued, and/or undercompensated; work overload; unfairness; and breakdown of community. Medical training provides the perfect recipe. As soon as we enter the hospital, the floodgates open with minimal relief. Our ability to advocate for patients’ safety is limited by our own emotional exhaustion and separation from administrators who set the institutional policies. We strive to serve patients, yet we spend most of our days cranking the hospital’s billing machinery.
Now saddled with debt from medical school, we are paid barely above minimum wage with limited flexibility to tend to other life responsibilities. Too much work, too few resources, too urgent: check, check, and check. And even though we are surrounded by our colleagues, a strong sense of community is diluted by ever changing schedules, rotating teams, night shifts, and hours lost in the vortex of Hyperspace.
This “system” we blame for physician burnout is in part a product of the system by which we train doctors. But because patient care is top priority, there is an unspoken tendency to consider changes to the work environment and training process as less important — even when these changes would clearly benefit patient care.
I am grateful to be a part of a supportive training program with leadership committed to helping me thrive. That said, internal research conducted by a colleague shows that nearly half of residents in our program experience burnout — no different than the national average. Recently, during my own bout of burnout, I sounded the alarm and asked for an extra day off (meaning my first 2-day weekend in nearly 3 months). Thankfully, my plea was granted. Yet the whole episode transpired behind closed doors to secure the necessary coverage and maintain parity in the program.
What could have been a catalyst to spark an open, program-wide conversation was confined to a covert operation. So instead, the conversation spiraled in my head. And what began as a proactive request for help soon morphed into feelings of guilt and shame for shirking my responsibility to prioritize patient care. I began to confuse preventive self-care for neglectful patient care, to mistake self-awareness for self-indulgence, and to suspect rest as a sign of weakness. I felt alone.
It is no wonder trainees often feel isolated, fearful of failure, and chained by perfectionism. Such an environment does not welcome questioning or self-doubt. It becomes easier to shut up, to accept the inevitable, and to internalize powerlessness in the system, rather than challenge the norms. When we repeatedly feel a loss of control in a situation, it is human nature to act in a powerless manner and overlook opportunities for relief and change. This so-called “learned helplessness” is strongly correlated with depression and is highly prevalent in hierarchical systems. Most disturbingly, learned helplessness is a self-fulfilling prophecy.
Based on conversations that I have had with many colleagues, I am certain that many more would abandon clinical training if not hindered by learned helplessness, debt, or the expectations of mentors and family. Perhaps in days of old, the medical training process was indeed a rite of passage justified by the shining promise of professional independence and authority. However, learned helplessness, once limited to the rigorous years of residency, now spans the entire career of many clinicians. Effectively, the medical training system conditions us to a lack of agency, which now underlies many practicing physicians’ feelings of professional dissatisfaction and burnout. Since we are complicit in creating this problem, we must be part of the solution.
How do we take an active role in unlearning learned helplessness? Start with the institutionalized norms that are contributing to trainee burnout. All residents should have representatives who have real negotiating power with hospital leadership, to protect our own well-being and to champion patient safety, both of which suffer when pitted against the pressure to rapidly turn hospital beds. (I am encouraged by the formation of the Brigham and Women’s Housestaff Council to cohere a collective resident voice across all training programs.) All residents should have the opportunity to innovate and drive change from within our own hospitals and clinics and out into the communities we serve.
To create an effective and equitable health care system, we need physicians who are not only patient advocates, but also social activists. To develop this skillset, residents should be offered formal training in effective communication and leadership of multidisciplinary teams. I am grateful that my co-residents are willing to use any spare time and even defer higher incomes for additional years to pursue management degrees, build advocacy campaigns, and spearhead quality improvement initiatives. Most important, all residents should have protected space and time to engage with the art of medicine by sitting alongside patients, rather than isolated behind a computer screen. I am relieved that even though we are often unable to realize this ideal, the desire persists among many.
The economics of health care and the traditions of medical training have made residents — this next generation of physicians who we desperately need to be leaders of health care reform — a standardized workforce shackled by tradition and dulled by inertia. A fellow intern said it best: “The key to looking inward, to strengthening our profession and institutions to better engage with the challenges around us, lies with residents, the link between what medicine is and what medicine can be.” Sadly, this friend is one of the five who left clinical training, each of whom would have been compassionate and competent clinicians. I feel sorrow for all the patients who could have benefitted from their care. And I feel frustrated for my profession, which could have rediscovered more joy, fulfillment, and solidarity under their leadership. Yet here I am, halfway through and stubbornly hopeful because beneath frustration lies the raw energy to activate change.