The problem with residency is not necessarily the work hours. The hours are grueling for sure. However, the hours are necessary. My second year, the work hour limits were changed- no one was allowed to work more than 24hr shifts anymore. What we found was not that we were more refreshed and rested, but that it made life more complicated. The way that you learn in residency is by seeing the problem, the intervention, and resolution in a medical concern. If you cut out too many hours, you miss some of these steps. So when the problem comes up again later, instead of remembering exactly how it looked before, you are left with an insecurity because you don’t know how all of the steps will turn out. You don’t know either how to recognize it, how and when this problem gets worse before it gets better, how long to wait before intervening, or how to know when it’s done. Cutting hours left many with more questions then rest. It leaves you scrambling through more books and more referrals and more questions that leave you just as exhausted.
Follow-up is what makes you a good doctor. Sadly, in this day and age, “I haven’t seen the patient so I assume they’re better” is not actually true at all. You have to reach the resolution in order to learn so you know exactly what to do next time.
So when I realized that cutting work hours doesn’t create wellness and fix burnout, I was initially stuck. What are the recommendations for improving your health and your care if they’re not that simple?
I heard a podcast of a customer service business where workers spoke over the phone with angry customers. The business had written in all kinds of interventions to make sure the workers were not being burned out. They had scheduled, required breaks during their work hours. They had on site relaxation and game rooms that were used daily. They even provided counseling after difficult calls. It seemed like a great top-down approach to employee wellness. But then I remembered several residency interviews I had gone on where they had relaxation and game rooms on site that were always empty. It wasn’t the lack of opportunities that were causing problems, it must be something else.
An article I read recently was a meta-analysis review of burnout interventions for physicians. The conclusion was that “Burnout is a problem of the whole health care organization, rather than individuals.” They found that nearly half of practicing physicians experience burnout in their careers. But fixing those numbers didn’t depend on the individual as much as the organization.
As a company- if you don’t have successful wellness campaigns in place with no workers reporting stress then you aren’t trying hard enough to prevent burnout. In the last few years, most successful interventions have been made top down- cutting work hours and call schedules. But, as described above, these are not the most effective ways to enhance learning for students, and even when interventions are available, they are not always utilized.
It wasn’t until I went to a wellness day during my residency that I realized the problem wasn’t numbers. It was expectations. The lectures we listened to that day were physicians explaining how they made their careers and family work together. How they afforded to be respectable clinicians and also make it to their kids’ soccer game. And they way they did it was, basically, by not sleeping. As they talked, I added up the hours they were working in my head and realized they were working the same schedule that the residents did- working through lunch, staying up late at night to finish charting and papers after a brief break hanging out at a soccer game in the late afternoon. It occurred to me that the problem in the field is not the amount of hours worked, the work involved, or the interventions involved as much as it is the expectations we have placed on ourselves.
Because that drudgery, that pace started in residency never ends, we are burning ourselves out. It’s said that the hours will only be required in residency, but then the same is necessary to finish fellowship, do research, work in private practice, or work in the hospital. It’s neither wise nor sustainable to expect ourselves to work 80hrs a week for the rest of our lives. What needs to change most is the expectations for what does a normal week look like? And more than that- what should a typical providers job look like? How do we create more realistic expectations for ourselves?
How do we create more realistic expectations for our future providers? When I was a student the older providers frequently disdained us, admonishing us that they had done more than that when they were young. If they had to put up with it, then surely we did too!? How can we get to a place where we are fighting for each other instead of demeaning and placing each other in impossible and unending circumstances? If we can get a combination of not only ourselves, and our companies, and our fields fighting for our health and wellness, maybe we can see this field in ways it hasn’t done in years.