The State of Residency Training

The good old days of medicine was when residents spent 120-150 hours a week in the hospital. Senior faculty fondly remember how much they learned and how little they slept. The kids at home would be taken care of by their wife and family time would be make up when residency was over. Medicine tried this training model for years, and it has failed horribly. We now live in an era with astronomical rates of physician burnout, unhappy marriages, and even physician suicide.

The 80-hour work week was instituted in 2003 as a direct result of the death of Libby Zion from drug-drug interactions leading to serotonin syndrome. Since these work hour restrictions were put in place, faculty of prior generations have been adamant that residents no longer receive the highest quality education and that residencies must be longer to maintain the same quality of training. The evidence for this claim is non-existent.1

As a millennial, I now want to know, “why would I want to be trained in the way that resulted in an epidemic of depressed, burnt out, and suicidal doctors? Is it true that I am seeing less patients or am a worse surgeon than our predecessors?”

The State of Physician Burnout

Physician burnout rates hover around 40-60%, depending on the survey or study sampled, which is substantially higher than nurses, retail workers, teachers, and even fast food workers. Physicians experience depression at a rate of 15%, compared to the national average of 10%. Worst of all, the suicide rate among doctors is twice the national average (28-40/100,000 vs 12.3/100,000).2

The most recent data shows alarming increases in burnout over time. Over just three years from 2011 to 2014, physician burnout increased almost 10%.3 Interestingly, a study on resident burnout, also in 2014, found burnout rates of 20-30%; significantly lower than that of physicians suggesting that this is NOT a “whiny millennial” problem. Also interesting is that the general US population is experiencing less burn out over that same time period.4 In the annual Medscape survey, the top four reported causes of burnout were

Too many bureaucratic tasks Spending too many hours at work Feeling like just a cog in the wheel Increasing computerization of practice (EHR)

There is some data to support these results.5 A Mayo Clinic study was able to correlate the time a specialty spent on their computer with the percentage of physicians in that specialty that felt burned out.6 The increase bureaucratic tasks that are now required by the physicians and cannot be done by the front office or nurses are a direct result of the EHR compartmentalizing everyone into specific roles. Even the layout on EPIC is different depending on your role in the team. Large systems work efficiently in an assembly line model, but working in an assembly line is not good for the psyche of a physician.

Now, repeat after me: ‘The demand for a greater work-life balance does not come from a place of being lazy.’ It comes from wanting to live a full-filling life. The older generations have proven to us that their training model is not successful in making me a happy person who will have a long and successful career. Maybe it is time to be open to something different. Does this mean that we will be worse at our job? I do not think so.

Can We Learn More in Less Time?

There is no doubt that physician shortages are growing. The shortage is exacerbated by (1) the increased utilization of healthcare by the aging population, and (2) the limited number of ACGME residency positions. Funding for residency training has remained stagnant since 1997. It’s therefore simple to deduce that there are more patients per resident now than there were 20 years ago. Regardless of the number hours worked, residents now are seeing and caring for more patients than they were in the past. Despite the commonly repeated mantra, there is mixed data on whether or not operative numbers have gone down since work hour restrictions were instituted.1, 7, 8 It may be true that there are fewer residents in the hospital at any one time, but the residents now are seeing more patients, caring for more complex pathology, and absorbing more information in a shorter time than the older generation. The AAMC understands all this and is supporting legislation to increase residency positions by 3,000 per year over the next five years.

Furthermore, trainees are now able to absorb more knowledge from the easily accessible articles, books, videos, and multimedia resources that did not exist in the past. The days of doctors past was one without the internet – where trips to the library and sifting through textbooks to find relevant pathology and disease processes was necessary. This world sounds like ancient history to the modern trainee, and the perspective on good training necessitating long hours in the hospital should also be ancient history.

The youngest millennials were born one year before Pubmed went public in 1997. The first iPhone came out 4 years after the Libby Zion Law passed. As technology moves rapidly, the access to publications and textbooks becomes easier by the day. This generation has instantaneous access to the world’s knowledge literally at their fingertips. There is no question that these current residents are able to gain information at a lightning fast pace when compared to previous generations.

It is easy to see why video learning would be better suited compared to reading in textbooks when learning about procedural and anatomical aspects of medicine. Looking at still images and reading about a bone marrow harvest or a Whipple procedure is nothing compared to actually seeing it being performed. Even anatomy is easier to understand while it is being actively dissected compared to looking at it in a book. Multiple studies have corroborated these theories.9, 10, 11 What is more interesting is that procedural videos have even been shown to be at least comparable to a live demonstration for teaching. Being able to pause, rewind, and cross reference videos with complete control has huge advantages from a live group demonstration –in the latter, rewinding to review a difficult component is impossible, and perspectives are limited to the teachers present. While there is no replacement for on-the-job cadaveric teaching, virtual reality training will soon disrupt the way medicine is taught. For now, videos provide the current generation with a huge advantage over those who experienced previous training models.12

The idea that trainees are now worse at their job due to work hour restrictions is not found in rational analysis. The improved rules and regulations regarding trainee working conditions is certainly a step in the right direction. For a multitude of reasons, physicians are struggling with mental health more now than ever. How can we expect physicians to do their best in taking care of patients if they cannot take care of themselves? As our world around us changes, we are exposed to different challenges as well as oppertunities, and our training system must adapt to reflect that. From a perspective of the betterment of society, we need doctors who enjoy their job and are able to have long and cherished careers. That is something we should all be able to agree on.

Where Do We Go From Here?

As we transition into junior and more established faculty I believe we need to reject the peer pressure that has been placed on us to despise those who want a more well-rounded life. We need to stop labeling those individuals as weak or not passionate. Only once these toxic mindsets are relinquished can we begin to put systems in place that empower physicians to lead more effective lives – both for themselves and their patients. Physicians can love their job. They need not feel like martyrs.

When I was a second-year resident, a senior faculty speaker discussed ways to combat burnout. It was a great lecture that highlighted the importance of taking responsibility for our lives beyond the hospital, including effective sleep schedules, proper nutrition, and regular exercise. The very next week, the same faculty member proposed during conference that the residents be more heavily involved in research. The week after that, another faculty member demanded we spend more time reading in preparation for our upcoming in-service. And the week after that, we had to spend more time in the microsurgical simulation lab to prepare for conference… and it goes on and on. The solution to burn out is not to demand that the burned-out individuals do more stuff. This is not a problem of the individual – weakness, poor time management, etc. – but rather a problem of the system.

Current systems are clearly not working. Nearly half of all physicians are burned out, and suicide rates amongst doctors is double the national average. In the simplest of terms, how can we get physicians to love their jobs again? On one hand, we can focus on the positive – how do we make physicians enjoy their work more? On the other hand, we can minimize the negative – how do we make physicians less burned out? While work hour restrictions aren’t the end all solution, it’s a structural change heading in the right direction.

MD Anderson and other pioneering institutions have begun sending daily emails providing recognition for physicians performing their job well. Recognition can be for something as simple as correct hand washing technique or helping with dressing changes or spending a little more time with a distressed patient during morning rounds. This has encouraged a culture in which the nurses are not only ‘writing up’ individuals who act out, but also ‘writing up’ physicians who display positive traits. I know this puts a smile on my face to get that email in the middle of a busy clinic day.

This is obviously not enough, but the whole is greater than the sum of its parts. With changes to the structure of medical training, even including the small things, we can engender more positivity in the hospital. It has been a few years since I was a second year, and my own program has made significant changes along these lines thanks to progressive and open-minded faculty. I truly believe that it has become the best and most well-rounded program in the country while guiding residents in a direction that teaches them to love what they do.

This is not a problem of the individual, and the onus of responsibility is not on medical students and resident physicians. While optimal time management and healthier lifestyle habits certainly help, it’s far from enough. Doctors need systemic change. Patients need systemic change. The future of medicine depends on doctors continuing to find meaning in their practice.