This article explores why residents are at even higher risk of burnout and mental health deterioration than the ‘average’ physician population – a population with a 63% burnout prevalence as of 2022. We then look at the evidence base for resident burnout prevention programs and consider why postgraduate education providers should seriously consider investing in these.
One day you’re a student, the next a #REAL DOCTOR (JNR) on the hospital wards. If you’re anything like me, there is a completely normal period of Impostor Syndrome overlaying feelings of panic, overwhelm, disappointment, and occasional tears (of laughter or not).
So, you’ve just graduated after 4 (or more) years of gruelling med school. You’ve now got the big M.D. after your name which, suddenly, makes your mother happy, the world your oyster, your marital prospects significantly better (according to my maternal progenitor).
One day you’re a student, the next a #REAL DOCTOR (JNR) on the hospital wards. If you’re anything like me (and the majority of physicians we have coached), there is a completely normal period of Impostor Syndrome overlaying feelings of panic, overwhelm, disappointment, and occasional tears (of laughter or not).
For many of us, this passes and we settle into Residency – the four or more years that make us a #REAL DOCTOR (SNR).
These Residency years can make or break us. They certainly did both for me.
I remember putting up my first central lines and chest drains in the ER; the lovely old Greek lady with terminal cancer who tried to pair me with her lovely daughter; death all over with occasionally successful resuscitations; trauma calls; bleep panic attacks; those loooong corridors and slow lifts.
Literally “catching” a very insistent crowning baby in a taxi in the hospital car park.
The taxi driver asking me if I was going to clean up the mess I had made.
I recall the camaraderie of our small group of Interns with fondness.
I also recall the 100-hour weeks (there are only 168 hours in a week; that leaves 9.7 hrs a day for sleep and everything else). That broke me. And the unnecessary and entirely preventable patient deaths in a city where life had little value.
Broke me: I also recall the 100-hour weeks (there are only 168 hours in a week; that leaves 9.7 hrs a day for sleep and everything else). That broke me. And the unnecessary and entirely preventable patient deaths in a city where life had little value.
Within 6 months I was burned out and shortly afterwards I was prescribed my first course of antidepressants.
I was fortunate. I felt able to approach the head of psychiatry. They were skilled at extracting the truth from this master of disguise. Together we worked out a care plan: medication and therapy. I got better.
Burnout appears to originate early in training. Studies of physician empathy and altruism metrics show that empathy begins to decline in medical school, and that trend continues during internship and residency.
A systematic review with meta-analysis, which included 47 cross-sectional and cohort observational studies with more than 22,000 residents from different specialties and from various countries in Europe, Asia, and America, found a 51.0% mean prevalence of burnout.
The same review found that Radiology, Neurology and General surgery were the specialties with the highest prevalence of burnout syndrome in its residents (>60%), followed by Internal Medicine, Traumatology, Dermatology, Gynaecology and Neurosurgery (50%), Psychiatry residents ( 43%) and those of Medical Oncology and Family Medicine (40%).
Most disturbingly, burnout rates increase with more time spent as a resident: In a review of burnout studies, multiple papers showed increases in burnout rates every year: from 60 to 70% in 3 months of residency in Ireland; in the USA, burnout increased from 38% in Residencey Year 1 to 64% by year 5.
It’s not only burnout that increases during residency. Depression and suicide risk increase too.
The seeds of mental illness risk may be sown during medical training, when thoughts and behaviors related to medical practice and personal lives are cultivated.
During internship, 25% of trainee doctors suffer from depression or significant depressive symptoms, and a large (pre-Pandemic) meta-analysis found that 28% of residents (data from 50,000 residents spanning 50 years) experienced significant depressive symptoms sufficient to meet the diagnostic criteria for major depression during residency training.
Ever since my residency, I have felt passionate about the question: could my situation have been prevented? What could have changed to improve my survival chances without burning out?
So why does starting as a real(ish) doctor in a very real hospital cause such problems?
Of course there were a bunch of structural issues that needed to change. They still do:
The list goes on – and each item has their own elegant solution – however these require political will, funding, and country-wide agreement, so as physicians we would be unwise to hold our breaths.
These all contribute to excessive stress, sleep deprivation, disrupted circadian rhythms, inflammation, poor self-care, and seeking solace in unhelpful things (carbs, ethanol, nicotine, and miscellaneous CB1/2 receptor agonists).
Until these systemic issues are addressed, what can be done to help residents not just survive but thrive during the most challenging phase of their careers?
Please note that I am not suggesting physicians lack resilience. We are, as I’ve already written, a resilient group with higher levels of resilience than the average Joe/Josephine. We do not lack grit.
We are however thrust into an environment not unlike a warzone. Outside of our First Responders and the Armed Forces, I cannot think of other professions exposed to as much trauma.
So even if we are resilient, given the demands of our professional training, it makes sense to explore evidence-based methods to enhance our coping styles. After all, prevention is better than cure.
In this article we have provided evidence on the prevalence of burnout and depression during residency, and the underlying causes. We note that many of the causes are structural and these need urgent attention by policymakers and medical leadership. I’m looking at you, AMA, CMA , and BMA (among others).
In the next article we critically examine interventions to increase coping skills and reduce stress – evidence-based coaching and mindfulness interventions.
