James MacDonald, MD, MPH
“At a cardiac arrest, the first procedure is to take your own pulse.”
I was reminded of this quotation when I recently renewed my BLS certification. In class we reviewed the basic steps of BLS (checking scene safety, responsiveness, calling for help and an AED, etc.). However, I often whisper this quotation to myself in stressful clinical moments, before going through the checklist. First, check your own pulse. How can one be of help to anyone if you are, yourself, a panicky, stressed out mess?
What is true in the stressful times is as true in the more mundane chapters of our profession. Much of the STREAM curriculum addresses the need for the physician to first address her/his own wellness: again, how can we be healers if we are not healing? Remember, the ancient adage states, “Physician: heal thyself.”
Still, many of you involved in STREAM, and certainly many if not most of the physicians I talk to about issues of wellness and burnout, rightly point out that the ‘system’ bears primary responsibility for our stressful professional environment. We can work on self-healing, but if the system remains broken progress may be fleeting. An often cited 2020 study in JAMA Network Open studied the relationship between personal resiliency among doctors and levels of burnout.[i] The study authors found statistically significant, and lower, levels of burnout in the most resilient physicians. But they also found that 30% of even the most resilient physicians were burnt out.
Like a physical material, the most resilient of us all have a breaking point. Systemic forces – the drudgery of the EHR, the corporatization and financialization of medicine, the levels of debt and delayed gratification we experience with years of training, and more – have driven our profession to a breaking point. According to an analysis on claims data, from 2021 to 2022 over 71,000 physicians left the workforce.[ii] With about 30,000 medical student graduates entering the profession, this unbalanced equation is quickly leading to physician shortages across the country.[iii]
If you have come this far reading this blog post, I would suppose much of what I have written is already known to you. You may be among the frustrated, the ones who know what a heavy load our healthcare system places on our physician shoulders.
You may also be wondering when I am going to properly attribute the quotation which opened this brief essay.
I hope many of you recognize it as one of the “Laws of the House of God,” from the hilariously cynical, Catch-22 like novel, The House of God. Published in 1978 and written by Stephen Bergman MD, (pen name “Samuel Shem”), the book takes a deep dive into the madness of medical training. I read the book when I graduated from medical school in 1995, but I had not thought about it until recently, when I read a fabulous article about the novelist himself. [iv]
Omne trium perfectum – or, as many of us better know this old Latin adage, ‘good things come in threes.’ Regarding my re-engagement with this “Law of the House of Good,’ this most certainly was true. In the past few weeks three events occurred which triggered my memory: I took BLS; came across the article profiling Dr. Bergman; and watched several of ‘my’ medical students go through “Match Day” and discover what they will learn and where they will work over the next many years as ‘residents,’ like the young anti-hero of The House of God.
I could not help thinking how useful it may be for them to read this novel. I also could not help thinking with some trepidation what their residency years will look like, what their careers will look like. The medical profession is, to repeat, already under stress, and many of the trends point in a negative direction. What does the future look like for them and for our profession?
There is evidence that medical trainees face a higher level of burnout in their training years than do attendings like me, a group which already manifests high levels of burnout. The burnout rate approaches nearly 50% of PGY-2s in one study.[v] Furthermore, there is an abundance of opinion, little consensus, and limited evidence about why this is so. One study points to the effect of high levels of medical debt, though not all experts in the field of medical training agree. [vi]
I care very much about the medical trainees I teach – the ‘pre-meds,’ the medical students and residents and fellows. I care for them as individuals and hope that they will enjoy years in our profession similar to what I have enjoyed: that, despite the travails and, sometimes, the days that can feel like drudgery or worse, I love my job as a doctor; that I would not trade this profession for another; and that for the majority of my days I come home from work happy. Over the years I have taught these students who just ‘matched,’ I have shared many of the discoveries I have enjoyed in my own journey to physician wellness. If they adopt some of these practices – breathing or meditation; self-reflection and journaling; accountability – I believe they will be more resilient in the face of adversity. They may enjoy a fulfilling career as I have.
But there is the training ‘system’ that they are going to come up against on July 1, and I understand that less well than I do my own circumstances, as a physician near the end of his career. The group of medical trainees entering and replacing the sixty year-old attendings like me who will be exiting the stage soon are the lifeblood of our profession. The trends I have mentioned earlier in this essay do not bode well for our profession’s future. I want to better understand what my younger colleagues will be facing. There needs to be evidence-based insight into why medical trainees have such high levels of burnout if we are to begin redressing the problem. We older physicians are often in positions of leadership and can effect change. Perhaps if we have a better handle on the key drivers of this phenomenon of resident burnout, we can positively change the system with the years we have remaining in our careers.
I end this post then not with answers but with a ‘share.’ A ‘share’ that I hope you adopt, as well, if you are in medical education, or if you simply care about these issues of burnout and wellness and the future of our medical profession, and you want to impact the direction it is heading. The students and trainees are the future of American healthcare after all. In trying to understand the root causes that contribute to medical trainee burnout, I have adopted two new habits:
1) I have subscribed to a very insightful AMA mailing, “Thriving in Residency,” which explores these issues Thriving in Residency | American Medical Association (ama-assn.org)
2) I have begun to listen regularly to a podcast from NEJM, “Not Otherwise Specified,” which also deals with these issues (link: https://open.spotify.com/show/1ivN99C71Ut3hPcBv8yWse
I plan in a future blog post to return to this subject of medical trainee burnout/wellness to share what I learn. I hope, as well, that many of you also pick up this baton, and we can begin a conversation where we can learn from each other.
James MacDonald MD, MPH james.macdonald@nationwidechildrens.org
PS: I hope this week you remember to check your own pulse first if you are under stress at work.
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[i] West CP MD, Dyrbye L, Sinsky c, et. al. Resilience and Burnout Among Physicians and the General US Working Population. JAMA Network Open. 2020;3(7):e209385.
[ii] Gooch K. Healthcare Workforce Lost 145,213 Providers from 2021 through 2022. Becker’s Hospital Review. 2023. https://www.beckershospitalreview.com/workforce/healthcare-workforce-lost-145-213-providers-from-2021-through-2022.html#:~:text=Definitive%20Healthcare%20found%2071%2C309%20physicians%20left%20the,workers%20left%20the%20workforce%20from%202021%20through(accessed 3/26/24)
[iii] Robeznieks, A. Doctor Shortages are Here – and They’ll get Worse if we Don’t Act Fast. 2022. https://www.ama-assn.org/practice-management/sustainability/doctor-shortages-are-here-and-they-ll-get-worse-if-we-don-t-act#:~:text=No%20shortage%20of%20medical%20students&text=The%20number%20of%20medical%20school,jump%20from%20the%20previous%20year. (accessed 3/26/24)
[iv] Lambert C. Diagnosis by Fiction. 2024. https://www.harvardmagazine.com/2024/03/feature-steve-bergman-samuel-shem
[v] Murphy B. PGY-2s see 27% Higher Rate of Burnout than Interns. Here’s why. 2023. https://www.ama-assn.org/medical-residents/medical-resident-wellness/pgy-2s-see-27-higher-rate-burnout-interns-heres-why#:~:text=Reflective%20of%202022%20trends%20in,%2Dyear%20residents%20was%2047%25. (accessed 3/26/24)
[vi] West CP, Shanafelt TD, Kolars JC. Quality of Life, Burnout, Educational Debt, and Medical Knowledge among Internal Medicine Residents. JAMA 2011; 306: 952 – 60.