AAOS Now

Published 4/1/2016
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Mark Schultzel, MD

Seeing the Signs of Resident Burnout

Strategies for mitigating stress may help avoid serious problems
Orthopaedic surgical residency programs have experienced a great deal of change in the last decade, including implementation of the 80-hour work week, greater use of simulator training, and increased documentation required of residents via caselogs and the Accreditation Council for Graduate Medical Education (ACGME) Milestone Program. All of these adjustments have been aimed at improving resident education and enhancing patient care.

But have these changes actually enriched overall resident quality of life and decreased fatigue, or have they increased stress? How important is it for residency programs to understand the signs of burnout and take steps to help residents cope with stress? According to recent data, resident burnout across all surgical specialties is at an all-time high, with orthopaedic surgery being no exception. A recent study performed by researchers at the University of North Carolina at Chapel Hill revealed that nearly 70 percent of all residents met criteria for "burnout," with 82 percent of subspecialty residents, including orthopaedic surgery residents, meeting the criteria. Residents reported feeling inadequately prepared by their medical schools to cope with the demands of residency.

Sargent et al also reported on orthopaedic surgery resident stress and burnout in several studies. The investigators concluded that resident quality of life was significantly lower than that of their faculty members, and that most residents reported feelings of burnout, depersonalization (negative, detached responses to others), and emotional exhaustion despite some feelings of personal achievement. These findings are consistent with those of Ishak et al, who published a systematic review of 26 studies on resident burnout across 18 specialties. Both showed a high rate of burnout among residents across specialties, with much higher rates in all surgical subspecialties.

What is burnout?
Burnout is a state of mental and physical exhaustion related to work or caregiving activities.  Originally coined by psychologist Herbert Freudenberger in 1974, the term was used to describe job dissatisfaction precipitated by work-related stress. Burnout is characterized by a triad of emotional exhaustion, depersonalization, and reduced feelings of personal accomplishment. Physical symptoms may include insomnia, appetite changes, fatigue, colds/flus, headache, and gastrointestinal distress, while psychological symptoms may include irritable mood, cynicism, decreased concentration, feelings of depression, and even suicidal ideation.

The literature suggests a variety of factors in medical school may contribute to burnout, as reported rates of burnout have ranged from 25 percent to 48 percent of students.

Contributing factors
In multiple studies, residents have linked the following to feelings of burnout:

  • lack of time to exercise
  • lack of time to fulfill personal responsibilities
  • lack of time to engage in enjoyable activities outside of work
  • conflicting responsibilities between work, home, and family
  • time spent on electronic medical records and documentation
  • work load and work hour restrictions
  • discord with coworkers (nurses, faculty, other residents)
  • lack of positive or consistent feedback by superiors
  • financial debt

Impact of duty hour restrictions
Recently, new research has called into question whether the 80-hour work week imposed by the ACGME actually serves to decrease resident fatigue and improve both academic performance and patient care. A study by Gelfand et al looked at the effects of work week restrictions in surgery residents, noting that despite an average reduction of 18 hours of work per trainee, there was no statistical difference in emotional exhaustion, depersonalization, or personal accomplishment symptoms. 

Another study of internal medicine residents conducted at Wayne State University School of Medicine reported that the work-hour restriction decreased teaching time by attending physicians, encouraged dishonesty related to reporting work hours to maintain compliance, and resulted in "cutting corners" in both patient care and educational activities. A common criticism by surgical programs is that work-hour restrictions lower total case volume and reduce exposure to surgery.

Preventing burnout
Although residents will always experience stress, burnout can be prevented if useful tools and strategies are in place for residents in need. A recent study cited the following possible methods for preventing burnout:

  • offering resiliency training and mentoring programs to medical students and residents
  • making available wellness-focused resources and activities
  • providing financial resources, such as assistance with tax preparation or loans/debts
  • offering residency-sponsored social events to which spouses/family members are invited
  • encouraging residents to seek a specific hobby outside of work
  • encouraging residents to develop a strong social support system (friends and family)

Residents have also reported the following interventions to be helpful in improving wellness and decreasing burnout:

  • access to on-site exercise facilities in the hospital
  • on-site child care
  • increasing amount of vacation time (currently varies from 2 weeks to 4 weeks)
  • restoring meaning to resident time requirements
  • encouraging supportive social interactions between faculty members and residents
  • promoting a separation of work and home life

Coping with and preventing residency stress and burnout remain important issues for residency programs across all specialties in medicine, with orthopaedic surgery being no exception. There may be no simple solution to the problem of burnout in residents, but it is crucial to continue the discussion for the benefit of future generations of orthopaedic surgeons.

Mark Schultzel, MD, is a shoulder and elbow surgery fellow at the Kerlan Jobe Orthopaedic Clinic, a member-at-large of the Resident Assembly Executive Committee, and a member of the Resident Assembly Practice Management and Global Health Committees. He can be reached at mschultzel@gmail.com

References:

  1. Ishak  W,  Lederer S, Nikravesh R, Seligman L, Vasa M, Bernstein C: Burnout during residency training: A literature review. J Grad Med Educ 2009;1(2):236-242. Accessed January 28, 2016.
  2. Holmes E: Resident burnout. The American Psychiatric Association 2015 Meeting, Toronto, Canada.
  3. ACGME: Frequently Asked Questions: ACGME Common Duty Hour Requirements 2011 [cited 2015 November 18]. Accessed January 28, 2016.
  4. Weatherby BA, Rudd JN, Ervin TB, Stafford PR, Norris BL: The effect of resident work hour regulations on orthopaedic surgical education. J Surg Orthop Adv 2007;16(1):19-22. Accessed January 28, 2016.
  5. Froelich J, Milbrandt JC, Allan DG: Impact of the 80-hour workweek on surgical exposure and national in-training examination scores in an orthopedic residency program. J Surg Educ 2009;66(2):85-88. Accessed January 28, 2016.
  6. Sargent MC, Sotile W, Rubash H, Barrack R: Stress and coping among orthopaedic surgery residency and faculty. J Bone Joint Surg Am 2004;86:1579-1586. Accessed January 28, 2016.
  7. Gelfand DV, Podnos YD, Carmichael JC, Saltzman DJ, Wilson SE, Williams RA: Effect of the 80-hour workweek on resident burnout. Arch Surg 2004;139:933-938. Accessed January 28, 2016.
  8. Shanafelt TD, Bradley KA, Wipf JE, Back AL: Burnout and self-reported patient care in an internal medicine residency program. (2002). Ann Intern Med 2002;136:358-367. Accessed January 28, 2016.
  9. AMA Wire: Ways residents have found to conquer burnout. AMA Wire, October 15, 2014. Accessed January 28, 2016.
  10. Daly MG, Willcock SM: Examining stress and responses to stress in medical students and new medical graduates. Med J Aust 2002;177:Suppl:S14-S15.
  11. Collier VU, McCue JD, Markus A, Smith L: Stress in medical residency: Status quo after a decade of reform? Ann Intern Med 2002;136:384-390. Accessed January 28, 2016.