MEdIC Series: The Case of the Fatiguing Fourth Year

2017-01-20T12:30:40+00:00

burnoutWelcome to season 4, episode 3 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, Alkarim Velji and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

In this month’s case, a senior resident is experiencing the effects of physician fatigue and burnout.

MEdIC: The Case of the Fatiguing Fourth Year

By Dr. Loice Swisher

It was 4 a.m. and George had just sat himself down into a hard plastic chair to catch up on some charting. This was his second rotation at a small, inner-city emergency department. The night shift was George’s chance to ‘run the department’, with only him and one attending on for the night. Now that he was near the end of his fourth year of residency, he was really trying to push himself. George had thought it would be great to feel ‘in charge’; the run of six 12-hour shifts, however, was gruelling and starting to take its toll.   It seemed there was never a chance to rest. The respite of a weekend off was just three hours away and he couldn’t wait.

As soon as George sat down, the ambulance doors opened to the sound of high pitched screaming. The woman on the stretcher was yelling expletives and demanding pain medicine. George sighed heavily; having seen her twice already during his rotation, he knew she didn’t have an acute medical problem – she just wanted opioids.

Sitting back down to complete his charting, George surveyed the department. A few intoxicated patients occupied beds and stretchers, and the man who had just refused a dental block for his toothache paced the hallway, agitated. If it weren’t for the poorly-controlled asthmatic breathing nebulized Ventolin in the resuscitation bay, there wouldn’t have been a single emergency in the entire department.

Suddenly, George turned to the attending blurting out, “Dr. Jones, how do you do it? Doesn’t it get to you? All the drug-seekers, drunks, and noncompliant patients…isn’t it exhausting?”

George’s outburst caught Dr. Jones off-guard. George had seemed to be managing the department admirably.

“Well, its tough at times but things will certainly get better when you start making more money,” Dr. Jones said with a chuckle, fumbling for words.

“I hope so,” George unenthusiastically replied.

George got through his shift and was about ready to collapse by the end. On his way home, George’s eyelids grew heavy and he drifted onto the shoulder of the road several times.   As he struggled to focus on the drive, his mind raced and he began to worry about his future.

Was it possible that he was already becoming burnt out, after just four years of residency? He had gone into emergency medicine wanting to ‘make a difference by helping patients’, but on nights like this, dealing with patients felt like a chore and only seemed to make him miserable. Could he keep this up long enough to pay off all of his loans? And what then?

When George arrived home, his wife listened sympathetically while he unloaded his frustrations of the night and his concerns about his future in emergency medicine.

“You’re just exhausted,” she reassured him. “Sleep and then see how you feel.   You’re off tomorrow; we can do something fun. I’m sure you’ll feel better then.”

Nodding his head unenthusiastically, George couldn’t shake the nagging feeling that there might be something more.   Neither his wife nor Dr. Jones seemed to understand. Exhausted, George crawled into bed, eager for a brief reprieve from the frustration of his gruelling schedule.

Discussion Questions

  1. What are the signs and causes of burnout?
  2. How can an attending recognized fatigue and sleep deprivation? What fatigue mitigation strategies can be adopted?
  3. What resources may be available to a resident who feels too fatigued?
  4. How does burnout and sleep deprivation affect patient care and physician health?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

This month, our 2 experts are:

  • Dr. Kevin Imrie
  • Dr. Nicole Battaglioli

On December 16,  2016 we will post the curated commentary and expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

MEdIC Series: The Concept
Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba
  • Nadim Lalani

    Very practical case. I think many (if not all) have been here. Speaking as someone who has:

    What are the signs and causes of burnout?

    For me it was a low sense of accomplishment, of failure, that there’s no end in sight and I should just throw in the towel, frayed interpersonal relationships and acting out of character.

    How can an attending recognize fatigue and sleep deprivation? What fatigue mitigation strategies can be adopted?

    Perhaps the biggest obstacle in terms of attendings is that [dunno who invented this term, but it’s awesome] ‘nostalgia imperfectica syndrome’ – i.e “in my day we did everything in our dad’s pyjamas, uphill both ways … in the snow … with broken legs. STOP IT!

    We need to look out for each other – that includes our apprentices … Being attentive to wellness IS NOT coddling. I believe that residents are the medical equivalent of olympic athletes and collectively we need to take the same approach to success that they do!

    some tips on identifying wellness:

    ANY attributing towards the patient, loss of emotional control or disengagement [hiding out/cherry picking cases] is usually a symptom of a Maslow’s Needs infraction.

    ANY struggling learner the top three on the ddx is wellness, wellness, wellness, … (then attitude and mindset then knowledge. learning and institutional factors)

    People who LOOK tired … ARE.

    When it comes to residency – poor sleep is probably one of the top reasons residents are unwell. If I may share – in my senior residency I lived in a noisy condo, with construction at odd hours of the night, pets and loud neighbors that kept me up and life-stuff that kept my mind too busy to rest!

    It took counselling and rearranging my life around my sleep in order for me to shake that monkey. Later I also found getting FIT helped me to have stamina for on shift and off shift activities. In short – TALK + SLEEP HYGEINE + FITNESS.

    I have heard of colleagues going for sleep studies – so that may be an option.

    How does burnout and sleep deprivation affect patient care and physician health?

    No question that Wellness is a missing quality indicator – it doesn’t make it onto ANY dashboard that I have seen, yet the evidence is emerging that disengaged health care professionals cost the system – were talking increased errors, poor patient care and 2-5% of the overall budget due to turnover alone [that’s 100’s millions of $$/year – talk about ‘Choosing wisely’] But these are secondary outcomes – the primary outcome that we are failing to adequately address is preventing the epidemic depression and suicide amongst physicians and medical trainees!

    What’s the way forward?
    Sharing openly about wellness and creating healthy residency programs is a must.

    We need a new counter-culture of allowing for human-ness in medicine and being intolerant of small-minded thinking. [i.e. they need to toughen up mentality]

    There has been a call to action amongst all programs to find innovative ways to foster resilience in residency. BUT I feel that it can’t just be piecemeal or at the “grand rounds” level – there have to be wholesale HARD structural changes and ONGOING support.

    There’s +++ science on sleep hygeine and this needs to be taught and incorporated into residency. As well as better scheduling. [Even attendings DONT work 6 in a row unless they make poor trades! ]

    I am biased, but …

    I feel the time is now to begin introducing coaching into residency programs. We can borrow from the business world and sports science to our benefit. With CBME the time is ripe to blow up the old and introduce innovative holistic curricula and talk about things like mission + purpose + brand + creating winning states. There is a smattering of literature around coaching in healthcare, but I’m telling you it works – period.

    Coaching fosters wellness, self awareness [around strength,blindspots, self-talk], EQ, a locus of control andgoal-setting and achievement. It also re-creates that pre-residency idealist only better – with an unwavering identity that immunises himher against burnout and the hidden curriculum.

    100% of the residents I have coached realise that they can’t be better at EM by being more physically present in the ED – it doesn’t work that way! 100% of the residents I have coached have had aha moments around their wellness habits, values and self-limiting beliefs. 100% of the residents I coach realise that part of the issue is their mindset and how they talk to themselves.

    I feel that if we truly want our trainees to succeed – we need to put our money where our mouths are and design training [and have a culture] that enables them to run downhill rather than swim up stream – again – its NOT coddling.

    Lastly – I know it was an awkward moment but I really disagree with the “it will be okay when you make more money” statement. Money is a surrogate marker for something else we truly value – a secondary outcome if you will. Why not go for the primary outcome instead?

    I hope that I have moved the conversation forward – keep the hits coming! cheers
    N

    • Tamara McColl

      Starting off the discussion with a bang! Thanks for sharing your thoughts! Very insightful and you’ve brought up some excellent talking points. I’d love for you to elaborate on this “coaching in medicine” concept! How did you implement it in the resident curriculum? Has this method expanded among your faculty? Do you have literature you can share on the topic?

      • Nadim Lalani

        Too big a topic to cover in comments and I fear detracting | derailing from the “sleep hygeine” theme of this case, but if interested …

        readers can look up life coaching | professional coaching | executive coaching

        here’s my vimeo link:
        https://vimeo.com/174462210

        here’s a neat article by Gazelle et al :
        http://www.ncbi.nlm.nih.gov/pubmed/25527340

        here’s another article showing positive benefits of implementation into Duke Univ program:
        http://www.ncbi.nlm.nih.gov/pubmed/25240635

        happy to talk off line re implementation – we are embarking on an ambitious project at U of C 🙂

        N

    • Loice Swisher

      I agree that the exchange was an awkward moment. I was wondering what you would have responded?

      My experience as an attending is that I haven’t been trained to recognize or respond to wellness/burnout issues. My education has been focused more on imparting facts and procedure. I don’t have scripts that I have learned from others- and making it up as I go along can be hit or miss.

      • Nadim Lalani

        So true! That mirrors my experience also.

        I feel we focus overly on medical expert at the expense of teaching other valuable skills. My residency fell short in terms of preparing me to be human in medicine.

        A few programs in Canada switching to academic full-days in recognition of the fact that there is so much to onboard during residency.

        I’d love to say “i would have done this or that” … truth is – I don’t know what I would have done in the moment.

        I try to mentor residents around stuff like empathy drain – it’s with honesty and sharing my experiences. Absolutely I gets to me when patients act out! I’m not always my best self in situations of conflict or high emotion. It’s part of the deal – being a human in medicine is messy.
        Thanks to cases like this we get to talk about it and reflect on how we deal.

        thank you for sharing | hosting this discussion – not my intention to detract or offend.

        • Loice Swisher

          Nadim,
          I hope you didn’t think I was offended or that any thing you said detracted from the case. Far from it- I think all you said adds. I am very seriously asking-in the time of reflection what is would the appropriate considered answer be.- how do we figure out how do we do it. It sounds like in residency you might have been in a similar place- what words would have rung best for you.

          I’m interested in an approach that includes-” mission + purpose + brand + creating winning states”.

          Loice

    • brianelevy

      BRAVO. RIGHT ON. The problem just might not be the resident him/herself but a sick system which is accustom to belittling people and afflicting endless stress and sleep deprivation on people who are often in quiet desperation doing their best to synthesize knowledge. Residency PROGRAMS need to take all this to heart. The TIPS need to go to the people running the programs at least as much as to the overworked residents.

  • Mary Jane brown

    An interesting vignette and certainly challenging for either physician described-heartfelt to be the resident who is experiencing self doubt physical fatigue and isolation personally and professionally and the seasoned attending who is caught off guard by what seemed ok externally.
    Burnout is multifaceted and and the manifestation and recognition equally many. I think simply there is a head and heart disconnect. (Rachel Remen – Gerald May two physicians who have written of their own personal struggles and then gone on to give some directions which I have found moving and encouraging in my own attempt to keep my head and heart on the same path)
    Recognition of burnout is a challenge for us as physicians -my generation had no education, mentoring or modeling of this condition; but I have come to see this condition as one of the perils of EM practice. This is not going away and that scares me for the individual practitioner and for our health as a culture. So I believe we have an obligation as we are our brothers and sisters keepers to ASK- hey how is it going hey what’s going on you look seem… prying no it’s taking a minute to connect with a colleague a resident a fellow traveler!
    Fatigue mitigation for me is a nap; but that is physical fatigue -the mind is helped by a nap too but mental and spiritual and relational and emotional fatigue have different tools for restoring resetting recharging. So where and when do we learn these and how ( from a book a podcast a worship experience a concert an art gallery a lecture) For Gerald May he went camping and after a diificult time or experience I have walked in the woods and looked at the sky. Returning to physical fatigue which often comes with our overnite shift work, the attempt to drive after a shift can be equal to the impairment of having a few alcoholic beverages ; and if friends don’t let friends drive drunk should we walk a line after an overnite. Coffee can only go so far and if caught in a traffic jam you may run out. All this to say I am encouraging a nap in the call room before getting out in traffic.
    The unwell impaired fatigued burned out physician(healthcare worker) is a patient safety issue. Burn out and fatigue often result in tunnel vision and self absorption and I think I make it hard to have a functioning patient centered team. A healthy mind and heart are as important as light in the laryngoscopes .
    thank you Dr Swisher for this important topic

    • Can you suggest some links and such for people to access if they want to learn more?

      • MJ Brown

        I would recommend internet Onbeing.org jul 29 2010 interview with Rachel Remen recapturing the soul of medicine- I have kept her book My grandfathers blessing on my bedside table for years gleaning some insight with each reading,
        Gerald May is deceased but left a legacy thru the shalem institute and books like wisdom of wilderness, dark night of the soul among many ; he was a contemplative and institutions in crisis need the wisdom of contemplatives who ponder and listen and help reframe questions

    • Nadim Lalani

      thanks for these pearls!

  • Minh Le Cong

    Hi and thanks for discussion of important topic

    Perhaps we try to soften mental health issues in health professionals by using terms like burnout ? This maybe unhelpful

    Depression and suicide are real in our profession and poor sleep and anhedonia are some cardinal symptoms so objectively they should be explored in a non judgemental manner by a supervising mentor

    It shouldn’t be a survival of the fittest competition in our profession . It doesn’t need to be despite our medical culture

    • Great points @minhlecong:disqus. I believe, however, that there is a spectrum. Burnout is probably an early stage of a number of mental health issues. Subacute versions of any of the DSM criteria (i.e. not yet interfering with life) can be rampant within our profession, and I think its important for us to find terms to call out early problems, rather than waiting till problems rear up later?

      • Minh Le Cong

        Well there are objective validated tools to assess for depression and having looked after a few colleagues it is worth using them to reach a diagnosis one way or the other

        It is true many maybe what we call adjustment disorders or acute stress reactions or anxiety disorders but they all lead to some level of suffering

        Burnout doesn’t really mean anything in pragmatic terms as it implies you can’t cope with job when others can . It avoids issue that perhaps job is the problem or deeper it is the culture of workplace . If we aren’t helping others cope with workplace or allowing a malignant workplace to exist , are we not in some way allowing bullying at work ?

        A psychiatrist I worked with once used term existential despair and that gives a bit more meaning to issue in my opinion

  • Robert

    As a former UGME Dean

    • Thank you for highlighting this Robert! I am glad you have raised the awareness that institutions need to make sure their faculty members are well equipped to notice and refer these types of behaviours.

      Thanks for providing the WELL office link.

      What do you think are key components of a Wellness program?

      • Robert

        Awareness, outreach and confidentiality.
        1. Learners must be aware that the program exists.
        2. The program must organize wellness activities to provide visibility and promote buy-in by the learners. At McGill, when we revamped the UGME curriculum we made Wellness a theme that was integrated into the system-based blocks over the first 18 months. In each of the 10 blocks there is a wellness activity for one hour – mindful breathing in the Resp block, cardio activities in the cardio block, focus on nutrition in the GI block, etc. And, it is assessed proportionately on the end-of-block exam, so that the role modelling is that Wellness in medicine is just as important as the Krebs cycle. The Wellness curriculum is coordinated by a student-led faculty-facilitated committee.
        3. Learners in distress who access the Wellness program

    • MJ Brown

      So are you familiar with Appreciative inquiry as a way to do post shift check in, focus on positive and review challenges in less threatening format, we had a program for faculty earlier this year to introduce this approach;
      I think this has potential but am not sure how to Integrate with overall wellness and resiliency education

      education

      • Robert Primavesi

        I am not familiar with Appreciative Inquiry. On the little I read it seems that this model is applicable to organizations and teams to create change but I am unsure of how this applies to the individual, unless we wish to create a culture shift for wellness or if we consider the resident as a part of a greater whole.

  • Megan Stobart-Gallagher

    Do we see more burnout in female residents vs. male? I suspect females due to their underlying need to say yes, do it all, and feel guilty if they can’t… should we be paying more attention to them for that reason? Females in EM need to look out for each other to help not only mentor for the future, but also to try and prevent losing fantastic docs. The older generation (yikes, am i old?) needs to be more aware that this even occurs and that things have to change.

  • Timely article just posted by @nadimlalani:disqus on Facebook on this topic.
    http://www.metronews.ca/life/careers/2016/12/05/doctor-diagnosis-burnout.html

  • brianelevy

    I think the sentiments of this resident are easy to understand. Advice:
    1. When you have a diligent hard working resident, reassurance is important. Frankly, residency programs are full of inuendo, threats, both spoken and unspoken, and there is entirely too much focus on evaluating a resident’s every step than teaching. Case in point: belittling a resident that they don’t already know a procedure , rather than working one on one demonstrating and helping resident through procedures.
    2. Stop giving residents busywork like endless and demanding research projects. Resident are already working more clinical hours than most staff. I’ve been out of residency (thank heavens) for a couple of years now and I can say for SURE that the best learning experience for residents is seeing more and more and more patients and then reading around cases. NOT RIDICULOUS RESEARCH PROJECTS.

    Sorry to be so blunt, but that’s the way it is.

  • Jason Brooks

    Some fantastic insights on a pressing problem. And so encouraging to see new programming and supports being developed to help not only mitigate against stress/burnout effects but hopefully provide pre-emptive tools and strategies.

    I like Minh Le’s comment that clearly the job itself with its unrelenting pressures and demands can take a toll on the most hardy of human beings. Be it scheduling, or fostering a more healthy/collegial work culture, there are external factors that need be looked at which certainly contribute and which can be improved. It is not a model of best practice or long-term sustainability to simply keep teaching physicians to become increasingly resilient to the external conditions–something has to give, and it shouldn’t be the physician who is drawn into an unhealthy state because of the conditions. Certainly there is a necessity to foster resilience/coping skills in the here and now as I am reminded of something a physician once told me about system change in medicine “it moves at a glacial pace”. Nevertheless, some of those systemic factors need to be addressed. What I have observed is, if you start with the individual and help them create efficiencies in how they manage their thoughts, emotions, reactions and perspectives to things they can’t control BUT can strongly influence (from within) it can make a big difference. It can help buffer against the external stuff and help one reclaim precious energy and focus otherwise given away to those things. And once better routines and patterns are in place, the person experiences an increase in those vital capacities Mary Jane talked about. THEN one is at a much better baseline to help others (be it mentoring, coaching, teaching, leadership etc.) and tackle some of the larger systemic challenges. We all are familiar with the O2 mask protocol when flying. Build capacity at n=1 to start. From that position, it seems more plausible to provide much needed support to those around you. In doing so is the ultimate energizer. It keeps us connected to a sense of purpose and meaning that is stronger than the daily burdens, annoyances, and frustrations that slowly chip away. A fundamental emotional need as human beings is to feel as though we are growing and contributing to something that matters. That is a feeling and a state not an outcome. People in this thread have offered ideas on how to create more of that sense–again, coaching/mentoring, supporting colleagues and learners, modelling great leadership and communication etc. There is much we can do to be readier for the moments in our day where our perception can lead to heightened feelings of control and purpose, or despair and exhaustion. The kind of exhaustion that Mary Jane speaks of–mental, emotional, spiritual.

    I have had the great privilege of witnessing so firsthand over the last decade. My background, like Nadim, is performance coaching. Though I am not a physician on top of that (Nadim, you are a machine! awesome video by the way). In terms of resources that are out there, we deliver a course through the University of Manitoba in the department of Emergency Medicine that teaches physicians how to develop practices and perspectives to sustain optimal health and performance. This program is called High Performance Physician (HPP). We help folks gain insight on the challenges that sap energy and focus and together, figure out some strategies to protect against those. Specific themes include managing acute and chronic stress, developing frameworks for setbacks and failures, optimizing performance focus, utilizing arousal control techniques, establishing a personal conception of worklife balance, performing under pressure and uncertainty, briefing/debriefing, effective communication, navigating conflict, everyday leadership, energizing and relaxing. I’d be happy to provide more info or share what we have learned with anyone here. Its going to take a community of practice to help shift things in a healthier direction. I applaud you all for your effort and initiative.