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.

[su_spoiler title=”MEdIC Series: The Concept” style=”fancy” icon=”caret”] Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the last Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we would love for you to get involved in the MEdIC series! Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.[/su_spoiler]

Tamara McColl, MD FRCPC

Tamara McColl, MD FRCPC

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