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Burnout

Ben_3Ben Bryner -- If you're in med school or applying now, someone has probably emailed you this article by Dr. Pauline Chen in The New York Times about medical student burnout. (Or, if you're me, four people have done so -- are they trying to tell me something?) In the article, Dr Chen refers to a survey of medical students that showed widespread signs of burnout and a high incidence of suicidal ideation, as well as relating her own feelings of despair during medical school. It’s certainly an interesting topic and I'd like to hear some of my fellow bloggers' thoughts on it, too.

Burnout, as defined by Dr. Christina Maslach (who designed the Maslach Burnout Inventory to formally assess it) includes three elements: exhaustion, cynicism and feelings of inefficacy. It seems to me that med students are already at a disadvantage because of the third one; med school is a means to an end, a gateway to another training program where one will acquire the specific skills necessary to achieve the end goal (helping people). One of the hardest things about medical school is not being able to really help. By far the most satisfying experiences in medical school have been when for some reason I've actually been able to help someone, and the most disillusioning experiences have been when not just me but my whole team hasn't been able to help a patient. Most of the former experiences have been when I've sat down with a patient for a half hour or so and listened to their story, as time is mostly what I have to offer as a med student, and occasionally that does some good. Not much, but I've noticed I'm usually happier going home on those days.

As far as the latter goes, one experience I remember was during my cardiology rotation. One of my patients (meaning I'd taken his history, examined him and written his admission note; "presented" him to the team the next day; called and kept track of his consults; and discussed all of the above with the intern assigned to him) was about ready to go home. Mr. E had a previous diagnosis of aortic valve stenosis that was causing worsening heart failure. After much discussion and consultation, it was agreed that the risks of a procedure on the valve outweighed the benefit. The increasing workload facing his left ventricle as it tried to generate enough force to push the blood through a narrowing valve would eventually cause his death. He understood the situation and the bleak prognosis.

I brought my draft of the discharge paperwork to my resident so he could look it over. One of the sections in our discharge summary is the clinical course, or a summary of all the progress notes that covers everything that happened from the point of admission to the time of discharge. With patients who've been in the hospital for weeks, the clinical course can get out of control. Our EMR imposes a character limit on the note, which can mean going back over the note several times trying to tighten it up -- maybe the only time that editing skills come in handy as a medical student. But this time it was fairly brief; Mr. E had only been there a few days. As my resident read that section, he remarked, "Wow, we really didn't do anything for this guy." He didn't say it angrily or sadly or cynically, it was just a neutral declaration of fact.

It was difficult to realize that he was correct. It's always tough to give people bad news, but that's part of medicine; what made this worse than usual was the fact that he didn't get a new diagnosis or a new definitive treatment, just confirmation that he was going to die. If I had taken the Maslach Burnout Inventory that morning, I'm sure the answer choices to the questions that assess inefficacy wouldn't have been strong enough.

Since it was the weekend, I had time to sit down with Mr. E and his wife and talk as they waited for their ride. He was upset about having to take his last potassium tablet. He wanted to wait and take it at home. (I told him I certainly wasn't going to stop him.) Eventually we started talking about something else, about the things he was going to do that week and for the next few months. It wasn't enough to completely ward off feelings of burnout that day, but it was something.

November 3, 2008 in Ben Bryner | Permalink

Comments

I think most of med students have experienced burnout and all they know how terrible it is.I think burnout may have some good aspects.I myself have experienced that whenever burnout happens to me,I study more and try harder and put more time & energy for patients and... to prevent it for the next time.

Posted by: naista | Nov 4, 2008 11:07:37 AM

don't try to hide the fact that med students do burnout by focusing only on the inefficacy aspect of the test. trying your best within the constraints of medicine today is the best we can do. focus instead on the quality of care and making the patient comfortable and empathizing with the patient (a luxury medical student do have time for), and you will begin to see how efficacious you can be as students.

Posted by: | Nov 11, 2008 3:51:02 PM

naista, if you "study more" or "try harder" when you are burnt out, you are by definition not burnt out. Burnout is much more serious than simply feeling like you can't do anymore. It is the inability to do more. Students kill themselves because of this; your comment takes this situation very lightly.

Posted by: Anonymous | Nov 11, 2008 3:55:19 PM

I commenced medicine in 1969; and loved the patients; disliked many of the physicians, my colleagues. Many colleagues were terrific but many were very critical and hostile and if "anything went wrong," you soon found yourself very alone and "hunf out to dry." Medicine, medical practice, is serious business but the economic competition and professional jeallousies we experience are sad and rive folks away formt he practice.

The compassion we find for patients must co-exist with a compasion and helful attitude for our own.

In years of litigation, I have seen doctors needlessly destroy one another.

Posted by: E.B.Oppenheim, MD,JD,LLM Health Law | Nov 11, 2008 4:25:46 PM

I personally didn't understand what burnout was until last winter, in my first year of medical school. I relocated to the rainy city of Portland, Oregon, after 7 years in a stressful job in Arizona. The combination of SAD and overscheduling had me missing meals just to make it to all my classes and appointments. It took some time to realize that I was completely exhausted. I went in for some tests and find out that my adrenals, ovaries and thyroid had all given up. To me, adrenal fatigue or exhaustion is the true definition of burnout. While feelings of inefficacy and cynicism are downers, if you can't get out of bed, you really are ineffective, and the fact that medical school did it to you makes you a cynic with a reason.

Posted by: Teresa | Nov 11, 2008 5:31:34 PM

As a pre-med applying to med school and also an Emergency Room Technican, I believe the idea of burnout must always be taken into perspective. Whether it is trying to get a few points higher on the next Organic Chem exam, or getting the IV stick on a paient in respiratory compromise, one must realize when they have done all they can and there is no more. One must also be able to be at peace with themselves after they realize it. If one starts blaming themselves for all events that do not go was we wish...the road to burn out can be rough and disheartening.

Posted by: Robert McLeroy | Nov 11, 2008 5:34:31 PM

I remember how hard applying to medical school was, but you really can't understand the burnout of medical school itself until you get there. The entire process is really beyond explaining to someone, they just have to go through it to get it. Burnout is when you've been up for 30 hours, cry in the bathroom because a resident yelled at you, nearly crash on the drive home, all while cursing your drug-addict patient's name under your breath because you're sick of his attempts to get demerol with benadryl, and you know that no matter what you do, he won't really get better until he starts helping himself. I can't say that I don't go there all too often, but there is one thing I have learned that is good. When I feel it getting really bad, I stop and work on taking time for myself. Thankfully, I've never felt so bad as to be suicidal, and maybe its because of the "small" things like taking a bubble bath, or having dinner with a friend when you just need to vent. My advice, don't keep it bottled up and you'll do okay :)

Posted by: Sarah | Nov 11, 2008 6:26:26 PM

hmmm.....my final exam is approaching and now I have go thru all the OSCE stuffs! BURNOUT yessssss! I've been studying alottttttttttttttt and I am not even close to being the top 25% of the class! My classmates r so competitive and they r sooooooooo smart and talented. ahhhhhhhh I wanna dieeeeeeeeeee. OSCE is killing meeeeeeeeeeeeee!!!

Posted by: losdelsur | Nov 11, 2008 6:28:04 PM

I am a second year and I had a daughter over the summer. Oddly, although second year is harder, I feel less burnt out. I think the distraction of the joy of hanging out with my daughter makes the hard times feel easier. I suggest forcing yourself to take a break and do something other than studying from time to time. I know it feels like it is not possible to take the time to do this. But, somehow, it is!

Posted by: Greg Fenati | Nov 11, 2008 7:27:19 PM

go read the blog. sounds like a bunch of whiners who arent used to challenge. how come engineers, which some consider more mentally challenging then medicine, never blog/complain about burnout?

Posted by: | Nov 11, 2008 8:12:11 PM

I'm in my 2nd semester of nursing school so I don't know the full challenge of medical school, but I too feel sooo burned out most of the time. Luckily suicidal feelings haven't emerged, but it does feel so bad when you've worked so hard with patients all day and still come home at night feeling like you haven't accomplish a thing. I had my first patient die on me last week and it paralized me for a couple of days. It's had to pull yourself back up when you feel like you've had the wind knocked out of you.

Posted by: molly | Nov 11, 2008 8:42:36 PM

Welcome to my life as a 4th-year pharmacy student on rounds every day. My colleagues and I really just kind of stand there and listen and it's hard to provide any real input because we're encouraged not to interrupt the much respected physician that is leading the rounds. Even when drug questions are asked, the med students are addressed. It gets frustrating when all I can do is talk about the patients with my preceptor and the other students after the fact.

Posted by: Brian | Nov 11, 2008 8:43:34 PM

Engineers aren't dealing with people, they aren't caregivers.

Posted by: Cindy Newman | Nov 11, 2008 8:46:58 PM

Its nice that someone would get on this and respond by insulting everyone whose posted. Exactly what year are you? Because I would really hope you wouldn't be a 1st or 2nd year whose calling people whiners. Or maybe its just that you don't care enough about anything to ever really feel...should have stuck with engineering (which by the way, I did a lot of math in undergrad, and it is NOT the same thing by any means). I will blog all I want about burnout, because I have faced the challenge, and I've done pretty well, and in a few months I'll get that little MD after my name...I'm just not going to act like it was always wonderful fun.

Posted by: Sarah | Nov 11, 2008 9:06:55 PM

You guys should have just gone to PA school. Same amount of stress, half the time in school, 3/4 the income. Balance that against much smaller student loans, earning an income sooner and the flexibility to move into different specialties down the road (less prestige, but I'm very OK with that)...not a bad deal.
I can understand where you are coming from though. I'm at the end of my didactic and if I had to do another year I'd do it, but I'd really hate it. Anyway, you have an opportunity to make a real difference in peoples' lives. Not many professions can say that with any real conviction. Plough through the obstacles and you will reap the rewards of knowing at the end of each day that you have genuinely helped your fellow man. I know that sounds trite, but it's true and you all know it. Good luck to you all!!!

Posted by: Greg | Nov 11, 2008 9:09:10 PM

This is a good topic to bring to light and discuss. In fact, it was one of the questions I asked my interviewer when I applied to med school 3.5 years ago. He recommended nothing to handle burnout. Burnout can be very upsetting to realize, because often times, people in the health field WANT to do anything to help others. Realizing that you can't figure out how to improve yourself, in the academic setting because of burnout, and feeling trapped in a city or climate or lack of city can be very frustrating. I agree with Greg above who mentioned deliberately spending time doing something entirely different and healthy. I also recommend developing a good social support system outside of the medical field (people young and old who you can laugh and cry with, support when they even need it, and people with whom you can be really honest). Burnout can affect one's thoughts not only about suicide but also sexual practices and substance abuse. Life is precious. Good support will remind you of this when you struggle to believe it. With good support, you can curtail serious repercussions to risks that burntout folks are at specific times inclined to take. This is a good topic to bring to light and discuss. In fact, it was one of the questions I asked my interviewer when I applied to med school 3.5 years ago. Burnout can be very upsetting to realize, because often times, people in the health field WANT to do anything to help others. Realizing that you can't figure out how to improve yourself, in the academic setting because of burnout, and feeling trapped in a city or climate or lack of city can be very frustrating. I agree with Greg above who mentioned deliberately spending time doing something entirely different and healthy. I also recommend developing a good social support system outside of the medical field (people young and old who you can laugh and cry with, support when they even need it, and people with whom you can be really honest). Burnout can affect one's thoughts not only about suicide but also sexual practices and substance abuse. Life is precious. Good support will remind you of this when you struggle to believe it. With good support, you can curtail serious repercussions to risks that burntout folks are at specific times inclined to take.

Posted by: Meg | Nov 11, 2008 9:17:22 PM

"sounds like a bunch of whiners who arent used to challenge. how come engineers, which some consider more mentally challenging then medicine, never blog/complain about burnout?"
Whoever wrote this has no idea what it's like being an engineer.

Engineering is more challenging than medicine to the Nth degree but most importantly, engineering is mentally refreshing. Also there is selection bias. Nobody in engineering doesn't think it is interesting. What's interesting about memorizing tons of little facts connected by minimal or no logic and reasoning??? What is refreshing about interviewing fake patients???

Posted by: M.S. Electrical and Computer Engineering, 2nd year med student | Nov 11, 2008 10:06:44 PM

It is a double edged sword: If we are compassionate and truly care for others who's lives and situations are (in reality) out of our control, then we are subjecting ourselves to the same ups and downs each of "our patients" goes through (and that involves many peaks and troughs a day, considering an physician's daily census)
If, on the other edge, we have mastered dealing with professional dissonance, and thus don't care about those who we are trying to administer care to...yes, indeed we can effectively shelter ourselves from the pain of inadequacy when we realize that in fact, very often we are unable to help many of "our patients"...BUT if we rationalize it that way, we would also deprive ourselves of the incredible gratification we get when a patient is actually helped.
If one is to be truly compassinate, then one must care. If one cares, then one is at risk of burnout from time to time, due to all of the factors already mentioned.
It takes a unique individual to balance all of this on a day to day basis, and make this a profession. This is a skill that is best learned and refined "on the job". It is not easy, but it is possible. Arguably, not everyone can do it. This is a not a profession for everybody, and we must encourage our peers, who are on both sides of the spectrum...whether they care too much or not enough...that perhaps if they continue down that road they are at risk of harming themselves or others.
We are still students, this is one of the most important things we need to learn...always remain compassionate and develop the tools and skills to cope with the hard times.
Do the best you can, with what you have...and be happy with that. If you can't be, then figure out how to become happy or find a different profession that will not run you into the ground.
Most importantly, take the time to help your peers, listen and be supportive. We are all human. We are no different than the patients we treat everyday, in terms of being at risk of health conditions, and must take active steps to prevent ourselves from letting it get the best of us.

Posted by: Jim | Nov 12, 2008 8:58:42 AM

I think Sarah hit it dead center.

Posted by: | Nov 12, 2008 9:33:25 AM

I think a good example of why med students get burned out is right here:
If any of the students in this forum worked for a company hiring an engineer, and they came in venting about their day, the engineer would show them the door and say they didn't want to work with you.
If the engineer came into a hospital or clinic complaining about their job, they'll still be seen completely objectively, no matter how difficult they are.
Its putting up with the good and the bad and then not having anyone else but other med students and maybe a spouse have any idea what you're going through to talk about it with. That leads to burnout.

Posted by: | Nov 12, 2008 9:41:07 AM

I'm in my second year, and of course I've felt the burnout on more than one occasion... One thing I've learned is that Medical School will humble you; you will soon learn that you cannot absolutely master every subject and have "a life" at the same time. However, if you give it your best, and do your best to stay consistent, all while finding time to enjoy the things that still make you "you", than it will be easier to make it through med school without burning out so much.

After my first year, I have realized and have accepted my limitations. Sure I can probably work even harder, but I refuse to do so if it means that I will be unhappy. I like to metaphorically think that I take in my information on an IV drip - stow, steady, and consistent. Try it out ;)

Anyhow, back to work ;/

Posted by: Hayden | Nov 12, 2008 10:16:51 AM

could someone pass sarah a kleenex?

i think she is wrong. I agree with the posting. Lots of people I run into in the hospital are just gigantic whiners. Even some attendings. the post is right...dont like, go work in a bar....

Posted by: | Nov 12, 2008 10:39:03 AM

welcome to my life: a 1st year med student, who just moved to another country...and has realized the hard way that he has no idea why he is where he is. even though he fought so desperately for his place in there...

Yeah, I agree with all those who said that the best 'cure' is to look for support from other people, to look for life outside of medical school, to talk to your friends...and basically be yourself, stay distanced from your studies/profession.

But I am at a point where I don't even know what being myself is... and guess what - I'm in my 1st year of med school. Maybe it's good it happened to me this early?

Posted by: daniel | Nov 12, 2008 11:04:20 AM

All medical students should be trained in Palliative Care and curative care.Only the last one is not enough to the students fell always helpful to his patients .

Posted by: Antonio Carlos Perrotta MD | Nov 12, 2008 12:19:21 PM

There is nothing in the world to compare med school too. 8 years of school, several more years of residency, $200,000 in loans, no sleep, pimping attendings, non-compliant patients, and nurses that talk behind your back beause they think they know more than you even though they have had 2 years of school and you have had 8. If it was so easy surely a lot more people would be up for the challenge. But they aren't, which is why the general public is so impressed when you say, "I'm in medical school," or "I'm a doctor." "I'm an engineer" doesn't demand the same respect. We are dealing with people's lives and we are emotionally involved, even though we try not to be - there is nothing more demanding than this. And I'm sure I will ball up in the bathroom and cry when I lose my first patient. It is a mental and emotional toll. Think engineering is more of a challenge? Be brave enough to put your name up there next time you idiot.

Posted by: Laura | Nov 12, 2008 12:21:20 PM

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