Temporary Measures

What some call “burnout” is really an epidemic affecting future doctors, and short-term fixes aren’t the answer.

By Amitha Kalaichandran, M.D.

“It’s just a temporary measure,” the nurse told me.

We were wheeling the patient – a teen girl – from her room in the intensive care unit (ICU) to the CT scanner on the second floor. It was a feat. An aide carried the portable ventilator. The respiratory therapist had to ensure she kept breathing. I had the meek responsibility of holding her hand and ensuring her lines and tubes stayed untangled.

Temporary measures. That was the CT scan that was ordered to see if her lungs had noticeably worsened. A fungus, we thought. It’s interesting how that genae could mean anything from charming toadstools in an enchanted forest to a massive clumps of mould that digest an immunocompromised patient from the inside. The teen, whose cancer had relapsed, was in multi-system organ failure. By some accounts she had some understanding that this was the end.

What could be done if her lungs looked worse? Perhaps start an anti-fungal medication. Another temporary measure. If there was fluid build-up: maybe administer a medication to cause her body to urinate the fluid out.  Another short-term fix. Surgery was out of the question at this stage.

Some say residency training is but a temporary measure. Keep your head down and focus on the end we’re told. Try not to stand out! Just get through this very necessary rite of passage so you can finally make your own decisions and not be coaxed into things you don’t agree with.

But this rite has stolen lives. It has stolen joy. It has stolen a sense of self.  Through what some call “burnout,” defined by Christina Maslach, is “a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job.” It involves: extreme exhaustion, feelings of cynicism and detachment, and a lack of accomplishment.

The term burnout is imperfect as it blames the victim; it would be like saying a cancer patient who loses weight is entirely to blame when it’s the Goliath of cancer they are fighting. Or a candle that becomes extinguished because the wax has waned, not because of heavy wind.

They warn you, when you start residency, to have thick skin; if you don’t have it, you’ll grow it. Yet medicine teaches us that thickened skin is pathological – skin hypertrophies to injury. It appears stronger at first, but the components are different. It appears stronger, but in fact, it may be weaker: consisting of non-native tissue – a product of both time and harm. We know that these scars are usually unsightly.

During an on-call shift, a more junior resident confided to me that he had ‘become of shell of who he used to be.’ Not knowing what to say, and the limits of the program in dealing with burnout while being heavily dependent on residents for staffing purposes, I encouraged him to take a long run when he got home to help clear his mind. He would feel better, I reassured.

It was a quick fix.

In recent years the epidemic of poor resident well-being has become rampant, and we don’t have reliable numbers because it’s often hidden; most are reluctant to admit their struggles.

Data we do have shows that up to 2/3 of trainees experience symptoms of depression. It can manifest in many ways: low mood, irritability, forgetfulness, lack of interest. Surveys point burnout rates at around 45% to 51%.  And sadly, the endpoint for many is suicide: the leading cause of death among medical residents.

Some have suggested the heavy reliance on electronic medical records,  or our pathologic altruism may be partially to blame for physician burnout. But I believe, as others point out, in the massive role of the learning environment. It’s night and day between various programs and hospitals, and the emphasis they place on both supporting residents and the investments they make in a healthy and collaborative learning culture.

Yet typically only temporary measures – perhaps a mindfulness initiatives, or a resilience training course are offered. These are a bit like my patient’s CT scan, ordered to make us feel better and less futile while a malignancy fearlessly overtakes the system and all of its component parts.

For residents, our training is a rite of passage, but it was never meant to steal our humanity: what brought most of us into the profession in the first place.

A closer, more humbling, look at how we teach and value those in our centuries old profession is desperately needed. The hierarchy must be flattened. Balance must be kept as a priority. Feedback must be productive, not punitive. Work hours should be limited. Differences embraced, not silenced or merely tolerated. Something as simple as encouraging kindness and tackling bullying by attending staff could make all the difference to allow trainees to become the best possible doctors they could be.

In other words, training future doctors requires more than small fixes for a devastating tsunami of burnout – it requires massive systems change where an antiquated culture evolves to ensure accountability is king.

My patient took her last breath in an ICU bed in the early hours of a Monday, or so I heard.  I believe her family was around her, and several doctors and nurses. I wonder who the last person she looked at was, what her last glimpse of this world might have been, and if the last sound she heard might have been the beeping of the bedside cardiac monitor. I wonder if she understood why all these interventions were taken; or if her disease prevented any understanding in the cognitive sense. If she could, would she have protested against all these short-term fixes?

If medical training itself is a patient, it is currently on life support. It’s our healthcare system’s most pressing patient, gasping under the reality of widespread burnout, in a world that somehow expects future doctors to inherit the chaos with expertise, equanimity, and professionalism. I’m left wondering if we will have the courage to finally address the underlying causes or if we will ultimately do what we often do:  that which seems easiest, a futile temporary measure.

Amitha Kalaichandran, M.H.S., M.D., is a resident physician and writer based in Ottawa, Canada. Follow her on Twitter and Instagram at @DrAmithaMD.

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