• How to make doctors miserable people (now with data!)

    I feel like I’ve been spending a lot of time on this topic lately, but it’s one of my issues. I hated residency, and not for the reasons most people think.

    Well, it turns out I’m not alone. A new study in JAMA shows that this feeling is pretty pervasive:

    Context: Physician distress is common and has been associated with negative effects on patient care. However, factors associated with resident distress and well-being have not been well described at a national level.

    Objectives: To measure well-being in a national sample of internal medicine residents and to evaluate relationships with demographics, educational debt, and medical knowledge.

    Design, Setting, and Participants: Study of internal medicine residents using data collected on 2008 and 2009 Internal Medicine In-Training Examination (IM-ITE) scores and the 2008 IM-ITE survey. Participants were 16 394 residents, representing 74.1% of all eligible US internal medicine residents in the 2008-2009 academic year. This total included 7743 US medical graduates and 8571 international medical graduates.

    Main Outcome Measures: Quality of life (QOL) and symptoms of burnout were assessed, as were year of training, sex, medical school location, educational debt, and IM-ITE score reported as percentage of correct responses.

    Big survey of all Internal Medicine residents, looking at quality of life and burnout. Right up my alley.

    Let’s start with this: imagine you have worked hard all your life to get amazing grades in order to get into college and then medical school. Then, you spent four more years earning that MD, again competing for limited residency spots. Now, you get to work. But pause and consider what it took to get here:

    More than 13% of all IM residents had more than $200,000 in education debt. The likelihood of paying this off during residency is slim, so interest accrues massively during those years.

    Really, ponder that for a minute. More than $200,000. Do you imagine they are going to be able to buy a house anytime soon? Save for a family? More than a quarter of residents owe more than $150,000 in educational debt. Almost 40% owe more than $100,000.

    So right off the bat, that’s going to sting. But then you get the privilige of spending the next three to seven years working for up to 80 hours a week for significantly less money than your education should bring in. The workload is brutal, the system is hierarchical, and it’s genuinely unpleasant. Does this result in a good outcome?

    I’m going to drop the snark, because this is absolutely serious. Depersonalization was reported by almost 30% of residents. High levels of emotional exhaustion were reported by more than 45% of residents. Burnout was reported by more than half of residents. That alone should make you pause. This is not a healthy and happy group.

    The problem here isn’t just that residents are unhappy and start to lose their empathy, though. It’s that, of all professions, we need them to be empathetic and personal. We need them to care. Yet we have a system that seems completely designed to produce the opposite result.

    I still work with residents all the time. I see how unhappy they can be. On more than one occasion, I’ve advised them to consider therapy for depression. People sometimes think I’m intense and unapproachable, but you’d be shocked at how many residents and fellows have cried in my office. I’ve been there; I understand. And, I’m sorry, but I get enraged when physicians “forget” and try to wax nostalgic about a system and profession that seems to value personal martyrdom over having a full life.

    Even though they should know better, and we trust them with our lives, physicians are just as likely, if not more likely, to become addicted to drugs. They’re also more likely to have a serious problem before it’s discovered. As I’ve said before, they are more likely to commit suicide than any other profession.

    This may sound like whining to some, but I’m not advocating for me. I’ve come out the other side, and I’m OK. But we continue to turn a blind eye to this problem at our own peril.

    In this study, almost fifteen percent of residents rated their quality of life “as bad as it can be” or “somewhat bad“. If that doesn’t make you squirm, I don’t know what will.

    • The two fellows I just hired are now started and underway. They each came out with over $250k worth of debt. I need to baby them a bit more than we used to have to do with new hires, but they are performing well so far. They seem especially anxious about peds cases, which seems to be the norm today.


    • Imagine the same study and analysis about the marines, navy seals, lawyers, architects, professional athletes, tenure track junior faculty, any demanding profession. It would sound rather silly. You can’t eliminate extraordinary effort and the accompanying stress, sacrifice, exhaustion, and duress from meanngful achievement. One consensus among experienced physicians – academic and in private practice – is that residents completing their training since the time commitments, intensity, and demands of residency have been relaxed are less prepared and less well-equipped than before those changes were made. (As a practical matter, they’ve had less clinical experience simply because the hours of training have been reduced.) Their attitude toward their work tends to be different as well. An increasing number of newly trained physicians also tend to approach practice as jobs and not professions. Lower the expectations and reduce the demands and you will attract a different kind of individual. Combine this with asking them to work in a needlessly complex and dysfunctional environment that is being made more complex and dysfunctional, and you will end up with low-achieving functionaries. That’s one place the enveloping bureaucracy is taking health care.

    • That’s so true.

    • I curse the day I decided to attend medical school. I have been practicing medicine for five years now and to be honest with you I will be leaving the profession within the next two years, The profession has been destroyed by crooked politicians.

    • Oh, Will and David, I can tell by what you are saying that you have never have this kind of catastrophic debt. Will thinks it has to do with our being weak due to fewer training hour. Oh! That makes sense. It couldn’t be that having a tremendous amount of debt and realizing that Will and David will be having comfy retirements while we will be struggling to put our children through college will make us anxious. It could be that there is just a generational difference in experience. You worked longer hours in training, but we may work until we die because we have to take care of the 10,000 people retiring into the sweet arms of Medicare everyday. A Medicare and Social Security that will not be there for us. The thing is that you have no idea what I am talking about.