Before medical school, I worked as a pharmaceutical quality auditor, where I frequently collaborated with a business partner located in a quaintly-appointed town in Germany. After conference calls with my German colleagues, I often wondered what we were missing on this side of the pond, as my German counterparts were consistently able to maintain a level of zest and vigor that my U.S. coworkers just could not emulate. I’m not going to pretend to be well versed in all of the social, cultural and economic variables that are likely at play here, but I do know one simple thing — my European colleagues were offered a very generous vacation package, and, more importantly, they weren’t afraid to use it. In 2014, the Tourism Economics team for the U.S. Travel Association examined paid time off in the United States and found that employees do not use an average of 3.2 vacation days per year. In total, this means that the U.S. workforce leaves 429 million vacation days on the table yearly.
To me, this sounds like another H&R Block-esque “Take Your Billion Back America” advertising campaign just waiting to happen. Although research has demonstrated significant benefits to taking paid time off, including more productive, focused and dedicated employees, the trend persists. The notion that “workaholic” is a title worthy of glorification infiltrates every industry, and as future physicians, we will not be immune to the cultural biases that aim to blur or eliminate the boundaries between personal and professional lives. My goal here is not to use untouched vacation time alone as an end-all-be-all litmus test for the differences between American and European workforce mentalities but rather as a starting point for beginning a discussion about the complexities surrounding physician burnout and the importance of maintaining physician well-being.
As medical students, we are familiar with the Triple Aim for health care improvement in the United States — to improve the patient care experience, improve the health of populations, and reduce the per capita costs of healthcare. While the move towards a quality-focused and patient-centered health system is encouraging in many ways, it cannot be accomplished by a workforce of burned out and jaded professionals. A 2010 study in The Annals of Surgery, for example, found a significant and adverse relationship between self-reported major medical errors and burnout. Others share my opinion and have called for the addition of a fourth goal — to improve the work lives of those who deliver care –thereby transforming the Triple Aim into the Quadruple Aim.
So what exactly is physician burnout, and what causes it? Burnout is defined using the Maslach Burnout Inventory, a methodology that focuses on three major domains — emotional exhaustion, depersonalization and a diminished sense of personal accomplishment. Physician burnout is caused by a number of factors, which include, but are not limited to, too many bureaucratic tasks, too little time with patients and compassion fatigue. A 2015 Medscape report found that when presented with a list of potential causes of burnout, physicians ranked “too many bureaucratic tasks” and “spending too many hours at work” as the first and second most important factors, respectively. We’ll be focusing on the latter.
Systemic changes aimed at tackling the issue of “too many hours” are already being implemented, including the institution of an 80-hour workweek in residency programs. In an effort to reduce medical errors, the Accreditation Council for Graduate Medical Education established restrictions on duty hours for residents in 2003 with revisions in 2011. A landmark 2004 study published in The New England Journal of Medicine found that interns in intensive care units made 36 percent more serious medical errors during traditional extended shifts (24 hours or more) than during shorter shifts, demonstrating support for the duty hour restrictions.
In addition to a reduction in the number of work hours, scheduling flexibility offers some protection against burnout by allowing physicians to tailor their hours to the lifestyle, schedule or care setting of their choosing. For example, locum tenens, which literally means “to hold the place of,” is a staffing strategy that allows physicians to fill in for other clinicians on a temporary basis, affording them the ability to take off as much time as they desire, an escape from political drama and the freedom to leave without repercussions. A second approach, hospitalist medicine, has the potential to allow for schedule customizations that encourage physicians to “work in the way they work best.” Furthermore, part-time work and the work-life balance that is made possible by a reduction in work hours is becoming increasingly popular among specific demographics, including physicians near the ends of their careers.
However, while the above options sound great, they don’t do too much to help us, the medical students, in the here and now. As future physicians, we too will come face to face with the mental maladies associated with careers in medicine, but what can we do about the classes, board exams, research projects and extracurriculars that populate our current schedules? In order to prevent the adoption of maladaptive habits that could diminish the future quality of our care, I propose that we begin by setting precedents — as students, for ourselves, right now.
I challenge each of us to give up the game that we all play — the “waiting for the perfect time” game. This is the game where we tell ourselves that we will make time for our personal lives after the next exam, after the next class, after medical school or after residency. Set the precedent now, establish boundaries and find outlets that allow you to alleviate stress. How you do so is not what is important but rather that you do so and you do so regularly. Put down that physiology syllabus for an hour or so to catch up on Netflix, head to the gym or, better yet, catch up on Netflix while at the gym.
The time will come when we all will have attendings to report to, packed schedules to balance and responsibilities to attend to that go far beyond the memorization of renal ion transporters. It will not be easy; we will not be able to cease the endless buzz of our pagers, and we will we be able to prevent the complicated cases that will come through the doors at our shifts’ ends. We have, nevertheless, signed up for a profession dedicated to helping people, a job that demands a great deal of skill, knowledge and humanity on a daily basis. To maintain that level of performance, we must carve out personal time to recharge and stay connected with ourselves. Our time spent away from the clinic will be important not only for ourselves and for our families but also for the colleagues and the patients who will trust us to be engaged — not burned out –physicians.