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Fellowship Burnout: What can we do to identify those at risk and minimize the impact?
Jeff is a high-performing first-year gastroenterology fellow who started with eagerness and enthusiasm. He seemed to enjoy talking to patients, wrote thorough notes, and often participated during case discussions at morning report. He initiated a quality improvement project and joined a hospital committee. Over the past few months, he has interacted less with his peers in the fellow’s office and stayed late to complete his patient encounters. He now frequently arrives late to work, is unprepared for rounds, and forgets to place important orders. One day, you notice him shuffling through several papers when the attending asks him a question about his patient. Later that day, he snapped at a nurse who paged to ask a question about a patient who just had a colonoscopy. When you ask him how he is doing, he becomes tearful and reports that he is under a lot of stress between work and home and does not feel the work he is doing is meaningful.
Introduction
The above scenario is all too familiar. Gastroenterology training can be a stressful period in an individual’s life. Long hours, steep learning curves for new cognitive and mechanical skill sets, as well as managing personal relationships and responsibilities at home all contribute to the stress of training and finding appropriate work-life balance. These stressors can result in burnout. The last decade has brought about a renewed emphasis on mitigating the impact of occupational burnout and improving trainee lifestyle through interventions such as work-hour restrictions, resiliency training, instruction on the importance of sleep, and team-building activities.
The problem
The World Health Organization (WHO) defines occupational burnout as chronic work-related stress, which may be characterized by feelings of energy depletion, mental distance from one’s job or feelings of negativity toward it, and reduced professional efficacy. Occupational burnout has been identified as an increasing problem both in practicing providers and trainees. Surveys in gastroenterologists show rates of burnout ranging between 37% and 50%,1 with trainees and early-career physicians disproportionately affected.1,2Physicians along the entire training spectrum are more likely to report high emotional exhaustion, high depersonalization, and burnout than a population control sample.2
Several individual factors identified for those at increased risk for burnout include younger age, not being married, and being male.2 Individuals spending less than 20% of their time working on activities they find meaningful and productive were more likely to show evidence of burnout.1
Symptoms of burnout can have a profound impact on trainees’ work performance, personal interactions, and the learning environment as a whole. The Accreditation Council for Graduate Medical Education (ACGME) annual survey of trainees asks them how strongly they agree or disagree on various components of burnout such as how meaningful they find their work, if they have enough time to think and reflect, if they feel emotionally drained at work, and if they feel worn out and weary after work. The intent of these questions is to provide anonymous feedback to training programs to help identify year to year trends and intervene early to prevent occupational burnout from becoming an increasing issue.
The solution
Considerations for any intervention should take several factors into account: the impact it may have on training and the development of a competent physician in their individualized specialty, the sustainability of the intervention, and whether it is something that will be accepted by the invested parties.
One method proposed for preventing burnout during fellowship has been designated as the three R’s: relaxation, reflection, and regrouping.3
- Relax. In order to relax, trainees need ways to decompress. Activities such as exercise and social events can be helpful. Within our own program the fellows have started their own group exercise program, playing wallyball weekly before clinical duties. We also encourage use of vacation days and build comradery by organizing potluck dinners for major holidays, graduation parties at the program director’s house, and an end-of-the-year golf outing in which trainees play against staff followed by a discussion regarding the state of the program. More recently we have added one half-day per a quarter for morale and team building. During this first year, the activities in which trainees have collectively decided to participate include an escape room, a rock-climbing facility, and laser tag. The addition of more team-building days has been well received by our program’s trainees and the simple addition of these team-building days has resulted in the trainees interacting more together outside of work, particularly in the form of group dinners.
Walter Reed National Military Medical Center fellows gathering for wallyball. - Reflect. They describe reflection as a necessary checkpoint which typically occurs every 6 months.3 These “checkpoints” provide an opportunity to provide feedback to the fellow as well as check in on their well-being and receive feedback about the program. We give frequent feedback to fellows in the form of spot, rotational, and mid-/end-of-year feedback. Additionally, we have developed a unique feedback system in which the trainees meet at the end of the year to discuss collective feedback for the staff and the program. This feedback is collated by the chief fellow and given to the program director as anonymous feedback, which is then passed to the individual staff.
- Regroup. Finally, regrouping to form new strategies.3 This regrouping provides an opportunity to improve on areas in which the trainee may have a deficiency and build on their strengths. To facilitate regrouping, we identify a mentor within the department and occasionally in other departments to meet regularly with the trainee. A successful mentor ensures effective regrouping and can help the trainee avoid pitfalls that they may have experienced in similar situations.
Moving forward
Occupational burnout is a systemic problem within the medical field, with trainees disproportionately affected. It is imperative that training programs continue to work toward creating a culture that prevents development of burnout. Along with the ideas presented here, the ACGME has launched AWARE, which is a suite of resources directed specifically at the GME community, with a goal of mitigating stress and preventing burnout. No one approach will be universally applicable but continued awareness and efforts to address this on an individual and programmatic level should be encouraged.
Dr. Ordway is a chief fellow, Dr. Tritsch and Dr. Singla are associate program directors, and Dr. Torres the program director, division of gastroenterology and hepatology, Walter Reed National Military Medical Center, Bethesda, Md.
References
1. Barnes EL et al. Dig Dis Sci. 2019;64(2):302-6.
2. Dyrbye LN et al. Acad Med. 2014;89(3):443-51.
3. Waldo OA. J Am Coll Cardiol. 2015;66(11):1303-6.
Jeff is a high-performing first-year gastroenterology fellow who started with eagerness and enthusiasm. He seemed to enjoy talking to patients, wrote thorough notes, and often participated during case discussions at morning report. He initiated a quality improvement project and joined a hospital committee. Over the past few months, he has interacted less with his peers in the fellow’s office and stayed late to complete his patient encounters. He now frequently arrives late to work, is unprepared for rounds, and forgets to place important orders. One day, you notice him shuffling through several papers when the attending asks him a question about his patient. Later that day, he snapped at a nurse who paged to ask a question about a patient who just had a colonoscopy. When you ask him how he is doing, he becomes tearful and reports that he is under a lot of stress between work and home and does not feel the work he is doing is meaningful.
Introduction
The above scenario is all too familiar. Gastroenterology training can be a stressful period in an individual’s life. Long hours, steep learning curves for new cognitive and mechanical skill sets, as well as managing personal relationships and responsibilities at home all contribute to the stress of training and finding appropriate work-life balance. These stressors can result in burnout. The last decade has brought about a renewed emphasis on mitigating the impact of occupational burnout and improving trainee lifestyle through interventions such as work-hour restrictions, resiliency training, instruction on the importance of sleep, and team-building activities.
The problem
The World Health Organization (WHO) defines occupational burnout as chronic work-related stress, which may be characterized by feelings of energy depletion, mental distance from one’s job or feelings of negativity toward it, and reduced professional efficacy. Occupational burnout has been identified as an increasing problem both in practicing providers and trainees. Surveys in gastroenterologists show rates of burnout ranging between 37% and 50%,1 with trainees and early-career physicians disproportionately affected.1,2Physicians along the entire training spectrum are more likely to report high emotional exhaustion, high depersonalization, and burnout than a population control sample.2
Several individual factors identified for those at increased risk for burnout include younger age, not being married, and being male.2 Individuals spending less than 20% of their time working on activities they find meaningful and productive were more likely to show evidence of burnout.1
Symptoms of burnout can have a profound impact on trainees’ work performance, personal interactions, and the learning environment as a whole. The Accreditation Council for Graduate Medical Education (ACGME) annual survey of trainees asks them how strongly they agree or disagree on various components of burnout such as how meaningful they find their work, if they have enough time to think and reflect, if they feel emotionally drained at work, and if they feel worn out and weary after work. The intent of these questions is to provide anonymous feedback to training programs to help identify year to year trends and intervene early to prevent occupational burnout from becoming an increasing issue.
The solution
Considerations for any intervention should take several factors into account: the impact it may have on training and the development of a competent physician in their individualized specialty, the sustainability of the intervention, and whether it is something that will be accepted by the invested parties.
One method proposed for preventing burnout during fellowship has been designated as the three R’s: relaxation, reflection, and regrouping.3
- Relax. In order to relax, trainees need ways to decompress. Activities such as exercise and social events can be helpful. Within our own program the fellows have started their own group exercise program, playing wallyball weekly before clinical duties. We also encourage use of vacation days and build comradery by organizing potluck dinners for major holidays, graduation parties at the program director’s house, and an end-of-the-year golf outing in which trainees play against staff followed by a discussion regarding the state of the program. More recently we have added one half-day per a quarter for morale and team building. During this first year, the activities in which trainees have collectively decided to participate include an escape room, a rock-climbing facility, and laser tag. The addition of more team-building days has been well received by our program’s trainees and the simple addition of these team-building days has resulted in the trainees interacting more together outside of work, particularly in the form of group dinners.
Walter Reed National Military Medical Center fellows gathering for wallyball. - Reflect. They describe reflection as a necessary checkpoint which typically occurs every 6 months.3 These “checkpoints” provide an opportunity to provide feedback to the fellow as well as check in on their well-being and receive feedback about the program. We give frequent feedback to fellows in the form of spot, rotational, and mid-/end-of-year feedback. Additionally, we have developed a unique feedback system in which the trainees meet at the end of the year to discuss collective feedback for the staff and the program. This feedback is collated by the chief fellow and given to the program director as anonymous feedback, which is then passed to the individual staff.
- Regroup. Finally, regrouping to form new strategies.3 This regrouping provides an opportunity to improve on areas in which the trainee may have a deficiency and build on their strengths. To facilitate regrouping, we identify a mentor within the department and occasionally in other departments to meet regularly with the trainee. A successful mentor ensures effective regrouping and can help the trainee avoid pitfalls that they may have experienced in similar situations.
Moving forward
Occupational burnout is a systemic problem within the medical field, with trainees disproportionately affected. It is imperative that training programs continue to work toward creating a culture that prevents development of burnout. Along with the ideas presented here, the ACGME has launched AWARE, which is a suite of resources directed specifically at the GME community, with a goal of mitigating stress and preventing burnout. No one approach will be universally applicable but continued awareness and efforts to address this on an individual and programmatic level should be encouraged.
Dr. Ordway is a chief fellow, Dr. Tritsch and Dr. Singla are associate program directors, and Dr. Torres the program director, division of gastroenterology and hepatology, Walter Reed National Military Medical Center, Bethesda, Md.
References
1. Barnes EL et al. Dig Dis Sci. 2019;64(2):302-6.
2. Dyrbye LN et al. Acad Med. 2014;89(3):443-51.
3. Waldo OA. J Am Coll Cardiol. 2015;66(11):1303-6.
Jeff is a high-performing first-year gastroenterology fellow who started with eagerness and enthusiasm. He seemed to enjoy talking to patients, wrote thorough notes, and often participated during case discussions at morning report. He initiated a quality improvement project and joined a hospital committee. Over the past few months, he has interacted less with his peers in the fellow’s office and stayed late to complete his patient encounters. He now frequently arrives late to work, is unprepared for rounds, and forgets to place important orders. One day, you notice him shuffling through several papers when the attending asks him a question about his patient. Later that day, he snapped at a nurse who paged to ask a question about a patient who just had a colonoscopy. When you ask him how he is doing, he becomes tearful and reports that he is under a lot of stress between work and home and does not feel the work he is doing is meaningful.
Introduction
The above scenario is all too familiar. Gastroenterology training can be a stressful period in an individual’s life. Long hours, steep learning curves for new cognitive and mechanical skill sets, as well as managing personal relationships and responsibilities at home all contribute to the stress of training and finding appropriate work-life balance. These stressors can result in burnout. The last decade has brought about a renewed emphasis on mitigating the impact of occupational burnout and improving trainee lifestyle through interventions such as work-hour restrictions, resiliency training, instruction on the importance of sleep, and team-building activities.
The problem
The World Health Organization (WHO) defines occupational burnout as chronic work-related stress, which may be characterized by feelings of energy depletion, mental distance from one’s job or feelings of negativity toward it, and reduced professional efficacy. Occupational burnout has been identified as an increasing problem both in practicing providers and trainees. Surveys in gastroenterologists show rates of burnout ranging between 37% and 50%,1 with trainees and early-career physicians disproportionately affected.1,2Physicians along the entire training spectrum are more likely to report high emotional exhaustion, high depersonalization, and burnout than a population control sample.2
Several individual factors identified for those at increased risk for burnout include younger age, not being married, and being male.2 Individuals spending less than 20% of their time working on activities they find meaningful and productive were more likely to show evidence of burnout.1
Symptoms of burnout can have a profound impact on trainees’ work performance, personal interactions, and the learning environment as a whole. The Accreditation Council for Graduate Medical Education (ACGME) annual survey of trainees asks them how strongly they agree or disagree on various components of burnout such as how meaningful they find their work, if they have enough time to think and reflect, if they feel emotionally drained at work, and if they feel worn out and weary after work. The intent of these questions is to provide anonymous feedback to training programs to help identify year to year trends and intervene early to prevent occupational burnout from becoming an increasing issue.
The solution
Considerations for any intervention should take several factors into account: the impact it may have on training and the development of a competent physician in their individualized specialty, the sustainability of the intervention, and whether it is something that will be accepted by the invested parties.
One method proposed for preventing burnout during fellowship has been designated as the three R’s: relaxation, reflection, and regrouping.3
- Relax. In order to relax, trainees need ways to decompress. Activities such as exercise and social events can be helpful. Within our own program the fellows have started their own group exercise program, playing wallyball weekly before clinical duties. We also encourage use of vacation days and build comradery by organizing potluck dinners for major holidays, graduation parties at the program director’s house, and an end-of-the-year golf outing in which trainees play against staff followed by a discussion regarding the state of the program. More recently we have added one half-day per a quarter for morale and team building. During this first year, the activities in which trainees have collectively decided to participate include an escape room, a rock-climbing facility, and laser tag. The addition of more team-building days has been well received by our program’s trainees and the simple addition of these team-building days has resulted in the trainees interacting more together outside of work, particularly in the form of group dinners.
Walter Reed National Military Medical Center fellows gathering for wallyball. - Reflect. They describe reflection as a necessary checkpoint which typically occurs every 6 months.3 These “checkpoints” provide an opportunity to provide feedback to the fellow as well as check in on their well-being and receive feedback about the program. We give frequent feedback to fellows in the form of spot, rotational, and mid-/end-of-year feedback. Additionally, we have developed a unique feedback system in which the trainees meet at the end of the year to discuss collective feedback for the staff and the program. This feedback is collated by the chief fellow and given to the program director as anonymous feedback, which is then passed to the individual staff.
- Regroup. Finally, regrouping to form new strategies.3 This regrouping provides an opportunity to improve on areas in which the trainee may have a deficiency and build on their strengths. To facilitate regrouping, we identify a mentor within the department and occasionally in other departments to meet regularly with the trainee. A successful mentor ensures effective regrouping and can help the trainee avoid pitfalls that they may have experienced in similar situations.
Moving forward
Occupational burnout is a systemic problem within the medical field, with trainees disproportionately affected. It is imperative that training programs continue to work toward creating a culture that prevents development of burnout. Along with the ideas presented here, the ACGME has launched AWARE, which is a suite of resources directed specifically at the GME community, with a goal of mitigating stress and preventing burnout. No one approach will be universally applicable but continued awareness and efforts to address this on an individual and programmatic level should be encouraged.
Dr. Ordway is a chief fellow, Dr. Tritsch and Dr. Singla are associate program directors, and Dr. Torres the program director, division of gastroenterology and hepatology, Walter Reed National Military Medical Center, Bethesda, Md.
References
1. Barnes EL et al. Dig Dis Sci. 2019;64(2):302-6.
2. Dyrbye LN et al. Acad Med. 2014;89(3):443-51.
3. Waldo OA. J Am Coll Cardiol. 2015;66(11):1303-6.