We have been hearing a lot about physician burnout and how we need to recapture the joy of practice that we feel has been taken from us by user-unfriendly electronic medical records (EMRs) and the swell of administrative responsibility we now confront on a daily basis, whether in private or academic practice. Increasing administrative burdens distract from what we want to do and are trained to do as clinicians and clinician educators. Similar influences affect the training environment, where residents are now required to meet increasingly complex service and training expectations but in a shorter time frame due to restricted training hours.
This past August, the medical community was stunned when 2 first-year medicine residents in New York jumped to their death within a few days of each other. These apparently unrelated events at 2 different training programs lend stark reality to the pressures of training, given that just a few weeks earlier both young physicians had celebrated their graduations from medical school. That these tragic events occurred in such close proximity caught everyone's attention, but knowing that the residents died within a few weeks of starting residency awakened us to the realization that physician burnout and distress may begin long before practice ever begins.
Burnout and the loss of joy in being a doctor have become an ever-expanding concern and a major part of our rhetoric these days. The modern paradigm of medicine demands “meaningful use” of EMRs, increased clinical productivity, and health care constructs that discourage long-standing and meaningful relationships with patients. We see signs of this every day in colleagues who are quitting early, cutting back, or changing course completely in their professional lives. We also see it in more dramatic and devastating ways. Between 300 and 400 physicians commit suicide each year, with the suicide rate for male physicians being 40% higher than men in the general population. For female physicians, the rate is 130% higher.
Depression and burnout for many physicians begin in training. A study published in the Nov. 5, 2014, JAMA by Rita Rubin, MD, found that upon entering medical school students actually had lower rates of burnout and depression and a higher quality of life than college graduates the same age who were not in medical school. But by the time they graduated, about half the medical students studied exhibited feelings of depersonalization, emotional exhaustion, and low personal accomplishment. Many were already burned out at the beginning of the most rigorous time of their professional lives, their first year of residency.
Depression and burnout are not new concerns for medical students and residents. I suspect we all have felt them at one time or another during residency, but these feelings continue following training for those more chronically affected. Deborah Goebert, DrPh, published a study in Academic Medicine in February 2009 in which 12% of medical students and residents surveyed had probable major depression and 9.2% had probable mild to moderate depression, with higher rates among women. Nearly 6% reported suicidal ideation, with higher rates among medical students and black respondents. Dr. Rubin suggests that rates of depression and suicide in medical trainees have not changed much in the past 10 years, though the data are not clear. That these problems have existed to this extent historically is concerning, however, knowing the demanding and often frustrating practice environment awaiting most following training.
Physicians, both in training and practice, are often reluctant to seek help when depressed or seriously burned out because of the stigma attached; a sense of failure; and fear of professional sanction, such as losing professional privileges or medical licensure. The Accreditation Council for Graduate Medical Education (ACGME) and others are hoping to foster changes in the resident training curriculum to make it a more positive and humanistic experience.
Dr. Rubin's article states that ACGME estimates about 20 residents (out of over 100,000) die each year, about half of them by suicide. This seems like a small number. But the recent back-to-back tragic deaths by suicide of 2 bright, freshly minted colleagues in New York may be the “sentinel events” warning us that professional burnout and distress often start early in the profession and while still in training.
If we are to prevent such tragedies from becoming more prevalent, we must do something about them now. We need interventions and awareness to enable physicians and other health care workers to better adapt to the pressurized and ever-changing practice environment. We also need to teach and develop skills very early in medical education and training so we can recognize distress in our colleagues and intervene when necessary.
ACP is also doing its part in this effort for the practicing internist. A new initiative announced at the fall 2014 Board of Governors meeting, “Patients before Paperwork,” is designed to reinvigorate the physician-patient relationship by challenging unnecessary practice burdens. It is attempting to piece together the practice enjoyment puzzle by exploring issues surrounding administrative complexity, EMR usability, team care, and other interventions designed to decrease physician burnout. Goals of this initiative will be to educate members, policymakers, and the public on the undue administrative hassles confronting physicians; identify those that are the highest priority; and implement the most effective strategies to mitigate or eliminate excessive administrative burdens in practice where possible. One of the highest priorities will be to work with other stakeholders and experts to refocus the EMR toward a more clinically grounded, patient-centered, and user-friendly model of care. The challenges in this initiative are substantive, but we are focused in this effort. You will be hearing much more on this in the months to come.
We also need to work with ACGME, the Association of American Medical Colleges, the American Board of Internal Medicine, and others to do what is needed to influence the education, training, and practice environments. A global effort is needed in both practice and training to learn about the issues, lessen undue burdens, and recapture the personal joy and fulfillment we all must have if we are to likewise teach those who will follow and fulfill the meaning of our profession. Finding ways to recapture the joy of medicine is a top strategic priority for the College because it is critically important to our members, our learners, and our patients.