Thoughts on Medical School Burnout

Lost month in the Annals of Internal Medicine a study on medical student burnout and suicidal thinking, and then a commentary in Slate.com. I hear a lot these days in the press, blogs, at work among colleagues, about how stressful the medical profession has become.

Having had a previous career prior to medicine, I can say for myself at least that there is more stress in medicine than the tech industry, but it is not because of long hours as many people think. I think it is primarily because of the type of stress - the responsibility of managing people with complex medical conditions, the pressure of high-patient turnover, and the legal implications of medical decision-making. These all make medicine more emotionally charged than in other professions. On top of that is the type of work schedule. Many people in other professions work 80 hour weeks. But only in medicine is it typical to work extremely long periods 30 or 48 hours, or be on call when you have to be available around the clock. That's difficult because it messes up routine, your sleep, it become impossible to plan anything. An 80 hour workweek is heavy, but it makes a big difference if those hours are predictable and separated with periods of recovery.

The stress of being a medical student is also unique. Commonly voiced complaints are the ridiculous cost of medical education ($100-150K) and the endless training (min of 7 years after college). These feed into each other since indebtedness leads people to seek more training in higher paid specialties.

For me "burnout" in medical school has not been about working long hours or dealing with unpleasant patients. It is about the pressure of getting good evaluations in a environment where expectations of my roles and responsibilities are poorly defined, combined with a sense of ennui because I am not given any responsibility for patient care.

There are high expectations of you to know a lot that you don't really know, often times before you've ever been trained. Expectations are constantly shifting and are totally dependent on the team you are working with that week. And just as you get the hang of something, you switch clerkships and possibly hospitals sites as well. This is like starting a new job every 4-6 weeks; new nurses and staff you don't know, a new space where you don't know where anything is, new residents and attendings - your bosses essentially - with their own way of doing things. And all along you get evaluated by every resident and attending you work with, even if it is for a few days.

But beyond all that, the worst part about the clerkship years for me was that I was totally useless. As a student you can't write medical orders, so your role is limited to glorified shadowing - following your team around and observing. At OHSU, a large academic medical institution where there are many residents and other students, there is considerable competition for patients. Residents and interns have priority in managing patients and doing procedures; the student is last to know new test results, handle a scope, or peak into a wound. Yes, you do your own exams and write your own notes, but these are meaningless to the patient's care because the resident and attending also do this as well (nothing done by a student can be billed to the patient). I was told by one attending that I needed to act as if the patients were my patients, that is, take ownership of them. This was really frustrating, especially for someone like myself with a previous career with managerial responsibility, because the system is not designed to allow a student to do that in any meaningful sense.

Most student's motivation during clerkship is to get a good grade, and that's done by convincing your team that your a good student. But how do you do that? Attendings and residents rarely, if ever, observe your exams or interviews. Often times they don't really read your note in any detail. So your evaluations hinge largely on your presentations, those few precious minutes during the day when all eyes and ears are turned to you. Presenting a patient is a vital skill in medicine and doing it well is an art; this kind of emphasis in medical school clerkship is corrupting.

And here why: If I had an hour to see and prepare a progress note for my attending, I would best be served by spending as little time as possible seeing the patient - get in, get out - and the rest looking up new literature or reading up on the disease. Indeed, knowing your literature is crucial to being a competent doctor. But shouldn't bedside care also be? Sadly, bedside care is actually one of the ways in which a student can "add value" to the care delivered to a patient. Our system does not reward the student who takes bedside care seriously. Patients never evaluate students; and attendings only evaluate what they see: the fruit of diligent study appearant in an impressive assessment and plan.

Sure, I've learned a lot the last 18 months during my clerkships, but I am eager to move on and actually do work, to have some responsibility and feel accountable.