It's absurd to try to train doctors to become more "resilient", MedicalBrief's Alastair McAlpine writes in his Digital Clubbing column. Doctors are unhappy, depressed, and are killing themselves – quite simply, we need to completely re-imagine healthcare and training.
If you ever wish to raise a doctor’s blood pressure immediately, simply send them an email informing them of a work-related, compulsory “resiliency” training course. Watch their heads slam the table as you let them know how you will be focusing on “mindfulness and relaxation techniques”, together with some helpful tips on how to improve their sleep quality. Eyes will roll as you expound on your plan to improve their interpersonal and work relationships through roleplaying and scenario-based learning. Finally, observe them curse and storm out as you happily detail how the day will end with some gentle yoga and meditation.
You see, it’s not that there is necessarily wrong with learning any of the above skills. Digital Clubbing is an enthusiastic proponent of yoga and your correspondent has been working hard on his downward dog. Rather, the issue is that resiliency training takes the focus away from the general systemic failings that damage so many physicians.
At its worst, it is a form of victim-blaming: the reason you’re so tired and burnt out and unhappy is because you’re just not a resilient human being. You lack the skills to cope and have clearly not been attending those yoga courses we recommended. Please complete this online module at once.
At its best, resiliency training is simply unhelpful: many of the skills and pieces of advice the resiliency courses advocate are not possible because of the nature of the job. It’s ridiculous to tell people to sleep more when their timetable has them working three 24-hour shifts in a week. Or seven nights in a row. It’s silly to advise doctors to eat more healthily when the cafeterias in the hospital only serve sickly Chelsea buns for breakfast, and the ICU is so busy that we haven’t had time to sit down to wolf down said Chelsea bun, let alone eat the healthy salad we were supposed to have packed. This despite the fact that we finished work at 11pm the day before, and all the stores were closed, and we were so tired that all we wanted to do was collapse on the couch when we got home. And when you have doctors working late days and three weekends a month, when exactly do you propose they find the time to exercise?
So, sending us on resiliency training hurts because most doctors are resilient. We worked hard and were disciplined at medical school. We spent our 20s studying when everyone else was partying. We’ve slaved away in creaking, busy public hospitals, working insanely long hours for fairly modest pay-cheques. We’ve handled life-and-death situations and witnessed sights that would haunt most members of the public. We’ve spent thousands of hours studying and reading and writing. There is absolutely no reason to assume that as a group, we lack resiliency.
The issue of physician suicide and burn-out is deeply, deeply concerning. Rates vary, but it tends to be higher among trainees, and ranges from 25-78%. And it’s not just the physicians who suffer: burn-out predicts medical error more than fatigue. Simply put, you don’t want a burnt-out physician treating you.
It is a major reason why the risk of suicidality in physicians compared to the general public is anywhere between 70 and 250% higher. Whenever you talk to the family of a colleague who has tragically taken their own life, the story is often depressingly similar: a vicious cycle of burnout and depression. Almost every doctor knows someone who was talented and dedicated but decided that it was all too much to bear. From a personal perspective, the suicide of Professor Bongani Mayosi affected me, and many others, very deeply. It is a worldwide problem and we are all at risk.
If “resiliency training” is not the answer, what is? Quite simply, we need to completely re-imagine healthcare and training. It doesn’t necessarily have to be expensive, but it requires changing our behaviour. And if there’s one thing doctors are bad at, it’s changing the way we do things. A bizarre “we did it and survived so why shouldn’t you?” school of thought pervades many of our teachers and seniors. But the numbers don’t lie: we are unhappy, we are depressed, and we are killing ourselves. Something needs to change.
Firstly, crazy shifts need to end. Yesterday. There is simply no justification for a doctor working anything beyond a 16-hour call. This isn’t a personal hunch. There are reams of data which demonstrate conclusively that beyond 16 hours, doctors become increasingly impaired, both in judgement and performance.(1) A study by Dawson in Nature showed that 24 hours of wakefulness was the equivalent of a blood alcohol level of 0.1% (the legal driving limit in South Africa is <0.05%).(2) Another review showed that a single missed night of sleep resulted in a clinical performance decline of 1.3 standard deviations below the mean.(3) Landrigan and colleagues showed that interns who worked 24 hours or more made major medical errors 36% more frequently than those on a kinder schedule.(4)
And it’s not all about patients. The deaths of young doctors Ilne Markwat in South Africa, and Lauren Connelly in Scotland, who both crashed while driving home after long shifts, are as tragic as they were predictable: the data showing the increased risk of driving post-call is voluminous and compelling.(5) Even for those fortunate enough to survive, prolonged periods of poor sleep are associated with depression, obesity and increased mortality.(6)
From a personal perspective, I can’t begin to tell you how exhausting and draining extremely long shifts are. They’re bad for your mental state as well: I remember having to do a clinic after 26 hours of no sleep, and just flying through it as quickly as possible because I was desperate to go home to rest. When I woke up later that day, I was mortified that my focus had been on myself, and not on my patients, who deserved better. And the next day, I was back again, having to perform at my best, when all indicators are that it takes many nights of sleep to make up for a single ‘missed’ one.
Any way you cut it, a system that routinely abuses its doctors and forces them to work long shifts without adequate sleep is going to result in burnout.
Secondly, a large reason for the feeling of burnout is doctors feeling disconnected from our patients. Most of us entered the career because of a desire to help other human beings. Technology was supposed to help by making everything more efficient. But instead, we are tied to our computers, performing mind-numbing electronic tasks and completing paperwork. A recent study by Arndt found that primary care physicians spend, on average, a staggering 6 hours per day completing electronic health records.(7) Billing, coding and security accounted for a staggering 157 mins of that, with doctors performing more than 4000 clicks per busy shift.(8)
Patients and doctors are crying out for more personal interaction, more time, more care, more humanity; a few extra minutes to explain a complex disease, understanding and patience when the world no longer makes sense and seems to be falling apart, a consoling touch to acknowledge unfathomable grief.
Instead, physicians spend their time clicking through cumbersome and inefficient forms and re-entering passwords for the millionth time, all to satisfy an insurance company, a manager, or a bureaucrat who has never seen patient in their life. One of the biggest complaints patients have, and one of the major reasons they go to alternative healers, is that they feel their doctors don’t listen to them. But if you’re a GP in the UK's National Health Service (NHS), and the word from on-high is that you have 15 minutes per patient, and 10 of these are taken up with screen time, how are you supposed to have any meaningful human interaction with those under your care?
Doctors need to be untethered from their computers and allowed to interact properly and profoundly with their patients. Long dictations or notes that no one reads, endless forms to allow us to prescribe what our patients require, cumbersome paperwork to benefit insurance companies… these should all be discarded or streamlined. Medicine is a human profession. Let’s stop spending more time with our computers than our patients.
Finally, the hierarchical nature of medicine needs to be seriously re-examined. Like all professions, there will always be some who know more than others, and those more experienced. But the notion of essentially ‘abusing’ interns and junior doctors, and lumping them with back-breaking volumes of work, is as regressive as it is unhealthy. Part of being a good clinician and dispensing life-advice to our patients is having actually lived ourselves. Forcing junior colleagues to spend endlessly long hours in the hospital doing boring skivvy work breeds dissatisfaction and depression. And for those who say, “Well, look, sorry, but there’s a lot of work and someone’s gotta do it…”, I urge you to examine the difference in productivity between motivated and tired, burnt-out colleagues. Creative use of the timetable can usually ensure that if everyone understands their role and works hard, the team can be finished by a reasonable hour. Let your docs out to enjoy the sunshine. You won’t regret it.
There are so many meaningful ways we can improve working conditions for ourselves, our colleagues and our patients. I haven’t even begun to scratch the surface. Better team work. Proper communication. Involving our allied health colleagues more. The possibilities are endless. Why not allow residency time to be “split” between two or three colleagues to allow those of us with other priorities time to focus on those? Why not “We Rock!” meetings as a counterpoint to morbidity and mortality meetings, where we focus on the things we did right, not just our errors? Why not anonymous ‘compliment’ boxes where we tell colleagues what we admire about them?
Doctors are the canaries in the coal-mine of the healthcare system. We can focus on making the canaries more “resilient” in a deeply toxic environment that grinds them up and spits them out. Or we can fix the damn coal mine. Let’s get started.
[link url="https://www.sciencedirect.com/science/article/pii/S0002961003001831"]1. Eastridge BJ, Hamilton EC, O'Keefe GE, Rege RV, Valentine RJ, Jones DJ, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. American Journal of Surgery. 2003;186(2):169-74.[/link]
[link url="https://www.nature.com/articles/40775"]2. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature. 1997;388(6639):235.[/link]
[link url="https://www.ncbi.nlm.nih.gov/pubmed/16335329"]3. Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep. 2005;28(11):1392-402.[/link]
[link url="https://www.nejm.org/doi/full/10.1056/NEJMoa041406"]4. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. The New England Journal of Medicine. 2004;351(18):1838-48.[/link]
[link url="https://www.nejm.org/doi/full/10.1056/NEJMoa041401"]5. Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, et al. Extended work shifts and the risk of motor vehicle crashes among interns. The New England Journal of Medicine. 2005;352(2):125-34.[/link]
[link url="https://oem.bmj.com/content/74/Suppl_1/A143.3"]6. Jorgensen JT, Karlsen S, Stayner L, Andersen J, Andersen ZJ. Shift work and overall and cause-specific mortality in the Danish nurse cohort. Scandinavian Journal of Work, Environment & Health. 2017;43(2):117-26.[/link]
[link url="http://www.annfammed.org/content/15/5/419.full.pdf+html"]7. Arndt BG, Beasley JW, Watkinson MD, Temte JL, Tuan WJ, Sinsky CA, et al. Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Annals of Family Medicine. 2017;15(5):419-26.[/link]
[link url="https://www.sciencedirect.com/science/article/pii/S0735675713004051"]8. Hill RG, Jr., Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. The American Journal of Emergency Medicine. 2013;31(11):1591-4.[/link]
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