WE ARE CONVERTED BURNOUT SCEPTICS.
When the first residents started asking for time off from training because they felt burnt out, we secretly thought that they were, you know, weak. It must be the new generation; they didn't make them like they used to in the days when housemen could do every other night call with no post-calls and still come back asking for more. However, it didn't stop at those first few. There were those who were just "sian" (Hokkien for weariness) with life, but there were also those who broke down at a "how are things going?", those who could not find anything left in themselves to give to those they were caring for and those who had gone beyond burnout into depression. It was then that we comprehended that burnout is a very real thing and wondered what the system was doing to our young, bright trainees.
In Prof Christina Maslach's words, burnout is "an erosion of the soul caused by the deterioration of one's values, dignity, spirit and will". The Maslach Burnout Inventory (MBI) measures three dimensions of burnout: emotional exhaustion, depersonalisation and personal accomplishment.1 Symptoms range from fatigue, lack of motivation and disinterest in patients, to physical symptoms and absenteeism. Clearly this does not bode well for both the patient and the physician. A distracted physician who is not paying attention to details is likely to make mistakes; there may be the lack of ability to engage and develop personal connections with patients, and absenteeism and attrition will adversely affect trained manpower. The physician may seek unhealthy coping mechanisms that lead to health problems and their relationships with family and friends may suffer.
A cause for concern
Worryingly, burnout appears to be on the rise. The 2017 Medscape Lifestyle Report showed that the percentage of burnout had increased from 2013, with emergency medicine, obstetrics and gynaecology, family medicine and internal medicine being the top four specialties affected.2 Burnout rates in US physicians are up to 54.4% with higher rates in residents, fellows and early career physicians.3,4 The situation is similar in Singapore; both the SingHealth residency and the National University Health System have published studies citing ranges between 71.8% to 80.7% in at least one MBI burnout domain.5,6 In the National Healthcare Group (NHG) residency, the preliminary results of an ongoing study presented at the Asia Pacific Medical Education Conference 2018 found that 64.3% of internal medicine residents are at risk of clinically significant burnout, with ranges of 46.7% to 61.8% in other specialties.7 Numbers like these tell us that burnout is not a problem of a few individuals with acopia; it is a systemic issue.
Studies have suggested that multiple factors contribute to physician burnout, including excessive workload with increasing patient demands, struggles to achieve work-life balance, inefficiencies in poorly designed systems, lack of autonomy over schedules and clinical decisions with increasing automated guidelines, the use of electronic health records resulting in less time interacting with patients, and an overall erosion of the meaning of work.8 Locally, many specialties require residents to complete both US and UK examinations, resulting in higher examination burdens. In internal medicine, that comes up to seven major examinations within a three-year residency. NHG's Resident Wellness Workgroup also identified factors such as the burden of administrative tasks, fear of making mistakes, anxiety over future career progression and concerns over physical safety in certain work environments (eg, emergency department) where cases of assault may occur.
How can institutions help?
So what can be done about this looming epidemic? We think that the first thing we need to do is talk about it. Talk about it so that physicians who are burnt out will know that they are not alone, that it is not a shameful secret and soldier on until they run out of reserves, and so that those at risk will be able to reverse it. Talk about it to the faculty and equip them so that they can identify the symptoms of burnout and be able to give good advice. Talk about it to senior management because an engaged leadership and institutional commitment to building supportive systems through quality improvement strategies is imperative. Recent systematic reviews have shown that tackling burnout does not rest solely on the individual's shoulders and a shared responsibility with both individual and organisational interventions works best.9
It is also essential to create meaningful social connections and group identification. One of the struggles we face as the number of trainees increase significantly is that people become lost in a system where they rotate through many departments and hospitals at short intervals. Our programme seeks to address this by creating smallness in bigness - creating "houses" for the residents with peer leaders and housemasters to increase social support and a sense of identity. In true Singaporean fashion, most events centre on food, but we also use the "houses" to compete in (mostly intellectual) games. We focus on interactions outside of the work environment, for example in art, sports and community service. We feel that a formal structure of support is integral to identifying and helping those in need. We have built in buddy systems, longitudinal mentorships by faculty, and have also engaged a psychiatrist to whom residents can either approach informally for aunt agony chats or be referred to for triage for psychological support, with full confidentiality promised.
How can each of us help?
Many of us are probably guilty of not taking as good care of ourselves as we should. Learning how to incorporate self-care skills into our practice can improve our well-being. Individual physicians may benefit from planning opportunities to exercise, learning and practising mindfulness and emotional awareness, and having a reflective practice. Mindfulness is one of the interventions that have been shown to improve cases of burnout.10 Many institutions offer group practice sessions and our programme is embarking on a study to look at whether a mindfulness-based stress reduction course can reduce burnout in residents.
Finally, and possibly most importantly (although we have spent the whole article speaking about burnout), we should shift towards talking about joy in work. Medicine has always been thought of as a calling, and as the Institute of Healthcare Improvement's white paper described, it is time to go back to the anchor of "what matters to you?"11 It may be difficult to remember this in the middle of fighting with computer systems that hang, demanding patients and endless tedious administrative tasks. However, we are confident that each of us had a good reason that led us to our pursuit of medicine, and if we keep holding on to this conviction, while practising self-care and self-compassion, we will not only help ourselves but also become role models to our juniors, demonstrating that the career we have chosen is truly worthwhile.