Residency is the crucible of the medical profession. Besides the long hours and huge cognitive demand, it is a physician’s introduction to the day-to-day realities of the U.S. health care system. It is meant to be difficult, but it should not be life or death for learners.
AMA member Scott H. Pasichow, MD, MPH, knows this all too well. When he was a PGY-2 at the Brown Emergency Medicine Residency, in Providence, Rhode Island, he found himself deep in the throes of burnout, and he didn’t know what to do about it. In fact, he didn’t even recognize it as burnout at first.
When he arrived at work one day, he got some bad news: A patient he had treated the day before had died unexpectedly.
“I thought we admitted them essentially for placement, assistance with physical therapy and finding a safe care plan,” Dr. Pasichow, now an assistant professor of emergency medicine at Rutgers University New Jersey Medical School, recounted in an episode of “AMA Moving Medicine.”
“It was just a huge blow to me. It really impacted the rest of my day,” he said. “I couldn't kind of shake that thought.”
Around the time, he noted, he had found himself frequently feeling angry.
“So I left at the end of the day and, driving home, found a road cone and took out some of my frustration on that,” he said. “The good thing is the car wasn't damaged. Nobody got hurt. I wasn't hurt, and the hospital ... didn't care too much about the cone itself. They were more interested in what it indicated and making sure that I got the help that I needed.”
That put him on a journey of healing and self-discovery through therapy, which included understanding how the health care system had thrust this situation on him.
Dr. Pasichow sat down with the AMA to talk about what residents need to know about preventing burnout and what to do if they do experience it so they can come out whole and reinvigorated for a career in medicine. At the top of that list: Understand that you’re not alone.
The system is set up to burn you out
“The rigor of residency training is important because we have to learn a lot, and learn how to do a lot, in a short amount of time,” he said. “And there's no way for you to predict, especially in emergency medicine, when a critical case is going to come in—something that is important for you to learn from on the medical care side or even the family interaction later in the interaction.”
A resident program’s desire for learners to experience as much as possible in a relatively short window of a few years is a laudable goal, but can end up undermining the profession, Dr. Pasichow said.
“It’s a hard job we're trying to do. None of us wants to get it wrong,” he said. “Wanting people to dedicate every moment of their lives for three to seven or more years to just one thing is what allows this to persist. Ignoring the humanity in all of us—our desire and the expectation that we be there for patients at any moment that they may need us—is what leads to a lot of burnout.”
As the leader in physician well-being, the AMA is reducing physician burnout by removing administrative burdens and providing real-world solutions to help doctors rediscover the Joy in Medicine™.
That includes an AMA STEPS Forward® toolkit to address resident and fellow burnout by creating a holistic, supportive culture of well-being.
No one (else) expects you to be perfect
“You'll have lots of challenging cases,” Dr. Pasichow said. “You’ll have a lot of experiences where you feel like you don't know what needs to be done for the patient in this moment and that you need to reach out for help. And as you go through training, you’ll get more comfortable with that idea. Even as an attending, I’m still finding cases that make me think, ‘I don't know what I should be doing with this,’ and I need to pull a colleague aside to get their perspective.”
But when they start residency, many physicians have the idea that when they complete residency or fellowship they need to be perfect doctors and know everything and do everything themselves.
“I don't believe at this point in my career that I'll ever get there,” he said. “And I don't think any doctor should ever get there, because that's when you make mistakes. That’s when you miss things. That’s when you falter. Reaching out for help isn't a sign of weakness; it’s actually a sign of strength.”
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Know the red flags
Residency can be full of trying moments, so where does one draw the line in evaluating their mental health?
“For me, the line is not wanting to come to work,” Dr. Pasichow said. “When that happens, we need to look at the next week or two and find a day or two days, when we’re not working to do something just for us. For me, that’s the shore or going ice skating. I’ll pick my kids up early from daycare and spend some time with them, watch the soccer match or a baseball game. Do something to pull yourself out of that environment and see if that resets things.”
Often that’s enough for him. But not always.
“Then I know, OK, I need a change in my therapy regimen. Maybe I'm not really understanding what is driving the stress,” he said.
There are other warning signs too.
“If, at the end of the day, you can't think of a single case where you helped someone, that should be a red flag that maybe things are starting to push in the direction of burnout or a mental health problem,” he said.
Another is crying on shift.
“I would love to pretend that that never happens, but it does. It happens more often than people think,” he said. “I'm not talking about crying about a very sad case, a sad outcome. There are emotional responses to what we see and experience in human suffering that are healthy responses, and I don’t want to suggest that crying is necessarily an unhealthy response. But if you're having that response to the presentation of a case or an interaction with another colleague or the normal parts of our job, that's a red flag.”
There are lots of avenues of help
In his darkest moments, Dr. Pasichow had his wife to confide in. But many residents do not have significant others and may even be far from family. In that case, who should they turn to for help?
“The residency program you're in has a vested interest in you completing your training,” he said. “They need you to show up for work and finish your training so that they can function. So while it might feel uncomfortable to reach out to program leadership, most programs or centers will have identified a mental health point of contact.”
One of those leaders is the chief resident.
“They've gone through what you're experiencing, and they can help connect you with resources,” he said, adding that other residents might be having similar experiences. “Make sure that some of your focus at the start of training is on making connections within the program or your resident cohort: these are the people you’ll be interacting with on a daily basis. This could mean getting coffee after a shift, or even a short break during a shift. Try to find the other people who have moved away from family and need a network.”
There are many available online resources “and telehealth is big in mental health right now.”
Telehealth has been particularly helpful, he said, for all the obvious reasons.
“It's easier for me to fit it into a hectic schedule. I can take a lunch break and sit in my car for an hour and do a therapy session as opposed to having to leave the hospital and go somewhere and then come back.”
Keep an eye on coworkers too
Checking on others is also part of preventing burnout, he noted.
“It’s important when you see a colleague who doesn’t look like they did a month ago or at the beginning of training—not necessarily a one-off day but frequently—to check on them,” Dr. Pasichow said. “Maybe they just don’t seem to be the same person, maybe they aren’t laughing as much, or they aren’t smiling anymore. There's some change happening. That's the time to bring it up and say, ‘Hey, you seem different.’”
Health care is all about teamwork, he noted.
“It’s important so that we can take care of our patients, so that we don't miss a diagnosis. But it's also important so that we don't miss a problem—we don't miss a diagnosis—in ourselves.”
It’s not incriminating
“To say that my mental health issues—my being on medication, my being almost continuously in therapy for the last four years—haven’t had an impact on my job would be an understatement,” Dr. Pasichow said, noting that he had gotten off a therapy session right before he joined this interview.
“I haven’t been asked to put it on any state reporting. I haven’t been asked to put it on any hospital credentialing,” he said. “The only way people know that I’ve been through this is that I have told them or through stories like this one.”
He was worried about being open about his experience early on, but he learned his doctor isn’t required to report anything about his condition—to his employer or anyone else.
“I was petrified of getting help earlier in the process because I felt like I would have to tell people about it all the time and I would never have had the privacy to deal with it on my own,” he said. “That’s so infrequently a barrier at this point. Yes, not every state is perfect in the way they address the mental health of physicians, but it improves all the time. It has had no negative impact on my ability to practice—only a positive impact. And it's not something I've been forced to divulge to anyone that I didn't choose to divulge it to.”
Dive deeper with this AMA issue brief (PDF) on the campaign to support the health and well-being of medical students, residents and physicians.
Don’t feel you need to change the system
“Burnout is a system problem, and I don't want people to confuse the things you need to do to make sure you can function every day with an obligation to fix the systemic problem, or that finding a work around that allows you to cope is a bad thing,” Dr. Pasichow said. “There is also a lot of conflation of depression and anxiety with burnout. I do think that burnout can lead to those mental health issues, and the ways that we treat anxiety and depression can at times be helpful for burnout, but they are two distinct entities.”
The upshot is that residents might think it’s their responsibility to right every wrong for future trainees, but it’s not.
“You want to show up to work and feel good about helping people,” he said. “But you shouldn't feel that that means you have to fix the entire system. Take care of yourself first, because that's how you'll be able to take care of others.”
Learn more about the AMA Resident and Fellow Section, which gives voice to—and advocates on—issues that affect resident and fellow physicians.
