Tuesday, March 29, 2016

Burning down the house, Part III

The doctors' dispute has been about as pleasant to read about as a dirty diaper, so I'll go back to my series on burnout.

In the last post, I included a link to a blog post by an esteemed neurologist full of rather unhelpful suggestions for health care workers coping with burnout. Ironically, he does make some good points around the causes of burnout, and I'll come back to those.

I argued that someone suffering with extreme symptoms of burnout--not ordinary fatigue and cynicism--needs rest and support if they're to recover. What does that look like, and what can be realistically implemented in a modern health care system? For starters, we need to distinguish between the burnout experienced in training (which has led to suicide in extreme cases), and burnout experienced by those in independent practice, where the problem is much less straightforward.

First, trainees:

There's a tendency among trainees (medical students and residents) to ascribe burnout to the long and brutal hours on the job, including the unseemly need to stay in hospital all day after a night of call. As a consequence, one of the major goals of residency contract negotiations has been to place and enforce strict limits on how many hours a trainee can be in hospital before being sent home. This makes intuitive sense, speaking in particular as someone who went through it and is married to a woman who went through worse. Over time, however, I've come to believe this might be the wrong objective.

A smarter negotiating objective would probably be more weeks of vacation, spaced out appropriately through the year. Giving trainees more mandatory time away from the job is likely to do more for their well being than sending them home a few hours early. Letting the post-call trainee take 10-15 minutes to shower before morning rounds will go a fair way to remind him or her that it's now "tomorrow"...plus everything feels better after a shower. Perhaps a system where the person on call that day provides the shower time relief makes sense.

Doesn't denying the early release put the trainee at risk of more mistakes, or at least personal harm by having to drive home while half-asleep? That's possible, but research is showing the mistake concern might be overblown, since med students and residents are chronically sleep-deprived. It's not like catching up on sleep over one or two nights is going to solve long-term exhaustion. That takes more like 2-4 months.

As far as risk of personal harm, some kind of carpool scheme, shuttle service, or taxi chits for truly exhausted trainees is a cost-effective way to make sure they get home safely.

Moreover, each teaching centre should take proactive steps to appoint people charged with monitoring the mental health of trainees, and these people have to be actively engaged. They can be nurses, social workers, mentors whomever. Trainees need someone to turn to without the immediate fear of career consequences, which they might feel going to their supervisors or program directors.

Finally, peer support is critical. In medical school this comes naturally, since the students meet in pre-clinical years. That might not be the case in residency, where trainees are coming from different centres, and rotate through different hospitals and/or departments from Day One. I'm the last person on the planet to come up with ideas around socializing, but seeking out residents to play a "social coordinator" role, and earmarking the money to pay for events, can fast-forward the building of friendships before fatigue starts to kick in.

As far as mindfulness training in residency? Acknowledging the documented health benefits, trying to meditate while losing sleep for months on end leads to a practice more aptly labeled a nap.

Next time, thoughts on burnout during the working years.

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