One of my overarching beliefs in life is The Environment Always Wins. And when addressing burnout, this becomes a really important part of the discussion.
When I talk with residents, they ask about where they should go for their first jobs. When I talk to students about what med school they want to go to, they’ll ask similar questions. They’ll pose the question like “well, one’s in New York and one’s in Colorado.” And they want to know which to choose.
I always give them the same advice. “They’re all the same. The thing that’s going to matter to you is: are you happy where you live? You’re going to be miserable if you’re in the wrong environment. You won’t be happy.”
If you love the outdoors and skiing, Colorado would be a great choice. But if you can’t go without getting a matcha smoothie at 4 a.m. and love being surrounded by people, maybe New York is going to be a better choice. The right environment can support you to become a better student and doctor. It’s not superfluous to think of the other parts of life that will help you become more successful.
Good Environments Make You Better, Toxic Environments Deplete You
This concept doesn’t change once you are a doctor. In fact, this concept translates to everyone. It’s the same throughout life. For clinical doctors, the problem isn’t about themselves not being good enough, it’s working in a historically malignant environment.
Here’s a small fact. A military person that is getting tortured for their secrets by the enemy, they are trained in how to deal with torture. But did you know that the official United State military policy states you’re only expected to withhold secrets for the first 48-72 hours. The military realizes 100% of the time you won’t be able to resist the torture. Their stance is “don’t give it up right away, but we know you’ll be giving it up.” It’s amazing that the military employs more empathy than the healthcare industry. You can’t give someone feel-good resilience anti-burnout training and think that’s enough.
School Trains Us to Expect a Burnout Environment
Forgive me for continuing with the torture analogies, but there’s another. The amount of things in medical training and what is euphemistically called “enhanced interrogation” aka torture are scarily similar. The specifics really overlap when you compare them side-by-side.
If I didn’t tell you which one was which, you wouldn’t know:
- Sleep schedule: You have to be up for 36 hours, sleep on cots
- Clothing: You don’t even have the choice of what you wear
- Bathroom: You don’t have the choice of when you go to the bathroom.
- Food: You don’t get to eat even though you’re hungry.
They sound identical, right?!
And we want the people to go through this and then be the most compassionate people and also the most skilled in complex medical issues. Approaching burnout as if it’s an individual issue is just insulting when you put it in this perspective.
It makes you wonder who designed this system. But of course, we know why this is the way it is. Residents are free labor for the hospital. There’s a reason we keep them there for 36 hours. If you had to pay three people for 12 hour shifts, it would bankrupt the health systems.
It doesn’t get any better when you’re on-call as a doctor. I don’t know if it’s possible to have insight about what on-call exactly entails until you actually do it over a long period of time.
On-Call Isn’t Time Off
Nurses work 12 hour shifts. That’s just your normal job, you aren’t working before and you’re not working after. But., when I’m on call, I’ve worked an entire day, now I have to do phone calls all night long and I’ll also have to go to work tomorrow. That’s three days of work straight. Other staff thinks I’m doing what they’re doing when they’re off work. But they don’t understand I’ve been up for 36 hours.
You can’t sleep when you’re on call. There will be times when you don’t get a call, but you’re still “on.” You wonder if it’s even worth it to try to sleep at all. The prevailing wisdom makes it seem like you’re 100% relaxing until you’re on that call. But for anyone who has been on-call, you’ll know, that’s not the way it is at all.
It’s of course painfully ironic that the industry that is closest to promoting well-being ignores how the brain works and how rest works. Instead, it’s probably the industry that is most out-of-touch with what a human body can actually handle.
How do we expect people to be nice when they can’t see their family, when they can’t go home and have dinner with their family? Until we really take a hard look at the expectations we’re placing on individuals in healthcare, we are not even close to getting to the solutions to burnout.