Roundtable Discussion: Addressing Burnout Among Gastroenterology Fellows

A substantial and increasing body of research has shown that professional burnout affects a significant number of physicians at all career stages. Physicians showed a greater risk for burnout (odds ratio [OR], 1.39; 95% CI, 1.26-1.54; P <.001) and lower satisfaction with work-life integration (OR, 0.77; 95% CI, 0.70-0.85; P <.001) in 2017 compared with other working adults in the United States, and 42.9% of physicians demonstrated at least 1 symptom of burnout on the Maslach Burnout Inventory, according to study results published in Mayo Clinic Proceedings.¹  

Previous studies consistently reflect burnout rates of 50% or more among physicians, including gastroenterologists at both later stages of their career and physicians in training, with especially high rates among women.^2,3,4 In a survey conducted by the American Gastroenterological Association, approximately  50% of gastroenterology (GI) fellows reported burnout and no significant differences were found between rates of burnout in this group and those observed in GI doctors at other career stages.⁵

While it may be difficult to understand how burnout could affect trainee physicians to a similar degree as practicing physicians, these high rates indicate that “faculty cannot scoff at the notion of trainee burnout…. It cannot be emphasized enough that educators have a duty to understand and reconcile this information,” according to Arthur J. DeCross, MD, AGAF, professor of medicine in the division of gastroenterology and hepatology at the University of Rochester Medical Center in New York.³ “To deny that trainees should experience burnout and to deflect the phenomenon with a righteous irritation over work ethic and value-based generational issues, is both unproductive and dangerous,” he stated in a paper published in in Gastroenterology.³

Dr DeCross describes various factors that may influence burnout among trainees — for which he suggests “trainee distress” may be a more useful term — in each of the domains generally associated with burnout. Emotional exhaustion represents 1 domain, and Dr DeCross points to generational issues that may contribute to this problem in trainees. For example, many trainees from the millennial generation may be less resilient to criticism and failure because of overprotective parenting. However, a significant number of these individuals enter medical school having already held highly accomplished, rewarding, and collaborative professional positions.

“What happens when high-performance individuals, accustomed to a certain level of autonomy, creativity, and collaboration, and possibly with less personal experience with failure and criticism, are put in the high-stakes medical training environment…. characterized by high workload, high stress, long hours, and a traditional reward system rooted in (much) delayed gratification?” he asked, also implicating the current environment of risk-averse over-documentation and over-supervision policies.

While programs have made efforts to reduce the amount of time trainees spend engaged in “scut work” such as blood draws, cultures, and insertion of catheters and intravenous lines, this has led to an unintended consequence of increasing depersonalization — another burnout domain. “Scut work was always a direct interaction with another human being. It was a chance to spend time with patients, to talk to them and get to know them better, and consequently to better establish a role in their care…,” Dr DeCross noted. “The time spent in traditional scut work has been decreased, but instead of freeing trainees to spend more time examining and talking with patients, a new version of scut work has been substituted—in front of computer screens. Same time wasted, less human contact.”

He also cites a low sense of personal accomplishment, fostered by changing policies and circumstances, as a trainee distress domain. For instance, the trainee’s clinical notes may not “count” toward the patient’s documentation as they once did, due to risk-management policies, and increasing productivity demands have resulted in less time with the endoscope compared to previous generations of trainees.

An additional and novel domain of trainee distress is loss of community, largely driven by inconsistent care teams. “We have attendings, advanced practice providers, fellows, residents, and students on the care teams, but the team composition is constantly changing,” Dr DeCross wrote. “It becomes impossible to establish effective and efficient interpersonal team dynamics when the team identity is not durable, perhaps most so for the students who are least likely to know the other team members in other contexts and who are at the mercy of wide variations in expectations and feedback styles.”

A range of potential solutions was suggested to address trainee distress among GI fellows, highlighting the critical need for institutional support. The University of Rochester Medical Center, for example, has added clinician wellness as a “fourth arm” to the triumvirate of improved patient care, reduced costs, and improved outcomes. Another aspect includes high-risk trainees being referred to employee assistance programs for confidential counseling.

At the fellowship program level, solutions may include limiting successive stressful rotations and hiring an advanced practice provider and answering service nurse to reduce follow-up volume and overnight phone calls taken by fellows. Various efforts should be made to foster a sense of community, such as establishing a “consistency of attending relationships during outpatient, inpatient, and endoscopy rotations.”³ In addition, fellows should have their own office space and should be invited to participate in quarterly program evaluation committees. Sponsored group activities can also help build a sense of community while showing appreciation of fellows. 

Finally, Dr DeCross emphasized the need for faculty to foster fellows’ conditional independence in patient care and encouraged attending physicians to provide appropriate supervision while avoiding managing every detail of each case. “The fellows’ longitudinal clinic is an excellent opportunity for this, in which senior fellows can and should be provided much more latitude in patient assessment and decision making,” he noted. “Senior fellows on consult services can assume the roles of an acting attending, in which their complete assessment and management of the case is not only expected, but transparently the substance of their evaluation.”

To glean perspective on this topic from current fellows, Gastroenterology Advisor interviewed the following clinicians: Edwin Lee, MD, gastroenterology fellow at the University of Rochester Medical Center in New York; Jordan Shapiro, MD, gastroenterology fellow at Baylor College of Medicine in Houston, Texas; and Amaninder Jeet Singh Dhaliwal, MD, gastroenterology and hepatology fellow at the University of Nebraska Medical Center in Omaha.

Gastroenterology Advisor: What are some of the main issues and circumstances that may lead to burnout in GI fellows?

Edwin Lee, MD: An unpredictable work schedule is 1 issue. Although we are not scheduled to work during weeknights and weekends, we are “on call.” We are thus limited in being able to plan activities outside of work when we are on call because at any minute we can be called to discuss a patient or see a patient in the emergency department.

Interacting with different teams is another potential source of burnout. As consultants, we are called by members of different teams, be they medical students, residents, or advanced practice clinicians. They have different styles and comfort levels in discussing patients’ issues and diseases. Sometimes the questions they have for us are appropriate, especially while the patient is in the hospital, but other times these are not appropriate. Yet, we are still awoken from sleep or asked to come in when we are on call.

Jordan Shapiro, MD: Tension between following your dreams and needing to earn money to pay off mounting educational debt, becoming a knowledgeable internist and realizing you’re back at the bottom of the knowledge and respect totem pole, between time spent on education and patient care — the reasons most of us came to love the field — vs charting in the electronic health record and performing administrative tasks, between being the primary provider vs a consultant, and between what others want from you and what you want for yourself.

Amaninder Jeet Singh Dhaliwal, MD: Front-loaded programs, high clinical volume, unplanned call schedules, few fellowship spots with minimal ancillary support, lack of wellness programs, and unreceptive administration and program leadership can all contribute to burnout.

Gastroenterology Advisor: What has been your personal experience with burnout in your fellowship program?

Dr Lee: Every individual deals with burnout differently. Our fellowship program is very supportive and has different programs to assist us, such as mindfulness training. We are considered friends and colleagues, not fellows, and attending physicians frequently take us out to dinner, for example.

Dr Shapiro: There have been 2 periods in which I’ve been burnt out, and at one point in time, I considered the advantages and disadvantages of completing my training. Our first year consists of 12 months of inpatient consults without a reprieve. Shortly after I had completed that, hurricane Harvey hit, and the following day my son was born, and I resumed doing several inpatient consults for months living in temporary housing while the damage to our home was repaired. The second period was when I was in the process of finding a mentoring team for research, as many of my initial plans hadn’t worked out — some after I had invested a lot of energy and others without generating much interest, and I wasn’t sure how to navigate this search.

Dr Dhaliwal: Burnout among GI fellows is a fact and is often unrecognized, and I have felt this personally for a number of reasons. It needs to be addressed early on or it can take a toll on your personal life.

Gastroenterology Advisor: What are some solutions or responses that have been helpful or harmful for you in this regard?

Dr Shapiro: Finding faculty, co-fellows, and family and friends to talk with was helpful, although I would not recommend overburdening a significant other with nighttime conversations about this — my partner could already tell I “wasn’t me,” and it took time away from the little amount of time we had together. Also, vacation time should be vacation time — no papers, no journals.

I had some experience running retreats as a faculty member before my fellowship and started our first-year fellows’ retreat as a second-year fellow. The retreat is entering its third year next week and consists of a semi-structured Friday retreat followed by a “golden weekend” in which second- and third-year fellows cover the clinical services. The support from our department chief and faculty has been immense.

Dr Dhaliwal: More fellowship spots with good ancillary support helps divide and share the workload. Leadership being receptive to changes to reduce burnout among GI fellows is helpful, as is the availability of more structured wellness programs. However, it can be harmful when the administration wants to implement the wellness programs only to check the box but is not really invested in understanding the root cause of this problem.  

Gastroenterology Advisor:  What would you recommend to supervisors and program directors, as well as other fellows, to help prevent and address burnout in this group?

Dr Lee: I believe that there is not one solution that works every time, for every person. It should be an individualized approach. As long as the supervisors and program directors see fellows as “disciples” and future colleagues, and not cheap labor who will eventually move on, burnout will be prevented and addressed appropriately.

Dr Shapiro: Make a public, demonstrative statement that burnout happens and that you’re interested in trying to improve burnout drivers. Make it incredibly clear that burnout is not a failure of any individual. At my institution, our section chief and program directors have started to do this, and I’ve had the opportunity to develop and run our first-year fellows’ retreats, as well as to sit on the faculty development committee, which started a quarterly GI grand rounds dedicated to wellness. These are promoted and attended by our section chief, and the response to having access to interactive sessions of interprofessional empathy, ergonomics, yoga, mindfulness, and faculty work-life balance panels has been amazing.

It’s not perfect, but it’s better. We talk about treating the individual patient, and often medical training can make you feel as if you’re being put through a mill. Creating opportunities for fellows to differentiate into the GI doctors they want to become — be it in clinical, research, education, or policy realms — can go a long way toward making them feel that are being seen as individuals.

Another point: I wrote a paper during my residency on burnout in the social network that exists in an internal medicine program — and I still experienced burnout. Residents who reported more loneliness had worse burnout. We talk about individual skills and resilience, as well as system factors that have an impact on our well-being, but we forget that we can be a salve to each other during those difficult times when we can’t quickly change systems and are too busy to attend a yoga class. Mother Theresa once said, “If we have no peace, it is because we have forgotten we belong to one another.”

Dr Dhaliwal: Fellows should seek help as soon as they recognize they are experiencing burnout. Program directors and supervisors should recognize burnout as a real issue and be open to changes and suggestions to encourage a work-life balance among fellows to prevent it. Fellows experiencing burnout should not be stigmatized; that is the biggest fear among fellows that prevents them from openly discussing the issue with administration or leadership. 

References

1. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general us working population between 2011 and 2017. Mayo Clin Proc. 2019;94(9):1681-1694.

2. Rothenberger DA. Physician burnout and well-being: a systematic review and framework for action. Dis Colon Rectum. 2017;60(6):567-576.

3. DeCross AJ. How to approach burnout among gastroenterology fellows. Gastroenterology. 2020;158(1):32-35.

4. Barnes EL, Ketwaroo GA, Shields HM. Scope of burnout among young gastroenterologists and practical solutions from gastroenterology and other disciplines. Dig Dis Sci. 2019;64(2):302-306.

5. DeCross AJ. The current state of professional burnout in gastroenterology. AGA Perspect. 2017;13:22-23.