4 ms·

I used to think I occasionally suffered from work burnout, but then my SO became a medical resident, and I realized "oh, that's what burnout is." What I used t

I used to think I occasionally suffered from work burnout, but then my SO became a medical resident, and I realized "oh, that's what burnout is." What I used to "suffer" as a programmer was the ebb and flow of productivity. As described by books like "Drive" and "Flow". This state-of-mind was perhaps best described for me by my colleague (also a programmer) in this public essay, "Find the right routine to surf productivity"[1]. What my SO suffers as a medical resident is true work burnout. They work 6 days per week, nearly 80 hours per week, for weeks (or months) on end. Their work is not only challenging intellectually, it's challenging physically and emotionally. Their work also buckles under the weight of administrative bureaucracy, which removes their sense of agency. Recently, after my SO got off a 5-week "night float" block (where she worked 6 days per week on an inverted 6pm-6am night-time schedule), she finally got a day off. It was really a day to re-adjust her schedule back to working "normal" daytime 6am-6pm hours. During that day, she said to me, "Can we look up Maslow's hierarchy of needs?"[2] Looking over that diagram, we realized her work had her floating around in the first couple levels of that pyramid, whereas in my work, I was very much at the top. My "burnout" feelings were really "not feeling perfectly self-actualized". Her "burnout" feelings were actually "not having access to basic physical needs (e.g. sleep) and emotional support (e.g. daylight, friends, family)." I am very much in favor of Jason Fried style "Calm Companies"[3], and I think in software/tech, we actually have the ability to "work hard" without burning out, usually hovering around the "self-actualization" level in the pyramid. One of the wonderful things about software engineering, in particular, is that since it is the art of automation, we can actually save ourselves labor, and think carefully about the notion of employee leverage. That is, one employee's code can do the labor of hundreds or thousands. It's really sad to me that the medical profession, at least during its training period for new medical school graduates, there is an epic contrast: the near-guarantee of burnout, with basically no recourse for residents except to "suck it up and power through". For those of you who feel your are in jobs in tech where managers "put the screws on you", you should recognize that you have all the power in the world to change job. Employers in tech should be fighting over you, ensuring you feel fulfilled, productive, and balanced. "All of the above" is possible; this isn't a "pick two" engineering trade-off. If you don't feel that way, it's bad management or bad culture -- period. In medical residency, it's "pick zero", and even worse, there is no way for those folks to change jobs (at least, not without derailing their entire career). [1]: http://lifehacker.com/5955115/find-the-right-routine-to-surf-productivity http://lifehacker.com/5955115/find-the-right-routine-to-surf... [2]: http://timvandevall.com/wp-content/uploads/2013/11/Maslows-Hierarchy-of-Needs.jpg http://timvandevall.com/wp-content/uploads/2013/11/Maslows-H... [3]: https://m.signalvnoise.com/the-calm-company-our-next-book-d0ed917cc457 https://m.signalvnoise.com/the-calm-company-our-next-book-d0...

kerbalspacepro 9y ago
How is it that medical residents have so much burn out? What are the economics that force them to have such horrible, shitty lives?
- pixelmonkey 9y ago
  It's a bunch of factors -- many of which I have been trying to understand at a systemic level. Here's what I know so far: 1. Are medical residents students or workers? This was actually an open question of law -- you can see a discussion of the issue in NEJM here[1]. 2. Regardless of your answer to #1 (or, even if your answer is "both"), hospitals unambiguously treat residents as workers (labor). Quoting NEJM again, "residents are clearly indispensable to the care provided at the hospitals where they are employed, even if their work is reviewed by supervising physicians." 3. Having a position in a residency program is viewed as a privilege -- that is, getting a spot is competitive, subject to The Match[2]. Since it's very difficult to "match twice"; nearly impossible to transfer to a different residency; and quite a leap of faith to quit the profession altogether (throwing away 4+ years of med school and $200K of tuition payments); you end up with something that feels more akin to indentured servitude than a normal job. 4. Residents are very wary about the possibility of being booted from their program for incompetence. I think the risk of this is actually quite low -- after all, to make it through med school and The Match, you are probably quite the high-achieving type. And for a program to lose a resident is a major hassle, since they rely on them so much. But this fear is supported by a strong sense of Imposter Syndrome[3] running rampant in the early years -- an inevitability of the inherent difficulty and complexity of patient care. This leads to a culture of deference to superiors, who seem to have a lot more confidence (and thus, seemingly, competence) than you. 5. Various economic and cultural factors combine to contribute to the encouragement of long hours. Wikipedia has a good discussion here[4]. The tl;dr is that hospital systems are themselves resource-constrained; residents are cheap & guaranteed labor; residents are therefore "easy targets" to pick up slack for an otherwise over-extended system. Since medicine has historically had ridiculous hours for residents, the higher-up "attending physicians" believe it's essential to medical training (survivor bias, etc.) Further, residents save the attending physicians, themselves overworked, from some of the scutwork of medicine (e.g. especially data entry and paperwork). So, they have no incentive -- and, often, no power -- to fix things. 6. Residency spots at hospitals are funded by the government and limited by federal regulation. There are too few residents. Further, hospitals are under no obligation to make sure their program can run without resident labor. Therefore, hospitals behave as though residents are "free" labor. 7. Residencies last 4+ years, and then these young doctors move on to other programs, usually in other cities and states. This means there is built-in turnover, which means hospitals don't have a strong incentive to invest in their own staff -- at least, not this specific part of their staff. 8. Medicine, on the whole, has long hours and difficult on-call expectations. This for the simple reason that patients can become sick at anytime and doctors feel a moral obligation to put in the most amount of effort possible for their patients, even at the expense of their own health. I will say, though, this strikes me as one of the weakest factors driving long hours for medical residents. It is, however, often used as the justification for long hours ("we care about patients", "we can't let them down", etc.). In reality, I think the "medical factory system" exploits the built-in altruism most doctors feel toward their patients in order to squeeze more revenue from them. If hospitals really cared about patients this much, they would hire some secretaries to save their doctors valuable clinical time, rather than using their younger/cheaper doctors as secretaries for the older/expensive ones. [1]: http://www.nejm.org/doi/full/10.1056/NEJMp1100414 http://www.nejm.org/doi/full/10.1056/NEJMp1100414 [2]: https://en.wikipedia.org/wiki/National_Resident_Matching_Program https://en.wikipedia.org/wiki/National_Resident_Matching_Pro... [3]: https://en.wikipedia.org/wiki/Impostor_syndrome https://en.wikipedia.org/wiki/Impostor_syndrome [4]: https://en.wikipedia.org/wiki/Medical_resident_work_hours#Causes_of_high_workloads https://en.wikipedia.org/wiki/Medical_resident_work_hours#Ca...

kerbalspacepro 9y ago

How is it that medical residents have so much burn out? What are the economics that force them to have such horrible, shitty lives?

pixelmonkey 9y ago
It's a bunch of factors -- many of which I have been trying to understand at a systemic level. Here's what I know so far: 1. Are medical residents students or workers? This was actually an open question of law -- you can see a discussion of the issue in NEJM here[1]. 2. Regardless of your answer to #1 (or, even if your answer is "both"), hospitals unambiguously treat residents as workers (labor). Quoting NEJM again, "residents are clearly indispensable to the care provided at the hospitals where they are employed, even if their work is reviewed by supervising physicians." 3. Having a position in a residency program is viewed as a privilege -- that is, getting a spot is competitive, subject to The Match[2]. Since it's very difficult to "match twice"; nearly impossible to transfer to a different residency; and quite a leap of faith to quit the profession altogether (throwing away 4+ years of med school and $200K of tuition payments); you end up with something that feels more akin to indentured servitude than a normal job. 4. Residents are very wary about the possibility of being booted from their program for incompetence. I think the risk of this is actually quite low -- after all, to make it through med school and The Match, you are probably quite the high-achieving type. And for a program to lose a resident is a major hassle, since they rely on them so much. But this fear is supported by a strong sense of Imposter Syndrome[3] running rampant in the early years -- an inevitability of the inherent difficulty and complexity of patient care. This leads to a culture of deference to superiors, who seem to have a lot more confidence (and thus, seemingly, competence) than you. 5. Various economic and cultural factors combine to contribute to the encouragement of long hours. Wikipedia has a good discussion here[4]. The tl;dr is that hospital systems are themselves resource-constrained; residents are cheap & guaranteed labor; residents are therefore "easy targets" to pick up slack for an otherwise over-extended system. Since medicine has historically had ridiculous hours for residents, the higher-up "attending physicians" believe it's essential to medical training (survivor bias, etc.) Further, residents save the attending physicians, themselves overworked, from some of the scutwork of medicine (e.g. especially data entry and paperwork). So, they have no incentive -- and, often, no power -- to fix things. 6. Residency spots at hospitals are funded by the government and limited by federal regulation. There are too few residents. Further, hospitals are under no obligation to make sure their program can run without resident labor. Therefore, hospitals behave as though residents are "free" labor. 7. Residencies last 4+ years, and then these young doctors move on to other programs, usually in other cities and states. This means there is built-in turnover, which means hospitals don't have a strong incentive to invest in their own staff -- at least, not this specific part of their staff. 8. Medicine, on the whole, has long hours and difficult on-call expectations. This for the simple reason that patients can become sick at anytime and doctors feel a moral obligation to put in the most amount of effort possible for their patients, even at the expense of their own health. I will say, though, this strikes me as one of the weakest factors driving long hours for medical residents. It is, however, often used as the justification for long hours ("we care about patients", "we can't let them down", etc.). In reality, I think the "medical factory system" exploits the built-in altruism most doctors feel toward their patients in order to squeeze more revenue from them. If hospitals really cared about patients this much, they would hire some secretaries to save their doctors valuable clinical time, rather than using their younger/cheaper doctors as secretaries for the older/expensive ones. [1]: http://www.nejm.org/doi/full/10.1056/NEJMp1100414 http://www.nejm.org/doi/full/10.1056/NEJMp1100414 [2]: https://en.wikipedia.org/wiki/National_Resident_Matching_Program https://en.wikipedia.org/wiki/National_Resident_Matching_Pro... [3]: https://en.wikipedia.org/wiki/Impostor_syndrome https://en.wikipedia.org/wiki/Impostor_syndrome [4]: https://en.wikipedia.org/wiki/Medical_resident_work_hours#Causes_of_high_workloads https://en.wikipedia.org/wiki/Medical_resident_work_hours#Ca...