One day, when Roy Ziegelstein was an Osler intern, attending physician Dana Frank (Osler, 1980) placed a hand on his shoulder. Then he said something Ziegelstein has never forgotten: “You know, you’re going to hear a lot of people say you have it easier than we did when we were interns. But they’re wrong. You have it harder.”
Some 30 years later, Ziegelstein, vice dean for education at the school of medicine, says the same is true for residents today. “The threats are greater now,” he argues. “The amount of documentation required for every admission and discharge is huge. And the length of stay is much shorter than it was when I was a resident.”
Osler Residency Program Director Sanjay Desai couldn’t agree more. He says this heightened level of stress contributes to burnout—“the top challenge facing our residents.” Mirroring national statistics on burnout among M.D.s, roughly half of Johns Hopkins Hospital residents experience burnout symptoms, a 2016 safety culture survey found. These include emotional exhaustion, medical errors, diminished feelings of accomplishment and difficulty appreciating the humanity in their patients. Burnout also raises the risk for suicide, failed relationships and substance use disorder.
But thanks to targeted efforts by the program’s leadership, Desai says, “we’re learning more about the drivers of burnout and creating interventions we think will help.”
Though it’s too early to draw conclusions, he notes, anecdotally, “The experience for our trainees seems to be improving. We are deliberately keeping our trainees at the bedside more and providing time and space for reflection. These changes seem to be helping, based on our assessments.”
This could reflect a national trend. A 2017 study from Stanford University, the Mayo Clinic and the American Medical Association reported a modest decrease in physician burnout.
At Johns Hopkins, Desai notes that the Dean’s Joy in Medicine Task Force has also helped foster a more positive milieu for everyone—not just for the residents. In their 2017 report, leaders laid out strategies to promote work-life balance and collegiality, and reduce inefficiencies.
Little things appear to be making a difference, says Desai. Residents are tapping into a school of medicine-led resident wellness toolkit and financial guidance programs. Trainees are taking advantage of drop-in massages, meditation and healthy snacks on the wards, courtesy of the offices of Graduate Medical Education and Wellness and Health Promotion. And more emphasis on bedside teaching rounds is also fostering deeper patient connections.
But concerns about technology overuse persist. Residents are spending as much as 50 percent of their time working online, according to a recent NCBI study, cutting into their time at the bedside.
“We have so much information to help guide care and can easily consult with anyone in the world,” says Desai. “But the way we diagnose people is by talking to them, examining them, getting to know them. We don’t have an algorithm for that.”
The greatest challenge for residents today, says Ziegelstein, is their ability to “stay human to patients, getting to know them as individuals while remaining human to themselves, making time for family and friends.” That requires knowing how to adapt to a rapidly changing world that incorporates more data into patient care.
Genitourinary oncologist Cathy Handy Marshall (Osler, 2012) served as an assistant chief of service in 2016. “My first priority as an ACS was resident education and well-being, before administrative demands,” she says. Always on the lookout for burnout, Handy Marshall urged residents to tap into team-based resources, such as pharmacy and social work, to help manage certain aspects of patient care.
That same year brought the debut of a physical exam-based “morning report” at the bedside. Led by Reza Manesh and Brian Garibaldi (Osler, 2007), the program builds physical exam skills while forging stronger patient bonds.
More recently, artificial intelligence (AI) to expedite recording patient data and notes appears to be winning favor. Hospitalist and school of medicine assistant professor Timothy Niessen (Osler, 2012) has embraced Dragon Medical One, the new speech recognition software, though he was skeptical at first.
“It’s so fast, so accurate,” he says. “By now, I think I’ve cut my note-writing time in half. I can type 60 to 70 words per minute, but I can dictate 150 words. That means I have that much more time to spend talking with my patients.” Patients and families also like it, he says, because they can listen and find the notes instantly in MyChart.
There’s no question, says Ziegelstein, that AI will eventually lighten the load for residents. “But the pace is much faster for everything.” One can’t put the blame entirely on the electronic medical record, he adds, because “we can’t go back to the old days.”
The synthesis of the physical exam and narrative description will always be important, Ziegelstein says. And, he insists, building relationships with patients offers the greatest potential for experiencing the joy of medicine.