Medical residents face enormous stress and pressure. From providing patient care during their long hours on duty to high-stakes exams and evaluations, physicians in training have to be resilient to withstand the weight on their shoulders — and come out the other side stronger, smarter, and wiser practitioners.

Many residents simply get burned out. A growing number of studies show that burnout, characterized by the loss of emotional, mental, and physical energy from continued stress on the job, is a common problem in medical residency programs — and among physicians in practice as well. I interviewed Benjamin R. Doolittle, MD, an expert in resident burnout and wellness and a program director at Yale University School of Medicine, on why the problem is so prevalent and what can and should be done about it.

Josette Akresh-Gonzales: Approximately 6% of medical students are unsuccessful in graduating from medical school within seven years. Are there equivalent percentages of resident dropout? Does resident burnout mean dropping out?

Benjamin R. Doolittle, MD: The prevalence of burnout among attending physicians is somewhere around 44% — and as high as 66% in some specialties, such as emergency medicine. Among residents, the prevalence of burnout is around 50%, with some studies showing burnout as high as 80%.

I think the medical profession provides a “perfect storm” for burnout. The barriers to get into the profession are high — years of school and training, expensive tuition. Once a physician, the pressures are great — patients, hospitals, insurance companies, and even ourselves. To move into a different field is difficult. Let’s face it, it would be hard to find a job that remunerates as well — and many of us carry significant debt. And so, most burned out physicians do not quit but rather soldier on — emotionally exhausted, stressed out, disengaged with patients, and wondering what it all means.

JAG: One study estimated that about 12% of medical students and residents surveyed suffered from major depression (about twice the national average for adults in the United States), and 9.4% had contemplated suicide within the past 2 weeks. Do you think this prevalence of depression in residents is caused by burnout?

BRD: The increased prevalence of depression and suicidality is such a tragedy. You take bright, caring, talented people, tackling a hard subject matter, put them in a tense environment, and some will despair. It is the hardest job. Patients are sick. Difficult, stressful conversations happen throughout every day. Residents are challenged to perform difficult procedures. Expectations for a positive outcome are high with little room for error.

And yet, the greatest stressors are often not the patients. Unfortunately, the culture of medicine is sometimes not the most supportive for our learners. There is a significant amount of work that seems peripheral to direct patient care — communicating with consultants and social workers, getting the notes and orders entered in a timely way, and clarifying them all with nurses and pharmacists. All of this needs to be accomplished within the time allotted for duty hours. For the learner—students and residents alike — there is also the uncertainty about knowing enough, being competent, being strong enough to do the job. Residents and students are at the limit of their skill and knowledge. To make their role even more stressful, their faculty evaluates them on the very skill and knowledge they seek to attain.

To answer your question about burnout causing depression, the answer is yes and no. Burnout does not cause depression. Rather, burnout and depression are similar manifestations of working within a rough environment. We educators need to do better fostering a supportive community for our talented learners.

JAG: What are the major contributors to resident burnout? Do you think temperament (a predilection for anxiety, perhaps) is a risk factor, or are the learning and training conditions more the problem?

BRD: There are certainly aspects of the training environment that correlate with burnout. Studies show that lack of autonomy, increased computer work, and performing other ancillary duties all are associated with increased burnout. The implementation of duty hour restrictions was an attempt to ameliorate burnout. While these rules did improve some aspects of the learning environment, it did not affect the prevalence of burnout.

At the same time, personality traits certainly do play a role in burnout. Some emotional coping strategies seem to be harmful: denial, venting, disengagement are associated with greater burnout. Problem-solving, acceptance, and resilience are associated with less burnout and greater job satisfaction. Interestingly, in our study at Yale, it was the quality of humility and reconciliation—the skill to extend and receive forgiveness—that was one of the strongest associations with less burnout and greater job satisfaction.

Many years ago, we had an especially hard winter. As a program, we were dragging, the interns especially—real “dark night of the soul” stuff. Not sure of what to do, we convened an evening of storytelling. The theme was “stories of redemption and restoration.” We all took turns telling stories—both the residents and the faculty. The interns just listened: it was an evening just for them. We told heartfelt tear-jerkers, raucous tragedies, everything. One of our faculty told the story of how he stayed in the hospital so long that the telemetry nurses bought him underwear. This moment opened my eyes to the power of the community to restore and to heal. Since then, we have similar community-building type exercises throughout the year.

JAG: What can program directors do to promote wellness in their institutions?

BRD: This is the most important thing a program director can do: listen to the residents. And then, respond as best we can. If we can empower the residents to craft their own solutions, even better. What is eating away at the gang? The tough heme-onc rotation? The lack of connection to the community? Terrible food in the cafeteria? We educators think we know. But we don’t really until we ask.

Several institutions have piloted wellness curricula, coaching programs, support groups and the like. These can go a long way towards establishing a culture of wellness. But nothing impacts the culture of a program more than engaged, empowered residents. The first step, I believe, is to listen. The next is to respond.

I am really interested in the power of culture—both the micro-culture of the wards and clinics and the macro-culture of the institution. How do morning teaching rounds go? Does the attending model authentic care towards the patient or is the attending rushed and apathetic? Does the attending share thoughtful teaching points? Modeling by leadership goes a long way towards shaping a supportive micro-culture. What about the macro-culture? Does the program director care about the residents’ personal well-being? What does the institution do to support residents?

I do not believe any single program will change the culture of a residency program. Rather, I believe it is the faculty leaders’ genuine care in the residents’ lives and responsiveness to issues. Residents do not want “programs” so much as they want real connection and a supportive community with great learning opportunities.

JAG: What is the best advice to offer residents who are feeling burnt out?

BRD: Although this might sound glib, I believe the most important advice is this: hang in there. Residency is such a thrilling, stressful, challenging time in life. You grow so much as a person — more than just the ways to become a physician. So much is deferred because of medical training — marriage, buying a home, raising kids. And then residency ends. Your career in medicine does not need to look like your residency experience. Choosing that next chapter carefully is important. And so, hang in there. If you are having a great residency experience, terrific. If not, stick it out. Life gets better.

That said, there is a lot a person can do to help themselves. Being plugged into a community outside of the hospital has been shown to be helpful — a group of friends, a religious organization, a community group. The residency world can be consuming — but you are more than a resident. Having a supportive community is critical to counter-balance the pressures of residency. Knowing that someone cares for you, that you have an anchor in the storm, can restore your sense of purpose and place in the world.

Benjamin R. Doolittle, MD, is an expert in burnout and wellness in residents and physicians. He is an associate professor and program director of internal medicine and pediatrics at the Yale University School of Medicine and the medical director of the Yale Medicine-Pediatrics Practice.

You can read more perspectives about handling stressful situations, resident burnout, physician burnout, and work-life balance on the NEJM Knowledge+ Learning+ blog.