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iCOMPARE and Wellness

March 25, 2018
by Mark David Siegel

Hi everyone, 

We’re ending our European adventure with a day in Sweden. Over the past two weeks, we visited our daughter, Isabella, in Hungary, explored Croatia and Slovenia, swooped briefly into Norway, Austria and Italy, and even spent a few minutes in Bosnia on the road to and from Dubrovnik.  We saw the Adriatic coast, as well as lakes, rivers, canals, castles, and markets. We tasted regional wines, truffles, venison, goulash, octopus, pasta, wild boar, and sachertorte.  Most importantly, we talked, read, binged on Netflix, caught up on sleep, and spent time together.   

During my time away, the much-anticipated iCOMPARE study came out in the New England Journal. As most of you know, iCOMPARE examined two approaches to intern work hours- a “standard” approach, which limited shifts to 16 hours, and a “flexible” approach, which permitted shifts up to 28-hour in length.  As a study site, we were randomized to the flexible arm, and our interns did extended shifts in the MICU and on Fitkin and Generalist. 

The data presented so far are striking for the disconnect between the perspectives of program directors and trainees. While program directors believed overnight shifts improved education, residents reported these shifts undermined wellness. I’m not surprised that the residents didn’t like extended shifts since our housestaff said roughly the same thing when the trial ended. For this reason, we ended 28-hour call for interns on Generalist and most 28-hour intern calls on Fitkin.  Opinions on the MICU were split, so we’ve kept that as a 28-hour call rotation for now. 

The most striking and distressing data in iCOMPARE are the high levels of burnout reported in both study arms: approximately three quarters of interns reported moderate to high levels of emotional exhaustion and depersonalization.  Although I don’t know our own scores, I have no basis to assume our residency did any better.  While high levels of burnout have been reported before, the prominence of this paper in the NEJM should compel educators to tackle this urgent problem. 

The causes of burnout are incompletely understood, although multiple factors undoubtedly contribute, including physical and emotional exhaustion, loss of control, and difficulty finding meaning at work. And while there’s no way to avoid the long hours and developmental demands required by residency training, I refuse to accept that burnout is inevitable, or that we have to choose between education and wellness. 

We’ve made substantial efforts to combat burnout at Yale.  For example, we developed the ambulatory block system to keep residents from having to juggle the competing demands of inpatient and outpatient responsibilities. The block system also created supportive mini-communities within the residency and ensured that residents could return to more reasonable hours at regular intervals.  Similarly, we instituted the MAC program to ensure that residents would get individualized attention from dedicated faculty members.  In response to residents’ requests, we created the Distinctions Pathways to help trainees pursue personal professional interests.  Finally, we created the Executive Council and resident-run Program Evaluation Committee (PEC) to give trainees a voice in how our program runs, and we directed a significant increase in funds towards the Wellness Committee to sponsor recreational and social activities. 

Are these efforts effective? I hope so.  Are they sufficient?  Almost certainly not.  We have to do more to address this issue. I’d love to hear your opinions on burnout.  What should we do differently?  What should we do more of?  What are we missing?  How can we ensure residents stay energized, inspired, and healthy throughout their training? 

I’ll be back in town tomorrow morning and can’t wait to see and hear from you.  But before then, we’ll spend the day exploring Stockholm before boarding the long flight to JFK. 

See you soon, 

Mark

Submitted by Mark David Siegel on March 26, 2018