Trigger warning: This article contains information on depression and suicide.
Burnout is a term well-known to most of us in medicine, but did you know it is highly prevalent among ophthalmology residents? In this article, we’ll outline the impact of burnout in ophthalmology, how to recognize it, and what we can do to combat it.
What is healthcare burnout?
The International Classification of Disease (ICD) defines burnout as a syndrome that results from chronic workplace stress, characterized by three core concepts: emotional exhaustion, depersonalization, and reduced personal accomplishment.1 As of 2019, it is also a billable diagnosis (ICD-10 Z73.0).1
Burnout in post-graduate medical training is highly prevalent, with a large study suggesting 27% to 75% of residents have burnout based on the Maslach Burnout Inventory (MBI).2 The presentation of burnout can overlap with those of several depressive and anxiety disorders, though by the ICD definition, burnout specifically refers to an occupational phenomenon rather than a generalized feeling towards life.
Reported symptoms of burnout include:
- Low mood
- Fatigue
- Sleep disturbances
- Difficulty concentrating at work
- Detachment from work environment and colleagues
- Frequent work procrastination
Burnout for ophthalmology residents
Many people have the misconception that ophthalmology is a great “lifestyle” specialty with manageable hours and that burnout is not common. They would be surprised to hear about the results of a survey study of US ophthalmology residents—a shocking 68.4% reported that they experienced or witnessed resident burnout, depression, or suicide in just 2017 alone.3 Lack of time to attend wellness programs (25.0%), academic stressors (13.1%), shift duration (10.6%), and administrative duties (10.6%) were cited by residents as the top reasons for burnout in that study.3
Ophthalmology training is also unique in that there is minimal exposure to the field in medical school. Hence, trainees need to absorb a significant amount of information in a short period of time, be comfortable handling emergencies, and serve as a consultant to medical teams as early as their first year of residency. This may contribute to work-related stress and burnout. Though further studies are needed, burnout is a growing concern among ophthalmology residents that needs to be addressed.
Other reasons for burnout in ophthalmology residents may include the following:
- Provider/caretaker fatigue
- Sleep deprivation
- Imposter syndrome
- Limited mentorship
- Financial stressors
- Harassment, sexism, and/or racism in the workplace
- Understaffing at clinical sites
- Lack of access to counseling and behavioral health services
- Difficulty with interpersonal relationships at work and/or with loved ones
- Lack of current curative treatments for glaucoma, hereditary degenerations, neurological diseases, and several other conditions encountered in the clinical setting
How to identify burnout
It is important to distinguish burnout from other states of mental exhaustion or disease, as the latter may require medical treatment. The Maslach Burnout Inventory is an online free tool and the most used test to measure burnout in studies. Anyone can self-administer this 22-item questionnaire, with each item scored from zero to six on the Likert scale.
Based on data from 1104 medical professionals, the inventory identifies burnout as follows:
- A cutoff of 27 or more points for emotional exhaustion
- 10 or more points for high depersonalization
- 33 or fewer points for personal accomplishment2
In addition to the general one, MBI products for educators, medical professionals, human service workers, and students are currently being used. Interestingly, other mental profile states have also been reported by Maslach and colleagues.
Identifying your profile may help tailor your initiatives to become re-engaged (see the section on preventing burnout below). It is also important to note if symptoms that accompany burnout become more pervasive and start affecting other parts of life. This could suggest that burnout may be transforming into a depressive or anxiety disorder. Seeking professional counseling is crucial in these situations.
Table 1 depicts mental profiles and results of the Maslach Burnout Inventory for each profile.
| Profile | Emotional exhaustion | Depersonalization | Low personal accomplishment |
|---|---|---|---|
| Engaged | No | No | No |
| Overextended | Yes | No | No |
| Disengaged | No | Yes | No |
| Ineffective | No | No | Yes |
| Burnout | Yes | Yes | Yes |
Table 1: Adapted from Pattern of MBI Scales Across Profiles in Mind Garden
Use this free PDF of the general MBI to calculate your score. If you want more information about other MBI products and formal testing for a fee, check out the website Mind Garden.
5 tips for handling residency burnout
Tip 1: Don’t dismiss burnout
It is very easy to attribute burnout to external factors and approach it as another difficult period in your lifetime. A large cross-sectional study of physicians suggests that burnout was not associated with suicidal ideation when adjusted for depression.
However, self-reported medical errors were significantly associated with increased burnout.4 It is also important to note that unrecognized burnout may lead to depression and anxiety, so identifying it is key and half of the battle.5
Tip 2: Identify reasons and potential solutions for burnout
Asking yourself what is leading you to feel this way can be daunting yet illuminating. For example, ask yourself, "Is the problem related to taking many night call shifts back to back? Or not being able to schedule personal appointments? Is there no dedicated time to reflect on positives, negatives, and new ideas with program leadership?”
“These are system-based issues that may be addressed with the program.”
Another question to ask is, “Do you not have time to pursue hobbies or live a healthy lifestyle?” Having a friend or a group to hold you accountable might help. Lastly, check in about your learning, “Do you feel you are falling behind on knowledge acquisition?” This can lead to working with your program director on a study plan with in-person wet labs, which may be helpful. Whatever change you need to improve the situation, try to find it and write it down to discuss.
Figure 1 demonstrates the author's ophthalmology associate program directors and co-residents doing a coloring activity and sharing their excitement during the first wellness hour of the year.
Figure 1: Image courtesy of Ogul Uner, MD
Tip 3: Approach your support network
Consider using online communication if you do not have someone you can talk to in proximity. If you are not comfortable discussing it with co-residents, consider reaching out to friends, family, and other loved ones outside of work. Professional confidential counseling is also an underutilized resource to keep in mind if you have access to it at your training institution.
If you are having suicidal thoughts, the Suicide and Crisis Lifeline (988) is available 24/7.
Tip 4: Go back to your core values and your why
Perform a core value exercise to see what you prioritize. Think about why you went into medicine. What made you excited to go into ophthalmology? Realigning yourself with your motivations and values can be a strong coping mechanism.
“Mindfulness meditation can also be a great platform to reflect on your values.”
I found Emory University’s Cognitively-Based Compassion Training (CBCT) to be a great resource in this regard. The program features online courses and audio tapes you can go through at your own pace. Practicing interpersonal and self-compassion can promote gratitude for your unique journey, reduce depersonalization by celebrating your support network, and encourage personal accomplishment by acknowledging small wins during your day.
Figure 2 shows the author practicing daily CBCT—it only takes 5 minutes or less.
Figure 2: Image courtesy of Ogul Uner, MD
Tip 5: Consider taking a break
If you have exhausted your options after discussing with your program and the burnout is debilitating, you may think about options for taking a break. Depending on the situation, this may entail anything from rearranging your vacation weeks to taking an extended leave of absence.
A leave of absence would not be a light decision to make and should involve multiple people, including your program director and professional counselor, if applicable. The effect that a prolonged leave may have on your program, fellow co-residents, your health insurance and benefits, student debt, and future career plans would need to be considered.
How to talk about burnout
As high-performing and driven individuals, ophthalmology residents may not be comfortable discussing burnout with program directors, colleagues, and even loved ones. However, sharing how you feel with your program director is vital to implementing change. If it is a problem at the systemic level, your discussion may help you and future residents avoid similar issues. If you are more comfortable talking to another mentor, they may also facilitate discussion with residency leadership.
Figure 3 shows five points to consider when deciding to talk to a program director or a mentor in the residency program.
Figure 3: Image courtesy of Ogul Uner, MD
How to start the conversation around burnout
Reaching out with one of the following pre-meeting statements is an effective way to start the conversation.
- “I’ve been reflecting on the past few months, and how overwhelmed I have felt lately. Do you have time to chat about this sometime this week in your office?”
- “I have been going through a lot lately, and it’s becoming less sustainable. Could we talk about some next steps when you have time this week?
- “I would appreciate a chat with you on some issues I have been facing recently. Would you be available for an in-person meeting?
Scripts for navigating conversations about burnout with program directors
The two scripts below, curated from multiple resident experiences, represent “best-case scenarios” that highlight the appropriate language to use and demonstrate the aforementioned points in action.
The first addresses the resident’s concern about clinic understaffing.
Program Director: How are you doing?
Resident: I have been okay, but I have been going through a lot lately.
Program Director: Tell me more about that.
Resident: I feel like my clinic days have been very long because several urgent patients are added to my clinic schedule, but we do not get help with their intake, dilation, and other tasks that a technician can perform. I have been consistently leaving late and having significant delays as a result.
Program Director: How do you think we can solve it?
Resident: I have been thinking about this more recently. I realize that senior residents have technicians assigned to their clinics, but multiple technicians do not have assignments in junior resident clinics. It would be very helpful to have them help with obtaining the initial intake and imaging. We can also have dedicated clinic slots for urgent patients that are distributed across senior and attending clinics such that not all urgent patients are added to one schedule.
Program Director: Thank you for bringing these concrete ideas. It seems like these changes would help you a lot. Let’s have a meeting with the comprehensive clinic directors to discuss.
In this second encounter, the resident shares their struggle with sleep deprivation.
Program Director: How are you doing?
Resident: I have been okay, but I have been going through a lot lately.
Program Director: What’s up?
Resident: I feel like it’s been hard navigating call with minimal sleep and having to continue working the next day. Though I am not breaking duty hours, I am close to it. I feel like my learning, and attention to detail are suboptimal during the day due to sleep deprivation.
Program Director: What do you think has been the main problem, and how can we solve it?
Resident: I have been thinking about this more recently. One problem is the number of consults that we receive from the emergency room overnight, which frequently includes non-urgent ones. Having an effective triage system that we can implement and teaching the emergency room providers to take the ocular vital signs appropriately would be very helpful in reducing the number of non-urgent consults.
Program Director: That sounds reasonable. Let’s get a group of residents together to talk about this further.
Resident: Sounds like a plan. I will start an email chain and follow up.
Preventing healthcare burnout as an ophthalmology resident
There is no magical solution to preventing burnout. Remember, the three pillars of burnout are emotional exhaustion, depersonalization, and a perceived reduction in personal accomplishment.
- Preventing emotional exhaustion may entail limiting your responsibilities outside of work, spacing out calls on your call schedule, and suggesting solutions to make your daily tasks more feasible or efficient.
- Preventing depersonalization is harder, as it requires breaking the “autopilot.” Taking time to bond with loved ones and yourself ("self-care days”) and doing activities outside of the routine can be a reminder of the unique life we all live.
- With regard to personal accomplishment, self-reflection and gratitude can be life-changing. Forming a gratitude list at the end of each day or doing a mindfulness meditation are some examples of practicing appreciation.
The best piece of advice I received from a mentor was to re-evaluate my values regularly. Our goals inevitably change as we move forward with our careers. Repeating the core values exercise, especially during career transitions and when adding on significant responsibilities, may help us prioritize what is important.
Creating a culture of communication
It is also key for residency programs to cultivate an environment of trust so that residents can talk about stress. Trust plays a large role in this setting, so being transparent about values and limiting side conversations like gossip greatly enhances this relationship.
Having regular residency meetings to invite people to share perspectives and ideas, acknowledging the prevalence of stress as a resident, and implementing an open-door policy to discuss any issues help to make the resident more comfortable talking about burnout.
If there are no platforms for residents to voice their concerns in a residency, it would be a good idea to approach the program director for its implementation.
Work-life integration in residency and beyond
The term “work-life balance” is commonly used in discussions of burnout. I do not think the term is a realistically achievable one. Residency is a time of challenging growth, but both personal and career responsibilities continue to increase after training. Hence, I prefer to use the term “work-life integration.”
“It underscores the complex interplay between work and life such that our focus will be disproportionately directed on certain areas at any given time—and that is okay.”
Intrinsic motivation and core values maintain this dynamic relationship in the long term. Though acknowledging this is the first step to integration, it is important to note when the focus becomes overwhelming, recognize burnout, and act to re-integrate.
Conclusion
Ophthalmology is a unique and incredibly rewarding specialty. Despite the steep learning curve, we go through arduous training to learn to save sight and empower lives. As we start what hopefully will be a long and fruitful career, it is important to check in and make sure we are taking as much care of ourselves as we do of our patients.
