Could incentives be the answer to resident burnout?

Within our hospital walls there rages a nightly war in the Emergency Department. The front-line soldiers (a.k.a. ‘residents’ – medical doctors still in the throes of training) work endlessly through the night to admit patients to hospital and provide care to those in need. On occasion, the combination of consistently overburdened teams and overworked residents can lead to disagreements between them over who the admitting service should be for a particular patient. This seemingly endless battle waged in the Emergency Department, along with intense work demands, limited control, and a high degree of work-home interference that abound in residency training programs takes a significant toll on resident well-being. It is not surprising then that resident physicians suffer from an alarming rate of burnout (defined as a triad of emotional exhaustion, depersonalization, and a sense of decreased personal accomplishment).

The possibility of a patient being cared for by a different service helps protects a team’s overall workload, and preserve the limited energy stores carried by each resident. The term ‘turf war’ is colloquially used to describe the inhumane fight that occurs when a consulting team tries to avoid admitting a patient under their care by referring them to a different service. These disagreements can become intensely heated when it occurs between two over-tired and overworked residents.

I find these inter-professional conflicts to be the most emotionally draining aspect of my job. They both contribute to, and are a reflection of, the high rates of resident burnout. Depending on the specialty-training program, rates of burnout among residents vary with a mean rate of 50% by the end of first year and ranging from 25-75% throughout the entire duration of their training. I happen to practice General Internal Medicine, which has a mean burnout rate of 63%; a stark contrast to the rate of burnout in the general population. Individuals who have completed a college or university degree and are between the ages of 27-40 (similarly aged to resident physicians) have a mean burnout rate estimated at 30%. Are there no ‘rules of war’ that can help avoid these battles?

Hospitals have created admission guidelines that spell out which services are to admit patients in a given clinical situation, with the aim of avoiding unnecessary turf wars. But from my experience the reality is that medical and surgical teams skillfully navigate these guidelines with a variety of interpretations, and often apply them in such a way that protects their team from admitting patients from the Emergency Department. I am consistently frustrated every time I am asked to see a patient who should be admitted under a different service according to our Hospital’s guidelines. Yet I often admit the patient to our General Medicine service at the slightest display of resistance from other services because the fight itself is emotionally exhausting and not directly involved in caring for that patient. An additional patient to care for means more work for our team, which provides no personal gain except the gratification of caring for someone in need and the learning experience that accompanies it. Is that motivation enough to keep residents going day in and out?

It is 3:30am and my pager has gone off for the 17th time tonight.  Down I trudge to the consultant’s area to prepare to listen to my colleague regale me with the story of a patient they saw, who likely needs to be admitted to hospital, but for some reason is more appropriate for my service over theirs. Tonight, the referring doctor is an Orthopaedics surgical resident, equally as bleary eyed as me and armed with the patient’s chart in hand, ready for battle.

His request for consultation is for an 87 year old woman with multiple medical problems who has fallen and broken her ankle. It is presumed that the roughly 20 medications she takes are partly responsible for her fall due to some complex drug-drug interaction (this is certainly true). The surgical team has reviewed her case and deemed that she will not need surgery to fix her fracture, but the sticking point preventing her from returning home is that the poor woman can’t walk. Our hospital guidelines clearly state that any fracture (operative or not) is to be admitted under the Orthopaedics service. There is a Medicine Consults team that can assist their team with the medication issues during her admission. Instead, they call in the General Medicine service to admit her under the premise that she is ‘best served’ under us in order to sort out her medication issues. Let the battle begin! (She was admitted to General Medicine)

Don’t get me wrong, I love my job, but I am certainly not immune to burnout and I have definitely experienced varying degrees of it over the past two years of residency training. I have come to realize that it is an unavoidable consequence of becoming a physician, yet wonder if there are other ways to mitigate its effects.

We have made incredible strides in improving resident working conditions, including the restriction on work hours, the provision of on-call stipends (that amounts to approximately $3 per hour for a 28-hour shift) and the general culture of appropriate work-place behavior toward residents in training. None of these seem to have had a significant effect on reducing resident burnout, and their effect on resident well-being is still in question. Staff physicians early in their career are not immune either, but have a significantly lower rate of burnout than residents. Could this be linked to the significant remuneration they receive for each patient seen? Although none of us entered into Medicine for the sole prospect of earning a sizeable salary (at least that no one will admit to!), I can’t help but wonder, ‘would I be more motivated and feel less burned out when seeing that 18th patient while on call overnight if I received some nominal fee-for-service just as our attending staff physicians do?

The comments section is closed.

  • Cain says:

    Burnout is not due to working hard, or working long hours. It’s from doing rote work that has no significance or meaning.

    The secret to reducing burnout is not to reduce resident work hours, but to increase the meaning of the work done by the residents. Most of what residents are doing after hours is clerical work that could be done by ancillary staff but is not because they either refuse to do it (and are backed up by their unions), or the hospitals refuse to hire people to do it.

    Additionally, residents are, in a way, trapped. Their MD is worthless without completing residency, and moving to another hospital, or another residency program, is damn near impossible. So they have no option but to take the abuse and have everything dumped on them. Otherwise they sabotage their careers.

    If a resident wants to change to another specialty, it is, again, damn near impossible. That resident will probably burn out, and will be a burned out physician.

    From a budget perspective, residents are a bargain. They’re an after-hours doctor, nurse, social worker, secretary and janitor all rolled up into one, for the measly price of $3/hr! The author of the article raises a good point; that residents should get a cut of FFS. I think this is fair. It is how it is done in dentistry with associates taking a % of all of the work they bill.

    In short, residents should be paid a percentage of FFS, resident training should be flexible in both specialty and location, and the MD should have some use outside of being a rubber-stamp for residency.

  • TapOff says:

    It sounds like the phenomenon of interaction with artificial or stanardized guidelines for billing and bed load management within a utilization bases billing hospital staffing and care administrative model is the true culprit of system burnout. Maybe a patient based evaluation of care and prevention to move the people being evaluated and served through their experience with a commitment to engineer a system that studies and focuses on contiunity and on assuring health improvement rather than isolated / resource use, treatment based administrative models. Such a shift may actually save time, money, and attitude and may require less overall hierarchical structuring, reduce, readmission rates (cost to health budget overall) and generate greater feeling of actuly providing excellent care in a real team environment at work. The load is shared not “turfed”.


Kieran Quinn


Kieran Quinn is a general internist and palliative care physician at Sinai Health System and an early career health services researcher affiliated with the University of Toronto and the Institute for Clinical Evaluative Sciences (ICES).

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