The Red Queen’s Gambit: Helping the Lab Avoid Burnout

In Lewis Carroll’s book Through the Looking Glass, Alice is being given a tour of Looking-Glass Land by the Red Queen when this happens:

Alice never could quite make out, in thinking it over afterwards, how it was that they began: all she remembers is, that they were running hand in hand, and the Queen went so fast that it was all she could do to keep up with her: and still the Queen kept crying “Faster! Faster!” but Alice felt she could not go faster, though she had not breath left to say so.

However, after running until Alice feels absolutely exhausted she looks around in surprise to find that they are exactly in the same place where they had begun.

Carroll, Lewis (1991) [1871]. “2: The Garden of Live Flowers”. Through the Looking-Glass (The Millennium Fulcrum Edition 1.7 ed.). Project Gutenberg.

“Well, in our country,” said Alice, still panting a little, “you’d generally get to somewhere else—if you ran very fast for a long time, as we’ve been doing.”

“A slow sort of country!” said the Queen. “Now, here, you see, it takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that!”

Laboratory medicine is one of many areas of healthcare where more is constantly expected to be done with less, where the inhabitants of our looking-glass land have to run as fast as we can just to maintain the status quo. Also like many areas of medicine, our already strained workforce suddenly became victims of an unprecedented global COVID-19 pandemic stressing and stretching our capabilities. The gamble then, is expecting members of our incredible laboratory medicine community to run so fast that they ultimately burn themselves out.

From the December 2020 New York Times article on laboratory workers in the time of COVID-19 titled, “‘Nobody Sees Us’: Testing-Lab Workers Strain Under Demand“:

Morale in the labs has flagged as the country continues to shatter records for caseloads, hospitalizations and deaths. The nation’s testing experts know these statistics better than anyone: They count the numbers themselves, sample by sample. But they are also easy targets of criticism and complaint.

“There is always this undercurrent of, it’s never good enough,” said Dr. Abbott, of Deaconess Hospital in Indiana. “It’s devastating. We’re working as hard as we can.”

In April 2020, just a few weeks after COVID-19 was officially declared a global pandemic, the April issue American Journal of Clinical Pathology opened with two timely editorials, one from Dr. Jeanette Guarner discussing the three emergent coronavirus diseases of the past two decades (SARS, MERS and COVID-19) and the next by Dr. Steven H Kroft titled “Well-Being, Burnout, and the Clinical Laboratory.”

In this issue were three different articles, the results of extensive surveys conducted by the ASCP to determine the job satisfaction, well-being and burnout prevalent among 1) pathologists, 2) pathology residents and fellows, and 3) laboratory professionals. Knowing now what clinical laboratories, leaders and trainees were about to go through thanks to COVID-19, made these publications about the stress and satisfaction felt by those in lab medicine was timely (if not grimly ironic).

What is shown in those excellent publications, and what we can only assume has become more true, is “burnout,” (the “combination of emotional exhaustion, depersonalization, and loss of sense of personal accomplishment”) prevalent in laboratory medicine, with the majority of pathologists, residents and fellows, and professionals reporting having experienced it if not experiencing it as an ongoing problem.

There is no single solution to burnout in the laboratory. As Dr. Kroft outlines in his editorial, these surveys can be seen as initial steps to understanding the problem and plotting potential courses forward (“a roadmap for what workplace landmines to try to avoid.”). But several meaningful pieces of data emerged from these surveys as well: Overwhelmingly, pathologists and lab professionals enjoy their work (91% and 86%) and feel valued by their colleagues (79% and 71%). Also telling is the fact that while well over 90% of laboratory professionals reported “a little bit of stress” to “a lot of stress,” 2/3rds of them reported feeling either “somewhat satisfied” or “very satisfied” with their jobs. Clearly, no one knows the value of laboratory medicine better than those of us doing it. But recognition and support coming from within the laboratory space should be seen as a good first step to acknowledging these contributions.

Recognition is needed from outside lab leadership as well, and especially should be accompanied by both stress-reducing measures (filling labor gaps, adequate compensation and benefits etc.) and opportunities to feel ownership and personal investment in the contributions we make to healthcare. Healthcare leaders, professional organizations, and all of those who were vocal supporters of labs’ contributions during the worst of the pandemic, should continue to advocate on behalf of laboratory staff’s well-being.

Even as vaccines and other mitigation efforts are providing more widespread pandemic relief in the United States, it’s clear that we are now through a COVID-19 looking glass. The lab was already running as fast as it could, but to get us to where we are now, many of us started running twice as fast. Hopefully we will both continue to run and also be supported in that ongoing race to stay where we are.

-Dr. Richard Davis, PhD, D(ABMM), MLS(ASCP)CM is a clinical microbiologist and regional director of microbiology for Providence Health Care in Eastern Washington. A certified medical laboratory scientist, he received his PhD studying the tropical parasite Leishmania. He transitioned back to laboratory medicine (though he still loves parasites!), and completed a clinical microbiology fellowship at the University of Utah/ARUP Laboratories in Utah before accepting his current position. He is a 2020 ASCP 40 Under Forty Honoree.

Set the World on Fire, but Don’t Burnout

Hello everyone and welcome back!

So here I am: a med school matriculant, top-choice program matched, doing exactly the training and work I’ve wanted to since before medical school. Totally made it! But before I go all “Fresh Prince of Maywood” on you, there’s a lot to unpack within the word “residency.” I’ve discussed this before, comparing pathology subspecialties with my primary care friend Dr. Raja’s rotation schedule, but you probably already know a little about what pathology residents do. I want to talk about what most folks might not know, why most residents absolutely disappear from their families or loved ones, and why going in with already greying hair isn’t going to make this any better, ha-ha…

Image 1. Me, and me. Look what 6 months of residency can do. Wow. Kidding. It’s an Instagram filter. Or is it…? It is. But what if it isn’t….?

I’m a resident at Loyola Medicine in Maywood, IL; I also went to undergrad (over a decade ago) at Loyola Chicago. So, for me, this is a very cool full-circle experience. I bring this symmetry up because a lot of people talk about the “culture” of an institution when they’re looking for a perfect match. I’ve talked about my experiences with hospitals’ institutional cultures before, at Bronx Care, Staten Island, Mayo Clinic, Danbury, Brooklyn, and more before medical school. I choose to highlight Loyola for you both because it’s already home to me, and also because it has a unique disposition.  When you walk across the stage at graduation, Loyolans are instructed to “Set the world on fire”—a quote from the university’s namesake and patron St. Ignacious Loyola. It follows a Jesuit tradition of valuing education as one of the most powerful tools to address social inequality, injustice, poverty, and whatever ails our society. By being bold and passionate (like a fire, get it…?) true leadership can manifest in graduates’ futures.

Image 2. Me again. Imbued with Jesuit mantras, ready to set the world “aflame.” Notice me in the bottom right, however, not really seeming to pay attention to the stage. Thinking about my poor future colleagues perhaps…

But all graduations are decorated with pomp and circumstance. As graduates sit and wait for their name, they are pontificated at about the importance, poignancy, and grand scale of opportunity that awaits them. But what happens after graduating, college, or graduate school, or medical school? The answer varies widely for many, but I can speak to those who end up with the long white coats. I’ll be honest, allegorically, college is a lesson in walking, graduate school is a lesson in running, medical school is a lesson in cartwheels—after you’ve somewhat mastered this, the world that awaits you demands powerful cartwheels (with tricks) up multiple Mt. Everests, and you might be able to use the bathroom…you might. Haha, a little hyperbole. I mean I am SO glad pathology training isn’t like some other specialties (looking at you surgery…) but the demand is there, nonetheless. I would say ours might be more cerebral because, what we trade in for not having an intern year, we are “gifted” with having to lean 4+ years of material presented as an iceberg tip in medical school.

In a recent Inside the Lab podcast, the topic of burnout was discussed. (Check it out here!) Labratorians—and healthcare staff in every role—have been feeling the COVID push all year. More is expected of us, more is demanded of our system and its output, and there is no relief or break in sight. That prolonged demand on our expertise (and time) puts a significant strain on all our collective psyche’s. Nowhere is that more apparent than in healthcare. Paramedics run long uninterrupted shifts seeing tragic emergency one after another. Nurses do 12hr shifts back to back for days, especially when there isn’t enough staff to support days off (while patient census climbs higher and higher). But in medicine, poor medical school post-graduates are expected to literally “reside” in the hospital, ergo resident. The term came from the training model coined at Johns Hopkins in the early 1900s. And, up until a few years ago, the powers that be decided that residents should log no more than a maximum of 80 hours a week with the longest shift you can work 24 hours. Fun fact: the IRS, yes those guys, defines full-time work as 30-40 hours per week or 130 hours per month. If you work a “full time” job, you probably work 40 hours a week/160 hours a month. So, for young resident physicians: that two full time jobs, coming in hot at just about the average US salary of 55-60k. Outstanding. However, while I find myself lucky and would anecdotally say that I don’t think I’ll be getting any notifications or flags on logging too many hours at the hospital, the reality is that many physician trainees work right up to the maximum (and more). The old guard cites that 80 hours isn’t enough time to train a functioning physician, as they leave patient care at a sensitive time where they effectively abandon their learning. But …burnout. The “reduction” to 80 hours one would think reduces stress and burnout, but lo and behold a paper (from FIFTEEN years ago) says nu-uh. “Changes in parameters of resident and faculty emotional exhaustion, depersonalization, and personal accomplishment did not show statistical significance…Despite successful reductions in resident work hours, measures of burnout were not significantly affected.” (JAMA, 2004)

Image 3. I’m not here to cite stuffy papers and the voluminous research on physician and resident burnout. Instead, I’m here to highlight the motivations those of us in healthcare cite as our driving force to keep at it, especially in a pandemic.

Regardless, those of us in postgraduate medical training are here for a reason. I identify as one of the few who finds himself in a lucky spot, where my institution—and my profession of choice—don’t demand that kind of hourly expectation of me. But many of my other colleges aren’t as lucky. Surgeons, internists, family doctors, and more are working themselves to the limit. And that doesn’t include anything about the COVID pandemic. Whether you’re a graduate of Loyola or not, we’re all expected to “set the world on fire,” I just hope we don’t burn out in the process. Stay in tune with your needs and your support system, learn to recognize signs of burnout as much more than fatigue, and remember to extend compassion to everyone—you never know what load they might be carrying. Remember those things and you can navigate a packed work-week…or a pandemic!

Thanks for reading!

See you next time!

Constantine E. Kanakis MD, MSc, MLS(ASCP)CM is a first-year resident physician in the Pathology and Laboratory Medicine Department at Loyola University Medical Center in Chicago with interests in hematopathology, transfusion medicine, bioethics, public health, and graphic medicine. He is a certified CAP inspector, holds an ASCP LMU certificate, and xxx. He was named on the 2017 ASCP Forty Under 40 list, The Pathologist magazine’s 2020 Power List and serves on ASCP’s Commission for Continuing Professional Development, Social Media Committee, and Patient Champions Advisory Board. He was featured in several online forums during the peak of the COVID pandemic discussing laboratory-related testing considerations, delivered a TEDx talk called “Unrecognizable Medicine,” and sits on 
the Auxiliary Board of the American Red Cross in Illinois. Dr. Kanakis is active on social media; follow him at @CEKanakisMD.

Preventing (Pathology) Resident Physician Burnout

Fellow residents, do you sometimes feel burned out, especially with the dismal winter weather than many of us have been experiencing lately? There have been many, predominantly small sample size, cross-sectional studies over the years on this topic. Methodological deficiencies in many of these studies may bring into question some of the generalized conclusions that they assert but does not discredit the truth that resident burnout exists and should be taken seriously by training programs.

In 2004, an article in JAMA on this topic defined “burnout” as a “pathological syndrome in which emotional depletion and maladaptive detachment develop in response to prolonged occupational stress.”1 Multiple studies have identified factors such as time demands, variability in faculty expectations, work overload that inhibits learning, systemic program issues, inadequate elective time, and lack of communication and support from faculty and peers as potent contributors to resident burnout.1,3 Furthermore,a subsequent study identified that burnout was associated with absenteeism, low job satisfaction, and medical errors.2

So, first, how can we identify if we are experiencing burnout? As with everything in life, know thyself. Conduct an honest self-assessment of your strengths and weaknesses as well as your absolute needs, both at work and outside of it. If you are not good at honestly evaluating yourself, then ask a trusted person who has your best interests at heart their opinion and truly listen. Then set aside designated time to recharge your batteries. For some this means exercise, for others, it may mean spiritual or community volunteer experiences, or even, just doing “nothing.” The key is to not do any residency work during this time. This is often easier said than done but the first step is to make a commitment to try to do so.

Next, be proactive to bring out the change you want to see. Often when we feel that a situation is out of our control or that we have no choice but to submit to a situation that makes us unhappy, fatigued, or emotionally drained, these negative feelings we internalize may manifest as burnout. So, find a way to take back some control. Frequently, part of this does mean cutting out those aspects of your life that have become toxic, whether it be negative situations or negative people. Of course, this is also easier said than done. If I had the cure for this, I’d bottle it and sell it.

Finally, find support. This statement can mean interacting with a mentor who will both personally and professionally “be in your corner” and help guide you through acquiring the necessary skills you need to be a good doctor. It also means to turn to those positive people in your life, whether it is a family member or a good friend, who will listen to you without judgment, let you vent, encourage you in healthy pursuits, but most importantly, remain honest with you and not just be your cheerleader.

Interestingly, a small survey study in 2013 by Medscape of pathologists showed that only 32% of respondents stated that they were burned out.4 Even though the methodology for this study is not stated to be able to determine the legitimacy of this study, it at least gives me hope that if I survive residency, there is hope at the end of the tunnel for a reprieve from those often seemingly, hydra-like tentacles of burnout that threaten to bring us down.

  1. NK Thomas. Resident Burnout. JAMA, 2004;292(23):2880-2889.
  2. LW McCray, PF Cronholm, RA Neill. Resident Physician Burnout: Is There Hope? Fam Med, Oct 2008; 40(9): 626-632.
  3. L Joseph, PF Shaw, BR Smoller. Perceptions of Stress Among Pathology Residents. Am J ClinPathol 2007; 128:911-919.
  4. Pathologist Lifestyles – Linking to Burnout: Medscape Survey. Last updated on 3/28/13. Accessed on 2/11/14 at http://www.medscape.com/features/slideshow/lifestyle/2013/pathology#1

 

Chung

Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.