Difficult Topics in Residency: Vacation

Time Off

As many of you know, I am currently on a post-residency, round-the-world business class trip. I booked the flights using points and miles, with very little cash outlay. You can read more about the booking process on my previous blog post! You can also follow along on my trip on Instagram (@thepointsdr), where I am posting a photo every day.

One of my goals in starting this website was to talk about burnout in the medical field. In all honesty, I have had a difficult time writing posts about burnout because I have come to discover that it is a rather difficult topic to fully define and tackle. Burnout can look so different from person to person, and it would be too simplistic to suggest quick fixes. It is, however, a real problem that needs to be examined.

In an effort to speak more on burnout, I am going to delve into subjects that always seemed contentious in residency. For the first topic in this series, I want to take a deeper dive into the issue of vacation.

I have had lots of time to think above the clouds this summer (2019  ©  JOEL ANG PHOTOGRAPHY)

I have had lots of time to think above the clouds this summer (2019 © JOEL ANG PHOTOGRAPHY)

The Current State

For medical residents in the United States, the Accreditation Council for Graduate Medical Education (ACGME) oversees the rules for all residency training programs. Interestingly, its guiding document for does not define any vacation time requirement. Rather, in section IV G, it simply states that each sponsoring institution must have a vacation policy in place.

The lack of clear guidelines has led to quite a large variation in vacation policies between residency programs. At my program, for example, all residents were given four weeks of vacation time. However, in the podiatry-specific addendum, we were only allowed two weeks off, with two additional weeks of pay to make up for lost time. I had no say in the matter.

In surveying my friends, most seemed to average three weeks off a year. However, there were also those in programs with three weeks off by contract, but could never take all their days off because that was always the residency culture. They were not compensated for time they should have had as vacation days.

As you can see, vacation time varies significantly from program to program, which results from a lack of specificity in the ACGME rules. Contrast this to medical residents in Europe, for example, who since 1998 have had a law stating that a minimum of four weeks paid time off is required.

My wife has also dealt with burnout as a physician assistant (Ko Samui 2019  ©  JOEL ANG PHOTOGRAPHY)

My wife has also dealt with burnout as a physician assistant (Ko Samui 2019 © JOEL ANG PHOTOGRAPHY)

The Learning Problem

There seems to be two issues preventing residents from having more time off. The first is what I call the learning problem, which is the belief that:

More time off = less time spent in residency = fewer things learned = inferior doctor

Perhaps this is an extreme reduction of logic, but in my experience residency directors do believe this to an extent. Naturally, residency is a time of focused learning, and after graduation it can be challenging to grow as much professionally due to numerous factors.

But I want to argue that residency should be designed to prepare doctors for a lifetime of learning. We all know the doctors who stopped learning after residency - they are not the ones you want taking care of you or your loved ones. There are also so many opportunities for education after graduating form residency, something which is never discussed. One of my attendings, for instance, is lecturing on the national level about arthroscopy, a skill he never learned while in residency. So believing that every second of a resident’s life should be optimized for learning, I think, is one of the factors leading to resident burnout.

If the above logic was actually correct, that would mean that residents in Europe, with their four week vacation time (and mind you, 48-hour work week), are significantly less trained. I do not think this is the case at all.

Would you trust a doctor in Europe? (Vienna, Austria 2019  ©  JOEL ANG PHOTOGRAPHY)

Would you trust a doctor in Europe? (Vienna, Austria 2019 © JOEL ANG PHOTOGRAPHY)

The Team Problem

The second reason for residents not having more time off is the lack of work coverage. This was particularly evident at my residency program since we only had a team of six residents. Whenever someone took a week off, the other team members experienced an increased workload. Even in larger residency teams, the workload issue is still prevalent. Naturally, if residents could take more time off, more work would fall on the other team members more often.

There are two facets to this team problem. First, I think the residents who are not on vacation could have a better outlook on the increased workload. I know there were instances where I felt bitter about more having more work, for example, when I really should have been happy for the person on vacation instead. I knew they needed that time off, but my attitude did not reflect that.

There is, of course, the other question of why there is so much work to do in the first place. As many studies have shown, residents feel that electronic medical record documentation requirements are excessive. There are also studies showing a decreased workload being correlated to improved patient care and a decrease in resident self-harm. While many more studies need to be done, there is clearly a need to address the amount of work residents, and medical providers in general, have to complete.

My old small team of residents (with two incoming interns)

My old small team of residents (with two incoming interns)

Does More Vacation Really Help?

So here I am advocating for residents to have more time off, but can an additional week on the beach really help? Well, the answer is complicated.

In a study of younger European oncologists, a lack of vacation time was identified as an independent contributing factor to burnout. Taking vacation can also allow individuals to come back recharged for work, but only if they can leave their work behind during their time off. While anecdotal, I can also testify that after being on a long break, I am feeling significantly less high-strung.

But we all know that after a week or two back at work, stress levels can return and vacation can seem like thing of the past. This is why the burnout epidemic is so hard to tackle. In order to really provide healthy changes for residents and medical providers, significant institutional changes need to be made. Offering yoga classes, lunchtime walks, or therapy dog sessions just will not cut it.

In the European oncologist paper, a lack of vacation time was an independent factor for burnout. But so was work/life balance and access to support services. These are two things which can only be addressed by the institution where medical staff work.

So do I believe that more vacation time will solve burnout? No, not on its own. Burnout is too complex and multi-faceted.

But I do think that there is power in a hospital acknowledging the work that residents put in on an hourly, daily, and weekly basis, while also realizing that they are human beings in need of rest. Nobody should be in an educational setting where their employment contract states that they have three weeks of vacation time, but are bullied into only taking one week off a year.

Vacation is not the cure, but respecting the need for time off - especially in the midst of stressful residency training - is the right step forward in the burnout fight.