Road to Burnout: An IMG Perspective

Arunava Saha, MD

I woke up with a start. The ear-piercing noise emanating from some dark corner of the room went straight through my eardrums and crashed into my auditory cortex. As I thrashed around dazed looking for my spectacles and waiting for my already terrible eyesight to adjust to the dark, the high-pitched sound reached a crescendo. After a few seconds of struggle, I finally managed to locate my spectacles lying on a corner of the bed, snooze the ongoing alarm, and discontinue the next five scheduled at 2-minute intervals.

As I extricated myself from the blanket and put my feet down on the floor, the extreme cold— despite being in an airtight room with the heating on— sent a shiver down my spine. I turned the bedroom light on and gazed out through the window into complete darkness. The lone streetlight on the corner was trying valiantly to pierce the darkness surrounding it, but all I could see was the glare reflected off the layers of snow collected on the streets overnight. “Oh no, not again!” I wailed, as I realized that there was another bout of snowfall overnight. I opened the weather map only to be greeted with a 21F/-6ºC temperature and blizzard predictions for the whole day. This meant an added twenty minutes of working to get my car out of the snow, defrosting the windshield, and then driving along treacherously slippery snow-covered roads to reach work by 6:30 in the morning.

For an international medical graduate from a warm tropical country like India, moving halfway across the world to the United States to pursue residency training had its fair share of joys and triumph, but also the associated sorrows and tribulations. Unfortunately, in this day and age of social media, it is only the glitz and glamour which is focused on, while we are expected to suffer the unsavoury aspects of our decision in silence. It is indeed an honor and pleasure to learn under the absolute best, with exposure to the best of clinical medicine, academic progress, and research. As international medical graduates, we work extremely hard during the training period in our home country. This involves taking on extra responsibilities from an early stage of medical school, a huge financial investment to travel for and complete clinical rotations in the United States, sitting through three of the most gruelling 8-hour examinations, getting certified to be considered on par with American graduates, and then going through the trauma of a match process, only for some to end up on the winning side, while a few are not as lucky and have to come back to try and match the next year.

The people who do make it successfully have to battle umpteen other problems along the way. Staying away from home and family, adjusting to a new country and a new social and work culture, trying to survive on our own, figuring out finances on a resident salary, maintaining long distance friendships and relationships while making new friends, battling completely different climate and weather conditions, learning to drive on the opposite side of the road; all the while staying in a foreign environment and working long hours taking care of patients to the best of our ability. It takes a toll.

In a recent study surveying J1 visa physicians, it was found that the most important challenges faced by international medical graduates included navigating cultural differences, followed by staying away from family and friends, bureaucratic barriers, language communication barriers and managing finances. Some of the factors which were identified as important to their wellness included having friends or family close by, exercising, socialization, healthy eating, and having a friend circle [1].

It is imperative to realize that international medical graduates form a very specific subset of the physician workforce in the United States. They have their fair share of problems, which they are often unable to share with anyone. The work hours and patient load is often never the problem for them when it comes to the U.S. healthcare system, but it is the social and cultural aspects which play a significant role. It is important to identify these stark differences in terms of the trigger for burnout in international graduates compared to American graduates, who have to deal with a very different set of social and financial issues. Once these obstacles have been identified, it is important to make sure that these issues are addressed appropriately, along with ensuring international graduates’ physical and mental wellbeing. It can involve small efforts on the part of their peers and friends to just check up on them as to how they are coping with the transition from time to time. It helps having dedicated mentors to follow up with them at periodic intervals about their well-being, and allowing them the flexibility to attend to their essential appointments as they get settled in. The resident training program as a whole can provide support and resources for obtaining accommodations and a means of travel as they arrive without any background credit rating, being vigilant about their needs in terms of training and supervision as they learn the new system; and overall, keeping an eye out for symptoms of burnout.

In 2014, the tragic suicides of two interns in the field of internal medicine in New York caused shockwaves and brought attention back to the longstanding issue of physician suicide. This concern was further highlighted by more recent suicides involving a resident in Anesthesia and a resident in Psychiatry, also within New York programs. Another study published in 2017 examined aggregated data from the Accreditation Council for Graduate Medical Education (ACGME), encompassing 381,614 residents in training from 2000 to 2014 [2]. The study revealed that suicide was the second most common cause of death among residents, preceded only by neoplastic disease. The importance of resident well-being is increasingly acknowledged, particularly in light of these unfortunate incidents. It is imperative to establish preventive strategies and ensure access to confidential mental health services and counselling for all residents. Moreover, both faculty members and residents themselves involved in the clinical learning environment must be vigilant for signs of burnout, depression, social isolation, or significant declines in performance among residents. These indicators are often overlooked but can have catastrophic consequences. The well-being of physicians is crucial not only for the patients they serve, but also for the medical profession, the general public, and the physicians themselves. Disruptions in physician well-being can significantly impact patients and their loved ones, as well as the dedication of the medical profession to societal service. Initiatives to enhance physician well-being should start during medical education and prioritize targeted interventions that promote self-care habits and increase the utilization of mental and physical healthcare services, with a specific focus on residents. Ultimately, improved physician well-being will benefit patients, as evidenced by a meta-analysis that identified positive correlations between occupational well-being and patient satisfaction, adherence to treatment, and the quality of interpersonal care [3]. +

Arunava Saha is an International Medical Graduate, and third year Internal Medicine Resident at Saint Vincent Hospital, Worcester, MA. Email: Arunava1.saha@stvincenthospital.com

References:

1. Murillo Zepeda C, Alcalá Aguirre FO, Luna Landa EM, Reyes Güereque EN, Rodríguez García GP, Diaz Montoya LS. Challenges for International Medical Graduates in the US Graduate Medical Education and Health Care System Environment: A Narrative Review. Cureus. 2022;14(7):e27351. Published 2022 Jul 27. doi:10.7759/cureus.27351

2. Yaghmour NA, Brigham TP, Richter T, et al. Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment. Acad Med. 2017;92(7):976-983. doi:10.1097/ACM.0000000000001736

3. Scheepers RA, Boerebach BC, Arah OA, Heineman MJ, Lombarts KM. A Systematic Review of the Impact of Physicians’ Occupational WellBeing on the Quality of Patient Care. Int J Behav Med. 2015;22(6):683-698. doi:10.1007/s12529-015-9473-3