Burnout may be a misnomer

Simon G. Talbot and Wendy Dean, arguing in STAT that burnout is actually a misdiagnosed consequence of unchecked moral injury:

We believe that burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the healthcare ecosystem to a tipping point and causing the collapse of resilience.

The term “moral injury” was first used to describe soldiers’ responses to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Which is why the chorus of hollow wellness outreach efforts for trainees and other physicians are so patronizing and eye-rollingly ineffective:

The simple solution of establishing physician wellness programs or hiring corporate wellness officers won’t solve the problem. Nor will pushing the solution onto providers by switching them to team-based care; creating flexible schedules and float pools for provider emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques or participate in cognitive-behavior therapy and resilience training. We do not need a Code Lavender team that dispenses “information on preventive and ongoing support and hands out things such as aromatherapy inhalers, healthy snacks, and water” in response to emotional distress crises.

Explanations for the 2018-2019 Official Step 2 CK Practice Questions

The NBME recently released an “updated May 2018” official “USMLE Step 2 CK Sample Test Questions,” but these are actually completely unchanged over the past two years since the June 2016 update, which was itself almost unchanged from the 2015 set.

Since it’s been a couple years, I’ve included the explanations below (which are, again, unchanged). You might see the comments on the old post for possible additional questions you may have. The multimedia question explanations are also at the bottom of this page.

Last year, helpful reader Jarrett made a list converting the question order from the online FRED version to the pdf numbers. I didn’t go through in detail to see if the online version order has changed, but the multimedia questions were in the same spots except that the block 3 question had shifted by one, so they may have done a little something.

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Fourth Year & The Match

Here’s a new book. It’s called Fourth Year & The Match, and you can get your copy by using this form to (at least temporarily) sign up for my new planned very infrequent/sporadic email newsletter:

Get your free book download (ebook and PDF) of Fourth Year & The Match.


If you’d like the book but aren’t interested in hearing from me, just click the instant unsubscribe link at the bottom of the download email. I don’t want to pester you.

And if you want to learn more about this project, keep reading:


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Explanations for the 2018 Official Step 1 Practice Questions

Here are my explanations for the new NBME 2018 USMLE Step 1 Sample Test Questions. This year there are 51 new ones (marked with asterisks).

Like in years past, the question order here is for the PDF version (not the FRED-simulated browser version). This facilitates using these explanations in future years when they change the available question set (because the old ones are always available via archive.org). The multimedia explanations are at the end.

Prior sets/explanations can be found here.
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More Perks of Flexible Duty Hours

You may recall the ACGME recently nixed its 2011 rule that mandated a 16-hour shift maximum for interns after “minimal” differences were noted in a study of surgical residents. I discussed those results here and the ACGME change here. Even in that study, the surgery trainees were basically less happy.

So, the ACGME didn’t wait for it, but now the results of a similar study in a cohort of presumably less self-flagellating medicine residents.

The study was designed to test the persistent leadership belief that the old days of infinite work were not only better for learning and patient care but also better tolerated by residents:

We prespecified four hypotheses regarding trainee education: that interns in flexible programs would spend more time involved in direct patient care and in education, that trainees and faculty in flexible programs would report greater satisfaction with their educational experience, and that interns in flexible programs would have noninferior standardized test scores to those in standard programs.

So, iCOMPARE randomized 63 internal medicine residency programs to flexible (read: long) or standard shifts. Both groups had the theoretical “80-hour” workweek cap. Standard programs adhered to 16-hour shift caps for interns and 24-hour caps for residents, while flexible programs “did not specify limits on shift length or mandatory time off between shifts.”

Contrary to the prevailing hypothesis, the flexible residents spent no more time on patient care.

However, the “flexible” (euphemism) program interns were “more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65)”

One thing that was similar was the high-rate of burnout:

Reports of burnout were high in each group. The interns in each group had a similar likelihood of having high or moderate scores on the Maslach Burnout Inventory subscale for emotional exhaustion (79% in flexible programs and 72% in standard programs; odds ratio in mixed-effects logistic-regression model, 1.43; 95% CI, 0.96 to 2.13), high or moderate scores on the depersonalization subscale (75% and 72%, respectively; odds ratio, 1.18; 95% CI, 0.81 to 1.71), and low or moderate scores on the personal accomplishment subscale (71% and 69%, respectively; odds ratio, 1.12; 95% CI, 0.84 to 1.49)

3/4 are miserable. It’s hard to divide an 80+ hour pie into something that isn’t too many hours a week.

I think the conclusion sums up the state of medical training fantastically:

There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied.

So, whose happiness matters more?