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Residency match system and flexibility: the hidden factors behind burnout

ERAS is now open, and medical students all over are compiling their applications to match into residency. As someone who is in a field they desired to pursue while in college but took a circuitous route there (four years as a generalist in the Air Force, practicing after completing an internship), I cannot help but wonder if some of our residency match systems is a contributing factor to burnout.

Many studies and articles have been written about burnout; this is not one of those to rehash EMR burden, insurance drama, or “wellness modules.” All those and many more contribute to our plight, but my thoughts are inspired by one of my favorite books, Range: Why Generalists Triumph in a Specialized World by David Epstein. One of the things covered in the book is “match quality” which is how well a job fits the person’s interests and values. In medicine and the residency match system, we risk not finding match quality which when compounded with the end-of-time illusion and sunk cost effect, can lead to burnout.

One of my favorite chapters discusses cadets at West Point. The majority of West Point graduates serve their required payback time for their degree and leave the Army. These cadets, who were selected while in high school and showed aptitude to be the future leaders of the Army, were leaving. Ironically, the officers that stayed the longest were Officer Candidate School (OCS) graduates, who came to the Army after college and already in their careers. After a failed attempt at a monetary bonus system, the Army started researching the problem.

Initially, they studied “grit” to see why they were selecting the “weak ones” that would not continue with Army service. They found their people had grit but were pigeonholed into jobs that did not match them well. These people had the knowledge and skills to do other jobs but were not getting that opportunity in the Army, so they left. The Army started allowing people to change jobs, and retention increased. With this, it was revealed that people change! Look back ten years ago. You were likely a different person and will likely be so in another 10 years. Not thinking you will change is called the “end of history illusion.” Where does the largest change happen? During the time between graduating from high school, leaving home, college, and the first part of a career … or typically someone’s 20s. Which also happens to be the time that people do research, stress about O-chem, volunteer, take the MCAT, and get into medical school.

Once in medical school, the typical changes of the 20s are compounded by exposure to different people, social inequality, and the realization that life is not black and white. Oh, and somewhere in there, the realism of medicine in America hits, along with exposure to burnout. When that realization hits, many are already $250,000 in debt and have poured out blood, sweat, and tears for thousands of test questions and multiple marathon-length tests. At this point, we are almost too far along to quit. We are so close; think of how far we have come and all that we have sacrificed for this dream! This is the epitome of a “sunk cost effect.”

As mentioned at the beginning, ERAS is now open, meaning newly minted fourth-year medical students are working on their residency applications listing their work, volunteer, research experiences, and any little thing to boost their application. They are working on letters of recommendation, of which almost all specialties require letters from the chosen field. These students have just finished third year, where they have done core rotations such as family medicine, internal medicine, surgery, OB/GYN, pediatrics, psychiatry, emergency medicine, and an elective. Some get true general experience in those, but some spend their internal medicine rotation in a rheumatology clinic. This means for many students, to get that letter of recommendation in time to submit for residency, they must schedule audition rotations when only halfway finished with third year.

Only about a quarter of medical students end up in the same specialty as they initially thought they would pursue. At this same time, we are seeing a bloating of extracurricular activities and research from students that are going into highly competitive residencies. This bloat results in some students networking to start research before completing their first medical school exam, let alone even seeing a patient in their chosen field.

I strongly believe that a well-rounded general medicine third year is great for our learning as physicians and allows for better exposure across specialties than other careers, such as the West Point graduates (though they now have more ability to retrain). However, as medicine continues this path to hyper-specialization and becoming more competitive, we are actively losing what we have.

We are never done learning, growing, and changing. With the medical education journey exceeding a decade in length, the end of history illusion is in strong effect, and the sunk cost fallacy keeps many stuck. Furthermore, cross-training in another field, like the Army started offering, is rarely an option for physicians. Medscape surveys show many physicians who would have chosen medicine all over again but would have done a different specialty.

While many things need to change within medicine, I hope we can allow ourselves and others to change. Third year needs to stay general! Non-traditional students need to be valued. Taking time to decide and experiment should be rewarded and not punished, as we allow medical students time to explore their interests prior to deciding on a life path. Maybe we should allow ourselves that exploration as well.

J. Tyler Bates is a physical medicine and rehabilitation resident.

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