Recently, two separate people commented negatively on my appearance. These weren’t people I knew well enough to excuse their unwarranted comments, yet I considered their observations seriously. Checking the mirror when I got home, I realized they were on to something: the woman in the reflection looked hollow. Residency had begun to feel particularly rough, and of course, there were hints of my burnout before this. I had started making mistakes and was struggling to keep up with my tasks. I dreaded going to work and often wished for reasons to stay in my apartment. I was growing frustrated with patients, sometimes visibly. When I got home, I had no energy and spent my time recovering in order to be able to go back to the hospital.
It has been helpful for me to look at this experience through the lens of a term used in pediatrics. “Growth faltering” (GF) — previously known as the more pejorative expression “failure to thrive” — refers to the clinical concern that a child isn’t growing as expected. Rather than treating the lack of growth as the problem itself, clinicians look at the child’s intake, losses, environment, and metabolic demands to understand why they aren't “thriving.”
When I think about residency through the GF framework, the parallels are uncomfortable. A resident has a tremendous amount of output. There are endless notes, messages, and administrative tasks, and they seem to multiply as soon as you complete something. There is also an unusually high metabolic demand. A regular day in residency requires sustained attention, compartmentalization, and the ability to keep going regardless of your energy level. We care for people who are often in the worst moments of their lives and going through every emotion possible, and we make life-changing decisions knowing that sometimes, we will be wrong.
The things that replenish us are often easy to give up. Nobody is going to send me a secure chat because I haven’t exercised in a few weeks, and my program isn’t going to email me because it’s been ages since I’ve talked to my friends. The work persists regardless of my ability to prioritize personal time. The reality is that if I don’t write a note or send a message tonight, it will still be there tomorrow, probably along with a few more. The parts of my life outside medicine don’t have the same ingrained urgency, so even though they keep me healthy and sane, they have become easier to postpone. As a result, when intake decreases while output and metabolic demand stay high, it isn’t surprising that growth is the first thing to take a hit. I’ve seen this stagnation not just in my career aspirations but also, recently, in my relationships and physical health.
The signs of failure to thrive in a resident are not always dramatic. Sometimes they look like the things I’ve experienced, like falling behind on previously manageable tasks, making more errors, feeling detached from work, or losing interest in hobbies outside of medicine. These things are easy to dismiss because they are so common in residency. We expect residents to be tired and for this job to affect our moods. The unsettling part of my experience has been that I’m still capable of doing my job and I still care about doing it well. Yet, acquaintances could perceive my burnout in my appearance and demeanor before I noticed it. It’s hard to say how long I had been seeing my deterioration as my new normal and just waiting for a breaking point to intervene.
If a child in my clinic is not gaining weight, I don’t just hand the family a high-calorie supplement — I ask why the child isn’t getting what they need, and I tailor my intervention based on the cause. Unfortunately, our system-wide current residency wellness infrastructure treats the outcome with “supplementation” rather than prioritizing evaluation and prevention. It’s much easier to send a resident to extra workshops on burnout than change the system that instigated the problem. At the point where intervention is obviously necessary, we learn when to send a kid to the hospital, but we haven’t figured out how to prevent a resident from experiencing severe depression or anxiety, or having thoughts of suicide or self-harm.
The process of identifying growth faltering in a child is to make actionable changes, like encouraging habits to improve pickiness, meeting with behavioral health specialists, or getting labs to work up a medical condition. Applying that same framework to residency requires us to consider whether residents currently have the resources and support to remain a whole person during training. I don’t have a clear conclusion regarding what that looks like, and I know it takes a while to change a system that has existed like this for so long. I’m also not going to pretend that becoming a physician should be easy and free from discomfort, but I think there is a difference between facilitating resilience and expecting depletion.
Every child is on their own growth curve, and when we consider their development, we compare to previous points on their lifetime growth charts. In my journey with burnout, this has translated into removing other people’s experiences for comparison, and instead focusing on where I am now in comparison to where I was before. In an effort to build my own rescue ladder to escape the pit of burnout, I’ve also begun to regularly contemplate what thriving means to me. While a previous version of me would have had lofty goals to run marathons and attend social events, these days I find pride in moving my body and going to therapy. One day, residency will be a distant memory, and my definition of thriving will become more robust, but for now, I’m just trying to stay on my own growth curve.
