Dr. Dan Fulton and his wife, Lois, talk about stress quite a bit. He's a third-year medical resident; she's a physical therapist. In addition to raising two daughters, 3 years and 9 months, the couple is chipping away at about $173,000 in student debt from medical school.

"We have an agreement that I can't log in from home," said Fulton, 30, a resident in internal medicine at Hennepin County Medical Center in downtown Minneapolis. "It means that at times at the end of a long day I have to stay at work and finish up reports. But when I'm home, I'm home."

Finding ways to keep a lid on the pressure is becoming ever more difficult for doctors-in-training, according to a new Mayo Clinic study.

Large numbers are burned out, depressed and becoming increasingly cynical about their work. They're deep in debt and finding it impossible to balance work and life.

Most jarring, according to the study of more than 16,000 U.S. graduate medical students, is that the stress is making it harder for residents to learn needed skills. The Mayo Clinic researcher who worked on the report warns that downplaying the signs could lead to mistakes and poor patient care.

"This isn't just a woe is me, look at those doctors complaining about how hard their medical training is," said Dr. Colin West, a general internist who co-directs the Mayo Clinic Department of Medicine Program on Physician Well-Being. "This actually has an impact on what we're providing to patients throughout the health care system."

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Dr. David Hilden, left, who burned out as a family physician, now practices at Hennepin County Medical Center. He talked to Dr. Dan Fulton, a third-year resident who is chipping away at about $173,000 of debt.

The results, published Tuesday in the Journal of the American Medical Association, are the first to draw connections between distress, debt and medical knowledge. The researchers used scores from tests taken each year by nearly every internal medicine resident in the country and added questions about burnout, work-life balance and other measures of well-being.

More than half of the internal medicine residents, about 52 percent, reported some symptom of burnout. Nearly 46 percent complained of being emotionally exhausted, and 3 in 10 showed signs of cynicism, lack of empathy or callous feelings on the job.

The report also found that those with more than $200,000 in debt had test scores 5 percent lower than their debt-free peers. Today's medical school graduate leaves school with an average of $160,000 in student loans.

Limiting work hours

Medical leaders have known for years that young doctors are under stress, with previous reports focusing on individual hospitals and training centers. Those results helped spawn industry regulations in 2003 that now limit residents to an average of 80 hours a week averaged over a four-week period. New rules came into effect in July aimed at interns -- doctors in their first year of residency -- that limits them to 16 hours in a single shift.

The Mayo report indicates that reducing hours may not be sufficient or the best approach.

"You reduce the work hours, maybe fatigue gets better," West said. "But even after you've helped with that, we're still seeing these national numbers of high rates of burnout, high rates of quality of life concerns. What are we going to do on a national basis to address those issues? That's a dialogue that's really in its infancy."

Medical experts say there's a certain amount of stress medical residents need to experience to become good at making quick decisions in high-pressure situations, and to get as much hands-on training as possible.

But the combination of the debt load and the stress is affecting the number of students choosing to become family doctors. Specialty medicine offers bigger paychecks and fewer midnight calls at home than primary care doctors get.

"When you graduate from medical school with well into the six figures of debt, that is a motivating factor for what specialty of medicine residents and medical students go into," said Dr. David Hilden, who works with medical residents and students at HCMC.

Hilden points to his own experience. He was a primary care doctor for six years, but got out "largely because of burnout." Two years ago, he became a hospitalist, where he sees patients at HCMC.

"A family doctor might see 20 patients or more before lunch and the same after lunch," he said. "And that's only a fraction of the actual work involved. You'll spend an equal amount of time doing the charting and the billing and the follow up of lab results and the phone calls for that patient."

"You never feel caught up," he added. "The pressures of the clock are extreme."

Fulton said staff physicians and resident fellows can help residents deal with the pressure and try to anticipate signs of stress.

"People don't always get better," he said. "As a physician, it's hard to see that and walk through that with them. The more that happens, the more burned out you start to feel."

West said he hopes this research, which documents the problem on a nationwide scale, will turn the focus away from documenting the problem to looking for solutions. The end game is providing better medical care.

"There's a balance," West said "You've got to have the right stress with the right support so you promote the best growth for the trainee. We're not at that point right now."

Jackie Crosby • 612-673-7335