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Author: Arlene Chung, MD MACM FAAEM
Originally published: Common Sense May/June 2019
My nightmare is waking up to a phone call in the middle of the night with a frantic chief resident telling me that one of our residents is dead.
We shouldn’t be teaching our doctors how to be well. Teaching the individual resident or physician is the easy way out, and as an educator, I do not say that lightly. Culture change is harder, but critical to protecting the wellness of our residents and physicians. Individual wellness education has a place, but increasingly our focus needs to be turned outward toward the places where we can make the greatest impact for both the individual and the system. We must be proactive, not reactive. Once a resident or physician is dead, no amount of after-the-fact education or policy change will bring her back.
I am a lifelong educator and advocate for physician wellness. But I no longer believe that any amount of classroom teaching about mindfulness or resilience will make my residents “more well.” I have watched the number of wellness lectures given to our residents rise, but our burnout rates have yet to fall. I have been part of a residency program that provides excellent food, retreats, and a robust wellness committee, yet I still receive texts from residents who feel overwhelming anxiety, shame, and sadness. With the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements now mandating residency programs to provide greater emphasis on resident and faculty well-being1, I worry that many institutions across the country will expend valuable time, money, and resources toward educational interventions that do not work.[1]
Teaching residents and physicians about wellness presumes the underlying assumption that un-wellness is due to a lack of knowledge. It assumes that individuals eat poorly, drink too much coffee, and suppress their feelings because they don’t know any better. Traditional wellness topics have focused heavily on physical interventions, such as healthy weight loss, smoking cessation, and nutrition. Although we now understand wellness to be a much broader concept, this also makes it a more nebulous topic. Knowledge is not sufficient for behavioral change and certainly not enough for cultural change. My resident may know that exercise is good for her, but that fact alone is not going to be enough to get her to the gym regularly.
I argue that teaching residents and physicians about wellness rarely makes an impact by giving them NEW knowledge. Instead, carving out the time and space for a wellness activity demonstrates to them indirectly that wellness is valued by the leaders in the residency program, department, or institution. It is the value demonstrated by their teachers, not knowledge that makes the impact. It is not difficult to convince the residents on our wellness committee to attend a lecture on resilience. The challenge lies in transferring that value to the residents and faculty who don’t grasp the necessity of training for wellness, until they find them-selves “unwell.” In the eyes of many, wellness does not have the same value as reimbursement, multi-center research trials, or cutting-edge patent technology. It is often perceived as a “soft skill” and a less essential one. Sadly, physician wellness only seems to receive mainstream attention once doctors start dying. We may understand cognitively that wellness is important, but it is not until we feel it emotionally that we begin to take action. I do believe that we have at least succeeded in creating a sense of urgency, however, due in large part to the efforts of Dr. Tait Shanafelt and colleagues, who have published extensive research on the prevalence of physician burnout, and Dr. Pamela Wible, who brought physician suicide to the public eye.[2,3]
A hierarchy exists for wellness interventions. At the most basic level, we can teach knowledge, which may change the values of individual residents and inspire them to engage in self-care. We can teach skills, such as critical incident stress debriefing or peer-to-peer counseling, which will allow physicians to go on to help others. We can create a local support network by engaging our colleagues in shared experiences. We can enact policies at the institutional level that encourage maternity and paternity leave, protect against workplace violence, and promote opt-out programs for mental health services. We can work with national accrediting bodies, such as the ACGME, to develop standards for physician wellness. Finally, we can lobby at the level of the federal government to change how health care organizations are reimbursed, in order to reward hospitals, clinics, and physician groups that demonstrate low turnover and other potential quality markers of wellness. Assuredly, interventions at the highest level have the greatest impact and that is where we should ultimately be directing our efforts.
I can hear you ask, “But if we focus solely on large scale interventions, won’t some residents and physicians become lost in the shuffle? Surely some would benefit from knowing more about sleep hygiene or mindfulness-based stress reduction?” The answer is, yes, of course. I am not arguing for complete elimination of classroom wellness teaching. But there is a danger to focusing too much on individual interventions that assume that burnout or alcoholism or mental illness is the fault of the individual.
Large scale change can be leveraged to the tremendous benefit of the individual. For example, shift work scheduling policies can have a much greater impact on a physician’s sleep habits than trying to teach him to reduce his daily coffee consumption. Also, large scale interventions often result in ways to improve our health care environments such that we can find joy in medicine again — for example, by reducing the burden of electronic charting to allow for more time to engage in meaningful conversations with patients and families.Thankfully, I have never been woken up in the middle of the night by a phone call from a frantic resident bearing terrible news. And I have hope in my heart that, if we all work together with the right focus and dedication, it will stay that way for a long time.
References:
1. ACGME Common Program Requirements. Accreditation Council for Graduate Medical Education, 2017. (Accessed November 6, 2017 at https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf)
2. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-85.
3. Wible P. Physician Suicide Letters, Answered. Eugene, Oregon: Library of Congress; 2016.