My nightmare is waking up to a phone call in the middle of the night with a frantic chief resident on the other end of the line telling me that one of our residents is dead.
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 help my residents to become “more well.” Over the years, 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 free food, twice annual retreats, and a robust wellness committee, but I still receive texts from residents who at times feel overwhelming anxiety, shame, and sadness. With the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements now mandating residency programs to provider greater emphasis on resident and faculty well-being, I worry that many institutions across the country will expend valuable time, money, and resources toward educational interventions that ultimately do not work.
Teaching residents and physicians about wellness requires 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 to teach effectively. While introducing physicians to the idea of mindfulness may be novel the first time, by the second or third time they’ve encountered the concept at a staff meeting, national conference, or on social media, they’ve stopped paying attention. Furthermore, 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, let alone convince her fellow residents to join her.
I would argue that teaching residents and physicians about wellness rarely makes a direct 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 value, not knowledge, that makes the impact. Almost by definition, engaged learners already value the material being taught. 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 do not perceive any use for wellness at all. 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 one that can be deferred until more pressing issues are addressed first. 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.
However, I do believe that we have at least succeeded in creating a sense urgency, 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. However, while urgency is necessary, it alone is not sufficient to inspire change. In order to make the greatest impact on our crisis of burnout, suicide, and unwellness, we must stop trying to spend so much of our precious resources on simply teaching knowledge.
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 healthcare 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 I strongly believe that we should be directing our efforts toward large scale change. Not teaching individual wellness strategies.
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 learning skills such as mindfulness-based stress reduction?” The answer is, of course. I am not arguing for complete elimination of traditional classroom wellness teaching. However, I do believe that there is a danger to focusing too much on individual interventions because they inherently assume that burnout or alcoholism or mental illness is the fault of the individual. Furthermore, large scale change can be leveraged to the tremendous benefit of the individual, which is particularly important for those residents and physicians who may be resistant to learning. 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 instead of looking for creative ways to escape it during our time off–for example, by reducing the burden of electronic charting to allow for more time to engage in meaningful conversations with patients and families.
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 much more critical to protecting the wellness of our residents and physicians. There is still a place for individual wellness education, 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. Creating a sense of urgency is the first step toward large scale cultural change, but 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.
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.
Watch Dr. Chung’s FIX18 talk below!
- ACGME Common Program Requirements. Accreditation Council for Graduate Medical Education, 2017. Accessed November 6, 2017.
- 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.
- Wible P. Physician Suicide Letters, Answered. Eugene, Oregon: Library of Congress; 2016.
Superb article that elucidates the central fallacy in most anti-burnout strategies involving not only residents but practicing physicians, which fallacy could also be encapsulated as: “Do as I say, not as I do.” The culture of medicine must be changed to one in which physician wellness is CENTRAL to our healing mission, not peripheral. See, e.g. my webinar for NorCal on same at http://bit.ly/NorcalWRC. And incidentally, giving so called state “physician health programs” access to our residents is a recipe for disaster. They are representing themselves as a viable solution to burnout, and may convince gullible residents to self refer… Read more »
I agree with the central premise completely, but I also think e can go further and call out the culture of medicine is a business and we must extract as much production as we can. We’re letting non-physicians (or physicians who no longer work on the ground) decide things like what the appropriate number patients to see her hour or per shift is and other similar metrics, and sometimes those metrics include patient care and quality but only in a very broad sense where it loses the importance nuance and challenges in a particular patient population. Wellness can involve individual… Read more »