A Wellness Framework (Part 1)

A Wellness Framework (Part 1)

I was so excited to spend this week in Basel, Switzerland  attending the AMEE 2018 medical education conference. I was asked to give a podium lecture titled, “Creating a Wellness Program for Postgraduate Medical Education in a newly accredited Medical Center.”  My co-presenters were Donna Brown, MSEd (Institutional Coordinator), James Kruer, MD (Internal Medicine Program Director), and Charles Richart, MD (Surgery Program Director). 

In this presentation, we described the process that we are undergoing to create a new wellness program for residents at Northeast Georgia Medical Center. We are a completely new sponsoring institution, accredited by the ACGME in 2017.  As we started building the infrastructure for our new residency programs (Internal Medicine, General Surgery, Family Medicine, Emergency Medicine, Obstetrics & Gynecology, Psychiatry, and a Transitional Year), it was my feeling that we had the opportunity to do something new. In all of my previous academic institutions, we were saddled with legacy commitments and structure, but as a new institution which has never previously had residency programs or residents we could design the system from the ground up.

As we started to think about wellness, I had to ask if we had a definition of wellness. We started out with burnout—a common starting point. Burnout has been defined as a state of emotional exhaustion, depersonalization, and decreased feelings of personal accomplishment.(1)  But is wellness the absence of burnout?  This feels inadequate, a bit like defining health as the absence of disease or joy as the absence of sadness.  So, we looked through the literature and found this definition for wellness.

Wellness….

“Is a dynamic and ongoing process involving self-awareness and healthy choices that results in a successful, balanced lifestyle”

“incorporates balance between physical, emotional, intellectual, social, and spiritual realms”

            “results in a sense of accomplishment, satisfaction, and belonging” (2)

But there is an inherent conflict. The work of a physician puts enormous stress and strain on us.  Many medical schools ask students to shadow a physician for a period of time, so that they know and understand what the physician lifestyle is like.  Any time you get a group of physicians together, someone will complain about missing one of their kids’ activities. Maybe a soccer game or a choir conference. Or maybe they are unable to attend a family member’s wedding. These don’t seem like well choices, but they are made all the time.

 

And the ACGME tells us we have to teach about this inherent conflict. The ACGME Common Program Requirements [CPR IV.A.5.e)(2)] say that in order to demonstrate Professionalism, residents are expected to show: “responsiveness to patient needs that supersedes self-interest”. The Professional identity, that is taught to medical students and then to residents includes self-sacrifice. This has led to many unintended consequences.

Our abbreviated literature review includes sections on stress, harassment, burnout, depression, suicide, and some useful interventions. 

In Part 2, I will start with stress.

References

(1) Maslach C, Jackson SW, Leiter MP. Maslach Burnout Inventory. 3rd ed. Mountainview, CA: Consulting Psychologists Press; 1996.

(2) Eckleberry-Hunt J, et al Changing the Conversation From Burnout to Wellness: Physician Wellbeing in Residency Training Programs. J GME  2009; 26(1): 225-230.

I recently saw this really interesting article (1) in Medical Teacher, the official journal of AMEE.  The authors, Renee A. Scheepers and colleagues from the Center for Evidence Based Education at the University of Amsterdam, asked a great question: which personality traits affect a supervising physician’s doctor role and teacher role engagement? They were also trying to determine if engagement in work would have an affect on the association between teaching performance and a faculty member’s personality.  Of secondary importance to this study, but arguably as important overall as the engagement question was the idea that engaged physicians may experience less burnout.

The authors started out with the Five Factor model of personality traits (2) which has five separate domains, including conscientiousness, agreeableness, extraversion, emotional stability, and openness. Prior work had identified that conscientiousness is associated with engagement and dedication to work and may lead to improvement in teaching engagement. (3) 

As physician burnout continues to make headlines in the US, there has been precious little progress in helping the physician community to adequately respond.  Physician suicide is disproportionately higher than the general population. (4) Gonzalez-Roma and colleagues (5), noted that work engagement is the opposite of burnout, it’s a positive and active state of mind. Feedback, particularly on your performance as a teacher, may stimulate engagement, and interestingly be protective against burnout. 

This study took place in 61 residency programs that were located in 18 different hospitals (2 academic, 16 community) in the Netherlands. The authors invited 815 resident physicians to participate.  By the end of the study period, 67% of the residents completed evaluations on 805 / 819 supervising physicians. 78 percent of the supervising physicians self-reported personality traits using the BFI-10 (Big Five Inventory). The authors used the validated Utrecht Work Engagement Scale (UWES-9) to measure overall work engagement, but the measure also was able to separate engagement in their role as a physician from their role as a teacher.

The authors found that conscientiousness, extraversion, and emotional stability were all positively associated being engaged as a physician, while conscientiousness, extraversion, and agreeableness were associated with engagement as a teacher. They didn’t find any direct association between personality traits and teaching performance as evaluated by the residents. It seems that the physicians’ engagement explained more of the residents’ positive evaluations than any individual personality characteristic. But since having the characteristics of extraversion, agreeableness, and conscientiousness led to more engagement as a teacher, the residents liked their teaching style better.

So, some of this is a no-brainer! If you are more engaged, the residents will see you in a more positive light as a teacher. When students identify their best teachers, they often mention things like passion and excitement for the topic. That would also fit in the extraversion model.  Agreeableness may be a proxy measure of the atmosphere of a safe, non-toxic teaching environment that is promoted by great teachers.

The authors also made the observation that conscientiousness, while seen as a positive teaching characteristic may lead to increased stress on the physician work side of the equation because it also includes goal-directed and achievement-oriented behaviors. This can lead to overly high standards and higher stress levels in physicians. 

The bottom line is that engaged teachers receive better evaluations from residents for their teaching performance than do engaged physicians. Unfortunately, supervising physicians were more engaged in the physician work than they were for their teaching work. We need to work to identify ways to help supervising physicians build engagement with their teaching role, while continuing to support and build engagement in their physician role.

References
1. Scheepers RA, Araha OA, Heinemana MJ, Lombarts KM.  How personality traits affect clinician-supervisors’ work engagement and subsequently their teaching performance in residency training.  Medical Teacher  2016; 38 (11): 1105–1111.
2. McCrae RR, Costa PT. Validation of the five-factor model of personality across instruments and observers. J Pers Soc Psychol. 1987; 52: 81.
3. Akhtar R, et al. The engageable personality: personality and trait as predictors of work engagement. Pers Individ Differ 2015; 73: 44–49.
4. Schernhammer ES, Colditz GA. Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis). Am J of Psychiatry  2004; 161(12): 2295-2302.
5. Gonzalez-Roma V, et al.  Burnout and work engagement: independent factors or opposite poles? J Vocat Behav 2006; 68: 165–174.