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.
“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.
(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.