A Wellness Framework, Part 2

A Wellness Framework (Part 2)

In 2009, Levy (3) described that resident physicians had many sources of stress (as any physician can attest to), but that many resident stressors are considered to be part of the job. For the most part, at least historically, we have just accepted them. The Resident Service Committee of the Association of Program Directors in Internal Medicine (APDIM) divided these into three categories including: professional (patient responsibility, supervision of junior learners, difficult clinical situations), situational (long hours, sleep deprivation, clerical responsibilities), and personal (financial, family, isolation). (4) In 1981, Dr Small described what he termed as “house-officer stress syndrome”.  Almost all residents experience four of the seven attributes of this syndrome, episodic cognitive impairment, anger, cynicism, and family discord. The other three are more problematic and may suggest further resident impairment.  These include depression, suicidal ideation, and substance abuse. (5)

Harassment can be a cause of resident stress. Historically, there was a high tolerance for harassment in medical training. In fact, one of my favorite stories is of a senior surgical resident whose favorite saying was “stupid, medical students.”  We didn’t even think twice about it.  A talk I attended at AMEE 2018, looked at the prevalence of bullying and harassment in Radiology residents. They found that more than 50% percent of the trainees had experienced harassment but only a small percent were willing to report the harassment. 

Burnout is another risk factor for resident physicians.  A study of Internal Medicine residents found that by the end of the first year of residency, more than 50 percent of residents met the criteria for burnout (emotional exhaustion and depersonalization). (6) A cross specialty study by Martini and colleagues, found that burnout varied by specialty during residency. (7) The overall burnout rate was 50% and ranged from 27% to 75% among different specialties. The variation among specialties was not statistically significant.

Depression and suicidal ideation are another area. It is not clear if the suicide rate for resident physicians is higher than the general population, but studies suggest that it is higher for physicians overall. The ACGME is concerned. (8) Part of the impetus for the ACGME focus on Well-being is tied to the deaths of residents and physicians due to suicide. There is also this concern that the lack of Well-being in residency carries on into a physician’s career. I experienced this in my own professional career when my boss, the CEO of our hospital system, killed himself unexpectedly in 2016. A systematic review of 14 international studies of suicide in physicians, in articles published from 1963 to 1991, found higher rates of suicide in physicians compared with the general population The higher risk was from 1.1 to 3.4 in male physicians and from 2.5 to 5.7 in female physicians. (9)  A cohort study from 1979 to 1995 in  England and Wales found elevated suicide rates in female physicians. (10)

Fortunately, there are some things that help but more research is needed to determine best practices and interventions. Universal opt-out programs seem to help. Basically, all residents need to be set up to meet with your wellness counselling center at the beginning of residency. This seems to make them more comfortable in reaching out to the counselors when they need assistance. (11)  Making residents comfortable with the concept of seeking out mental health services is an integral part of ensuring wellness. Small groups, such as the Balint groups that are common in Family Medicine programs, seem to be helpful, and not just as “bitch” sessions. But more broadly as a way to discuss difficulties that residents at different levels are experiencing.

So, what did we do in our institution? We started with the Core Values of our institution. These values were coalesced during a year-long process that included representation from all of our employees, from housekeepers to vice presidents, from nurses and physicians, from volunteers to our board members.  It was an inclusive process.  We believe that our core values define the ethos of our institution. Therefore, it makes sense that these values should inform the wellness program for our residency training programs. Our Core Values are: Respectful Compassion, Responsible Stewardship, Deep Interdependence, Passion for Excellence. 

We have tried to hardwire these into the operations of our GME office. We hired a Director of Resident Wellness. We created a GME / Resident Wellness committee. We engaged with our organizational EAP program. We looked for Institutional and Physician Champions. And at the leadership level, I have tried to keep this front of mind. So far, while there have been barriers, we are trying to keep pushing forward. Not everyone thinks that this is important, but there has been some recognition by physicians. The Medical Staff Executive Committee even hosted a speaker to discuss burnout. But in a world that is ruled by RVU generation, there is still resistance to the concept of physicians working less hard or focusing on wellness or anything outside of medicine. There is still the belief that residents already have it easy and they should not complain. The argument often goes, “I worked hard in residency and look how great I am”, so the residents should work just as hard in their training programs. 

Clearly, there is still a lot of work to do…   

  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.

3. Levey RE. Sources of Stress for Residents. Acad Med.  2001;76(2): 142-150.

4. Stress and impairment during residency training: strategies for reduction, identification, and management. Ann Intern Med  1988;109:154–61

5. Small GW. House officer stress syndrome. Psychosomatics. 1981;22:860–9.

6. Rosen IM, Gimotty PA, Shea JA, et al. Evolution of sleep quantity, sleep

deprivation, mood disturbances, empathy and burnout among interns. Acad Med. 2006;81(1):82–85.

7. Martini S, Arfken CL, Churchill A, et al. Burnout comparison among residents in different medical specialties. 2004; 28(3):240–242.

8. Nasca T.  President’s Address. 2018 ACGME Annual Educational Conference. Orlando, Florida. 

9. Lindeman S, et al. A systematic review on gender-specific suicide mortality in medical doctors. Br J Psychiatry. 1996;168:274-279.

10. Hawton K, et al. Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J Epidemiol Community Health. 2001;55:296-300.

11. Batra M, et al. Improving Resident Use of Mental Health Resources: It's Time for an Opt-Out Strategy to Address Physician Burnout and Depression 2018; 10 (1): 67–69.