Physician
Well-being: A Critical Missing Link in Medical Education
At
the Southern California Permanente Medical Group (SCPMG), the physician-led
care delivery system that partners exclusively with Kaiser Foundation Health
Plan and Hospitals in Southern California, we are committed to helping solve
physician burnout and see this as a critical aspect of transforming health care
in America.
Practicing
medicine today is far more demanding and multifaceted than when I began my
practice in 1984 as a family physician at Kaiser Permanente.
Medicine
has made remarkable progress in technology and outcomes, but advances have come
with a price for physicians.
Doctors
are experiencing greater stress due to a myriad of causes: Long hours, loss of
autonomy, complex and often inefficient systems, and additional time-intensive
responsibilities such as maintaining electronic medical records, diagnostic
coding, regulatory compliance and administrative duties.
This
stress is compounded by personal attributes of self-sacrifice,
hyper-accountability, perfectionism, challenges with boundary setting, and
equating asking for help as weakness.
Altogether,
this too often leads to poor work-life integration and burnout for physicians.
In
their noble calling to take the best possible care of their patients, many
physicians put their own well-being at risk.
Physician Burnout on the Rise
Physician
burnout in the U.S. is rising at an alarming rate. A survey by the Mayo
Clinic revealed that from 2011 to 2014, physicians experiencing at least one
symptom of burnout rose from 46% to 54% – a much greater level than in other
professions. Of those surveyed, 39% experienced depression, increasing the
risk of suicide.
At
SCPMG, I have made physician wellness a key focus of our vision to help
transform health and health care in America.
I
began by asking our physicians how they viewed our culture of health. The
initial results were not encouraging.
This
led to my appointing a Physician Chief Wellness Officer. In four short
years,
Dr.
Dawn Clark has helped lead the creation of a robust physician wellness program
that provides support, knowledge and tools to help physicians better manage
their busy lives and embrace their own health and resilience.
Second
Victim Syndrome (the burden providers feel after an adverse patient outcome)
and peer-to-peer support groups have been formed and provide emotional support
to colleagues.
However,
this is just one part of the equation. Leaders in health care must take
ownership for the creation of a wellness culture that supports physician health
along with the design of efficient systems and workflows that maximize a
physician's unique contributions to patient care.
Bureaucracy
and inefficiency in care delivery systems must be addressed.
Some
of the systemic changes we’ve made since our program began include workflow
redesigns that off-load clerical work from physicians, help physicians manage
email volume through support staff, and train doctors on using our electronic
medical records system with greater ease and efficiency.
We
also have worked to increase availability of alternate and flexible schedules
to better meet the needs of physician work-life integration.
As
a result of this work, a recent survey of our physician colleagues indicates
significant improvements in how doctors view our wellness culture since the
initial survey three years ago. Physician ratings of key workplace
“culture of health” measures improved by a range of 11-23 percent. Although we
are making progress, there is more work to be done.
For Many, Burnout Begins in Medical
School
Part
of the solution to achieving greater physician wellness and resilience lies in
influencing the medical culture in America further upstream – in medical
school.
For
physicians, asking for help when we are stressed is counter to what we have
been taught, consciously or otherwise: That to be a good physician, we must be
superhuman, self-sacrificing care providers, able to work long hours while
putting our patients’ needs before our own.
A
study published in Academic Medicine in 2014 concluded that students entering
medical school have better mental health indicators than age-similar college
graduates in the general population.
However,
by graduation, the mental health, resilience, and optimism of medical students
have declined.
Anyone
who has attended medical school understands some of the contributing factors:
Long hours spent studying volumes of information; the unrealistic pressure to
be perfect; the emotional impact of dealing with death and dying; a fear to
admit that one may need help with mental health issues; inadequate boundary
setting; and feelings of isolation.
Recognizing
and addressing causes of burnout can potentially alleviate depression and
prevent suicide, not only in medical school but throughout one’s career.
To
do so will require providing students with emotional resilience tools that they
can use throughout medical school and beyond, making it safe to talk about
their struggles and ensuring that effective mental health resources are
available when needed.
A Different Kind of Medical School
Kaiser
Permanente is planning a national school of medicine in Pasadena, California
with a curriculum that will incorporate new ways of training doctors.
It
is our intention to establish a learning environment and curriculum that
supports, teaches and models well-being and resilience – skills and techniques
that students can employ throughout their careers as physicians.
Our
physician-led school will embrace a holistic approach not only toward
curriculum development and mentoring, but in helping students achieve
resilience and a healthy lifestyle in body, mind and spirit.
We
have designed the new facility to include space for socialization, a rooftop
meditation area, a yoga garden and a fitness center, so the school will be a
convenient place to practice what we teach.
A
demonstration kitchen on campus will be a place for students to learn about
nutrition, and how to prepare their own healthy meals.
The
curriculum will emphasize the importance of sleep and encourage students to
find a personal exercise regimen to promote fitness and reduce stress. They
will learn that it's okay to ask for help and be connected to mental health
resources.
Connecting
students to their purpose will also be key.
As
a school that reflects Kaiser Permanente’s values of diversity, inclusion,
health equity and community health, our students will be connected to the
meaning of what they do through aligned curriculum and experience, engaging
with patients and the communities we serve.
We
will teach students change management and how to work effectively within
systems of care -- to be both leader and effective team member -- so as
physicians they can be agents of change in improving the care delivery
systems in which they practice.
Most
importantly, our intent is to create a culture that declares that physician
wellness matters. In fact, physician wellness is essential if we are to
have healthy patients and an effective health care system in America.
Burnout
and poor physician wellness can negatively affect quality of care, patient
satisfaction, medical errors and malpractice risk, as well as turnover of staff
and early physician retirement.
We
need strong and resilient physicians to lead the needed transformation of
health and health care in our country.
Finding Solutions
This
past April, The Kaiser Permanente School of Medicine invited medical students,
medical educators and leaders from across the country to brainstorm about how
to shift the paradigm of medical education towards supporting and sustaining
greater levels of well-being and resilience for students.
Several
members of the AAMC attended and participated in the conference, including the
president and CEO of the AAMC, Darrell G. Kirch, MD.
I
was honored to give the keynote address and participate in the ensuing
discussions. I began my talk by asking the audience a somber question: “How
many of you were aware of a fellow student committing suicide in medical
school?” Sadly, about half the room, including me, raised our hands.
The
mood became more optimistic throughout our conference as we brainstormed a list
of root causes and declared a commitment to find solutions for mitigating
burnout in medical school and beyond.
We
ended the day with a sense of hope and renewed purpose, and yet we were aware
that this is just the beginning.
I
invite all who see themselves as stakeholders in creating both the culture and
structure that fosters greater physician resilience and well-being to join our
continuing conversation to solve for physician burnout in our country.
Dr.
Ed Ellison believes Permanente Medicine and Kaiser Permanente’s coordinated,
integrated model of high-quality, affordable care provides an answer to health,
health care and physician wellness in America. In his effort to achieve
wellness, Dr. Ellison enjoys time with family, favors a plant-based diet, tries
to get enough sleep, and always takes the stairs.
Source: Linkedin
