Physician Well-being: A Critical Missing Link in Medical Education

Physician Well-being: A Critical Missing Link in Medical Education

By Edward M. Ellison, MD

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.

The convening began with a tour and dinner at the Association of American Medical Colleges (AAMC). 

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

Medical School Seeks To Make Training More Compassionate

After the SUICIDE of a 4th Year Medical Student, a Medical School is seeking to change its training culture

A New York City medical school has embarked on a soul-searching campaign of culture change after a 27-year-old student there jumped to her death last summer from her eighth-floor dorm residence.

“Rocked by waves of anguish, anger and frustration, guilt, fear and profound sadness,” the Icahn School of Medicine at Mount Sinai is trying to forge a kinder, gentler system of training, according to an essay by a dean at the school​in the New England Journal of Medicine.

The school is considering significantly expanding access to mental-health specialists, as well as changing aspects of its grading system. Another idea on the table: creating a hub for activities related to student health and well-being.

“Medical school is a cauldron,” says David Muller, the school’s dean for medical education, and the author of the essay that promises to improve conditions for Sinai’s doctors-in-training, both students and residents. The residents are at the front lines of care, Dr. Muller added in an interview, and “feel very often helpless and hopeless, the machine is intense and churns on relentlessly.”

One morning in August, the fourth-year medical student took her life on Mount Sinai’s campus on New York’s Upper East Side. Several months earlier, a medical resident, also female, committed suicide at the school’s West Side campus.

Jordyn Feingold, a first-year medical student, lived next door to the woman who committed suicide in August. Ms. Feingold had arrived at Sinai only 10 days before the tragedy and recalled how she and her peers were racked by “cognitive dissonance”—excited about starting training but distraught at the tragedy. “It was very weird,” she said.

Ms. Feingold, who is 24 and has a master’s in applied positive psychology, joined a task force Dr. Muller charged with figuring out how to improve Sinai’s academic culture and doctors’ well-being. “We are so focused on taking care of patients, to give quality care, but absent from our education is how we can take care of ourselves,” she said.

In 2014, two other young doctors-in-training at two different New York-area medical schools committed suicide. “We are all in the same very, very, scary boat,” Dr. Muller said.

The deaths underscore a broader problem, researchers say: That young doctors and medical students face grueling academic pressures and are experiencing high rates of burnout, depression and psychological strain.

But it isn’t because individuals drawn to medicine are necessarily more prone to angst. “We found at admission that the kids look fine,” says Liselotte Dyrbye, professor of medicine at Mayo Clinic in Rochester, Minn. “It is as if they go through our training process, and they develop worsening mental health.”

Dr. Dyrbye blames this on an “absurd” medical system: “It is the curriculum, it is the learning environment, it is the type of stuff you do as a [young] physician, and it is not unique to Mayo, it is not unique to Sinai.”

The Mayo researcher, who studies physician well-being, says in addition to mastering vast amounts of information, medical students and residents cope with “complex patient interactions, the suffering, the deaths.” Too often, “it is not a supportive environment—students are set up to compete with each other.”

Arthur Caplan, a bioethicist at the NYU School of Medicine, describes physician burnout as “a kind of epidemic” that can also hurt patients.

“There is trouble for patients in having a work force that is burned out,” he said in a video on the medical-information website Medscape, noting that these physicians may have “compassion fatigue” and could be prone to making medical errors.

It isn’t clear what drove Kathryn Stascavage—the student referred to as “Kathryn” in the New England Journal essay—to suicide, nor what role the pressures of medical school may have played.Through Dr. Muller’s office, the family declined to comment.

Even so, Prameet Singh, vice chair of psychiatry at Mount Sinai’s West Side campus, says the tragedy “gives us a chance to pause and look at what is the matter with our medical system—what do we do to contribute to the stresses and tribulations.”

Dr. Singh, along with about 30 faculty members, medical students, fellows and residents, took part in the task force, and proposed steps to remedy the academic culture. They were split into three areas—mental health, physician well-being and the learning environment.

Dr. Singh’s group, which focused on mental health, grappled with making it easier to consult a therapist. That meant both removing the stigma of psychiatric care, and arranging access to affordable practitioners, since many don’t accept insurance. One proposal calls for making more therapists in the institution available to students. Another idea: identifying 15 to 20 therapists willing to lower their fees for students. The school also would like to ask students to have regular mental-health checkups, with an “opt-out” possibility if they don’t wish to have them.

Jonathan Ripp, an internist on the faculty of the Icahn School who co-chaired the working group on well-being, believes young doctors and trainees are suffering because medicine has changed dramatically.

“There are a lot of new pressures and physicians are being scrutinized more than before,” Dr. Ripp says. An older generation “could spend most of the time looking at the patient and speaking with the patient,” whereas now, “you have 15 minutes to see someone.”

Dr. Ripp’s group suggests dedicating space on campus to a clearinghouse where young doctors and students could avail themselves of a “menu of well-being”—such as finding a psychiatrist or signing up for a mindfulness training session.

His group wants “protected dedicated time” built into the schedules of medical students and trainees, to allow them to take a break, meet with peers, and review stressful incidents such as the death of a patient. “Until now, it was expected you would deal with it,” Dr. Ripp said, “but it is not normal to experience a death and go about your business.”

Dr. Muller is most concerned about the academic culture: “I said to the group, we can have an army of psychiatrists, and have mindfulness and yoga every day, but if we don’t change the fundamental culture of academic medicine, all we will do is produce more burned-out people.”

Sinai tackled one source of angst—a high-stakes grading system marked by quotas for third- and fourth-year students that limited “honors,” a coveted distinction that helps an individual enter residency programs—to 25% of the class. After “honors,” the “high pass” distinction was limited to 25%, while the remaining half of the class would receive a “pass” grade. The system provoked intense rivalry among students, Ms. Feingold says.

The school has rejiggered the distribution to allow one-third of students to receive “honors,” one-third “high pass” and one-third “pass,” Dean Muller said, with an eye to creating a system that will drop the limits altogether.

Dr. Muller is hopeful the tragedy will accelerate change: “The same kind of compassion and humanism we are teaching them to show patients, they should be showing each other and we should be showing them.”

Source:     WSJ