A new case study by family medicine educators indicates that to create a more positive educational environment for residents and faculty, academic medicine has to change from a focus on the causes of physician burnout to a focus on physician wellness. In addition, educational programs need to create interventions for residents and faculty that encourage them to think about overall physician wellbeing.
According to the authors of "Changing the Conversation From Burnout to Wellness: Physician Well-being in Residency Training Programs(www.jgme.org)" in the December issue of the Journal of Graduate Medical Education, academic medicine must develop a shared definition of physician wellness, as well as interventional strategies. The benefits of achieving this culture change include a more positive educational environment for residents and faculty, more awareness of burnout and its symptoms, less stigma associated with admitting burnout, more prevention strategies and a more positive approach to understanding the effect of physician-patient relationships on physicians.
"The main thing about culture change is that first, people know it's OK to talk about burnout and wellness and personal balance," says co-author David Lick, M.D., residency director at the William Beaumont Hospital Family Medicine Residency Program in Troy, Mich. "For a long time in the medical field this was not a priority. It was a badge of honor to work long hours and sacrifice your personal life for medicine."
Co-author Jennifer Tucciarone, M.D., a faculty physician at the William Beaumont residency program agrees. She found that in her residency program, the culture changed when faculty members established their own wellness goals. Role modeling healthy behaviors and discussing wellness with residents are important to the cultural shift, she noted.
- Designate a faculty member who owns wellness and has time to champion it. Then enlist the help of the chief residents. These individuals can develop a plan based on the program's needs.
- Define wellness.
- Administer a burnout tool, such as the Maslach Burnout Inventory, twice a year to both faculty members and residents. Provide individual and group feedback.
- Schedule "difficult patient" panels twice a year to discuss as a group how to manage difficult situations and interactions.
- Schedule class meetings every other month with faculty mentors who model the human side of medicine.
- Assign wellness partners to faculty members and residents and set goals. Send quarterly reminders.
- Schedule a yearly retreat with team-building and self-awareness exercises.
- Assign office staff to encourage fun social events for the entire office.
- Take time to publicly celebrate accomplishments and hand out appreciation lists.
- Change the culture over time. Create an environment that does not focus on pathology.
According to the report, work-life conflicts start early in a physician's career. For example, the Accreditation Council on Graduate Medical Education, or ACGME, competency in professionalism guidelines state that residents must demonstrate a "responsiveness to patients' needs that supersedes self-interest."
Residents learn quickly that self-care is secondary, even though evidence suggests that physician burnout is related to medical errors, says the report. Thus, culture change must start in residency because this is a formative period when physicians develop patient relationships and work habits. It also is an ideal time for residents to learn techniques of self-care.
"There's a perception among residents that when you graduate from residency, life will get easier, but that's often not the case," says Lick. "We wanted to teach them that when you're done with residency, you'll have different types of stress, and you have to work on it now."
The William Beaumont Hospitals Troy Family Medicine Residency Program started changing its culture in 2003 when it hired a health psychologist with a special interest in physician well-being who helped develop a curriculum that made physician wellness a daily part of residency education.
The residency program started by defining wellness as "A dynamic and ongoing process involving self-awareness and healthy choices resulting in a successful, balanced lifestyle." In addition, faculty members started administering the Maslach Burnout Inventory, or MBI, which is the standard for measuring physician burnout, to the residents. The test measures the extent of residents' emotional exhaustion, depersonalization and diminished sense of personal accomplishment. Although the test is administered anonymously, residents -- individually and as a group -- discuss the results. Faculty members also discuss the results to determine causes.
"Residents appreciate that the faculty go to these lengths to make their well-being a priority," says the case study. "Some residents think that the MBI results restate the obvious -- that is, resident training and burnout go hand in hand. Others believe that feelings of burnout will vary depending on the rotation experience."
In addition, the residency sponsors an annual weekend retreat for residents, faculty and their family members. Other interventions have included lecture series on work-life balance and managing difficult patients, semimonthly meetings between residents and faculty member mentors, and end-of-the-year celebrations to boost residents' self-esteem.
The program also started a resident physician support group that emphasizes the joys of medicine. It features activities such as discussing current events and literary works, mentoring, reading, reflective writing, and sharing experiences. The program also drew up a list of confidential resources -- including local psychologists, psychiatrists, social workers and primary care physicians -- that could be accessed anonymously.
Faculty members also climbed onto the wellness bandwagon. They chose wellness partners, set wellness goals and checked in with their partners regularly. They designed a professionalism contract for themselves and the residents, and they even agreed to take the MBI anonymously twice a year and discuss the results.
According to Lick, the result was that residents discovered faculty members struggle with the same emotional demands due to caring for increasing numbers of patients and that work-life conflicts are pervasive throughout medicine.
Now, because of these interventions and prevention strategies, the culture of the residency program has shifted, says the report. Residents and faculty members openly discuss their feelings of burnout.
These discussions have been a particular source of support recently as the residency has undergone the construction of a new family medicine center, the implementation of a new electronic health record system, visits from the ACGME Residency Review Committee and the American Osteopathic Association, and the challenging economy in Michigan.
"Leadership support, a designated advocate, creative collaboration, patience and persistence are essential elements in changing to a wellness culture in medical education," says the report. "We need to begin talking about what wellness for physicians actually is rather than what it is not."