As I take stock at the slightly-over-midway point through my medical internship, I can’t shake an unspoken but disturbing irony: medical training is often antithetical to health itself. Like the time I was discussing the logic of a salt-restrictive diet for a patient in heart failure, and my beeper announced the pizza had arrived at a noon conference. Or that morning when the attending brought donuts and pastries for breakfast during a lecture on insulin dosing for diabetic patients. And daily, as I encourage patients to get adequate rest for optimal healing, I suppress my own yawns and yearn for my own bed. Practicing my own basic self-care requires near-herculean effort against antiquated institutional policies and noxious cultural norms. No wonder many residents nationwide register signs of burnout.
Today, at any given time, more than half of physicians experience burnout, characterized by decreased enthusiasm for work, cynicism, depersonalization, and a low sense of personal accomplishment and professional satisfaction. The seeds of burnout are often sown during residency. One third of all residents suffer from depression or depressive symptoms. Nearly 1 in 10 residents and medical students have active suicidal thoughts. Ignoring this epidemic would be malpractice, both for physicians and the patients we serve.
Thankfully, the governing bodies of graduate medical education are bringing the issue to light and searching for solutions. The Accreditation Council for Graduate Medical Education held its first Symposium on Physician Well-Being in 2015 and is hosting follow-up webinars to involve key players in the discussion. The ACGME, in partnership with Mayo Clinic and the American Foundation for Suicide Prevention, recently launched a library of educational resources for training programs to use when responding to a resident suicide or developing resident well-being plans. The American Medical Association endorses an expansion of health care’s Triple Aim — lower cost, enhanced quality, and increased access — to a Quadruple Aim that includes professional satisfaction. AMA’s STEPS Forward program offers a series of online modules educating physicians on best practices to streamline clinical workflow, reduce administrative burdens, and boost efficiency. As AMA President Steven Stack, MD, recognizes, “A healthier, happier nation is going to require a healthier, happier physician workforce.”
The Problem with the Current Prescription
These are laudable first steps. But the approach is problematic. First, consider pure practicality — the hope that busy clinicians, already spinning in a revolving door between patients and documentation, will take their free time to sit by themselves, watch modules, and then revamp their clinic’s workflow, seems like a reach. Second, delivery — we already spend our days isolated behind a computer screen, and we know how difficult it is to motivate behavior change through educational resources alone, yet this is what we self-prescribe. Third, resource allocation — precious hours are being expended to “medicalize,” research, debate, and over-describe burnout rather than experimenting to innovate solutions. And most importantly, the message and action plan itself — that to avoid burnout, the solution is for individual clinicians to practice self-defense against increasingly untenable clinical demands.
Burnout is a symptom of a systemic disease. The medical profession is attempting to address burnout with symptomatic management and treatment of the individual, similar to how our health care system approaches illness. The current prescription is resiliency training, which teaches physicians the ability to survive the long and grueling training process, to be adaptable and flexible to the stresses of work, and to remain compassionate caregivers in the face of adversity. This is akin to giving metformin to a diabetic who lives in a food desert, or an antidepressant to a victim of domestic violence. It is necessary, but by no means sufficient.
Instead, a public health approach is needed to prevent burnout during medical training through inspired messaging, institutional reform, and ultimately, cultural evolution.
Performance Training for Physicians
Rather than resiliency training, how about performance training? In addition to training to be competent clinicians, we must train in order to maintain that high performance — both for ourselves and for our patients. Meeting our high professional standards day in and day out requires systematic and intentional training. Whereas stress management is defensive and reactive, performance is offensive and preemptive. Depression screenings and mental health resources help with coping, whereas performance training optimizes for thriving. A campaign against burnout combats disease, whereas a campaign for performance promotes vitality. Self-care sounds soft, whereas performance is hardcore. Performance is immediate and tangible, whereas wellness is delayed gratification — a notoriously hard sell. Mindset is important; building a new skill set in personal performance to enhance both self- and patient care generates an internal locus of control, which drives motivation and action.
Given that medical culture is learned and perpetuated during training, performance efforts should be focused on medical students and residents. During medical school, part of the curriculum should be devoted to learning and practicing the fundamentals of human performance — sleep, physical activity, nutrition, mindful awareness, energy management, and self-compassion.
It is no surprise that these are also the tenets of what is termed “lifestyle” or “preventive” medicine. In addition to clinical mentors, trainees should have access to personal trainers, dieticians, sports psychologists, and psychotherapists to develop a personal performance plan. Physicians, just like business executives and Olympic athletes, need coaches, drills, and routines to stay at the top of their game. Peer groups in which to troubleshoot, process emotions, and practice leadership skills should be woven throughout medical education to provide social support and accountability. For example, in the Mind Body Medicine Program at Georgetown University School of Medicine, medical students experiment with techniques like meditation, guided imagery, and biofeedback to enhance self-awareness and stress management. And through The Balance in Life Program at Stanford Medicine, surgical residents receive leadership training and practice team dynamics with a clinical psychologist. Such innovative programs could help pioneer the path forward. Indeed, common sense and research affirm that doctors who practice healthy behaviors provide better counseling and motivate their patients to adopt such health advice.
As medical trainees are encouraged to train for peak performance, so must the medical training environment be concurrently redesigned to support such behaviors. A starting point is to consider a few simple fixes. Most residents spend 12-plus hours each day jam-packed into windowless rooms lined with computers and littered with stale food. Now that nearly all of our work is done on the computer, team rooms could be built with space to stretch, standing desks, and natural lighting. If we are expected to work nights and weekends, what if we had affordable and energizing food options? Pizza, pastries, and bagels — the standard fare — satisfy our sleep-deprived carb cravings while slowing us mentally and physically. Instead, provide a refrigerator explicitly for resident use in a designated break room.
What’s more, every few weeks, we are uprooted and transitioned onto different services, with different teams, in different recesses of the hospital. This transience is unsettling. If we are indeed “residents” of the hospital, we should have a home base for relaxation, gathering, and laughter. Community and belonging are essential human needs. As the nature of our work evolves, professional and personal commitments are no longer mutually exclusive. Our workplace must reflect this.
For years, physicians and physicians-in-training have operated under the belief that our obligation to patients comes at any cost, even when this cost is our own health. Martyrdom is a prideful part of our identity. However, as patients become empowered consumers of health care, they question the doctor who does not walk the talk. “Do as I say, not as I do” is no longer a valid prescription. When empowered and supported to take care of ourselves as whole people, we are more willing to treat our patients in kind.