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The Role of Medical Culture in the Journey to Resilience

Beckman, Howard MD

doi: 10.1097/ACM.0000000000000711
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There is growing concern about the difficulty primary care practices are experiencing both recruiting and retaining practitioners. Frustrations stemming from integrating electronic medical records, satisfying external documentation requirements for oversight and billing, and the divide created between inpatient and ambulatory care teams all contribute to practitioner and staff burnout. Addressing the current culture of medical education and primary care is clearly an essential issue for health care leaders and medical educators.

Using two experiences, a workshop on resilience with a large primary care practice group and a medical student studying for the United States Medical Licensing Examination Step 1, the author describes the cultural imperative, beginning in medical school, to sacrifice self-care for productivity and individual achievement. This approach has consequences for practitioners’ levels of burnout and selecting primary care as a career. The author concludes by providing recommendations for both individual and organizational approaches to addressing these concerns.

H. Beckman is clinical professor of medicine, family medicine, and public health sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, and chief medical officer, Focused Medical Analytics, Pittsford, New York.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Howard Beckman, Focused Medical Analytics, 125 Sully’s Trail, Suite 8, Pittsford, NY 14534; telephone: (585) 381-5488; e-mail: hbeckman@fma-us.com.

There is growing concern about the difficulty primary care practices are experiencing both recruiting and retaining practitioners.1 Frustrations stemming from integrating electronic medical records (EMRs),2 satisfying external documentation requirements for oversight and billing,3 and the divide created between inpatient and ambulatory care teams4 all contribute to burnout among primary care practitioners. How we address job stress in primary care is clearly an essential issue for health care leaders and medical educators. An initial step to understanding the problem should be examining our current culture of medicine and the environments in which our trainees and their role models work and function day to day.

I recently returned from Boston where I led a discussion on resilience for primary care practitioners. The participants—physicians, physician assistants, and nurses from a large medical group—and I talked about the importance of self-care to successfully manage today’s workload. All agreed that getting through the workday has become increasingly stressful because of the demand for higher productivity, the request to create and trust care teams, the new focus on shared accountability between specialists and generalists, and the transition to EMRs.

At that session, we brainstormed what each individual could do to manage these stressors. Examples included practicing mindfulness, meditation, or yoga; listening to music before and after patient care; exercising regularly; and stopping midday to eat lunch or share personal or professional stories. I was impressed by these practitioners’ determination to create restorative time within their busy days.

Although participants articulated the value and methods of self-care, they stressed the workplace’s critical role in actively supporting these behaviors. If we are asking providers and staff to listen carefully to patients and respond to their needs, do the providers and staff not deserve the same from their practice administrators and health system leaders? If we are feeling harried and emotionally drained, what are the chances that we will have the energy or carve out the time to create treatment plans that incorporate patients’ goals and opinions into the planning process, and monitor progress toward those goals over time?

Although examples of system-wide promotion of practitioner self-care are limited, some of my colleagues at the University of Rochester developed and implemented a mindfulness training program for primary care physicians. The program resulted in significant reductions in levels of burnout, anxiety, and depression among participants.5 A year after the training was completed, I worked with colleagues to conduct interviews with a convenience sample of 20 of the 46 primary care physician participants, focusing on what they found most helpful about the program.6 The practitioners reported that peer conversations centered on the experience of doctoring, as well as integrating mindfulness skills into daily practice life, were most helpful. However, we were surprised to learn that many practitioners reported feeling guilty carving out the time to participate in the mindfulness training program, even though their families supported their participation.

Physicians, it seems, have become quite skilled at sacrificing personal and family time in service to patients and the increasing demands of practice. This is especially true of primary care physicians. They are rewarded by their organizations for forgoing relaxation or reflection (i.e., self-care) in favor of increasing their monthly RVUs. This can play out in ways such as working through lunch or completing charts at home during evenings and weekends.

The irony becomes that, as health care practitioners, we counsel our patients to dedicate time and energy to make the behavioral changes needed to improve their health and well-being, yet we find ourselves unable to make these changes in our own lives. How did we learn to push ourselves so much or to ignore self-care to the point that many of us are experiencing the symptoms of burnout, anxiety, and depression that we try so hard to prevent among our patients?

I returned from Boston to discover what, I believe, is part of the answer. My daughter, completing her second year of medical school, had come home to study for Step 1 of the United States Medical Licensing Examination. Of our four children, she is by far the most even tempered and buoyant under pressure: She exercises, she laughs, she reads, she cooks. By nature, she has strong self-care skills and she had used them successfully while she was in college, while working at a high-powered medical think tank, while preparing for medical school, and while managing the demands of the first two years.

But on my return home, I observed how my daughter’s confidence and habits were changing under the pressure of the upcoming exam. Given a warning that performance on Step 1 is a significant contributor to securing competitive residencies, she was advised to use the six-week hiatus between years 2 and 3 of medical school to study 9 to 10 hours a day for the exam. Not wanting to limit her options, she took the advice to heart, taking only a few isolated days off but adding more study hours onto other days.

As the weeks passed, I observed the consequences of pursuing excellence at the expense of self-care. Her confidence was challenged; her enthusiasm for learning medicine drained; she felt overwhelmed that she would not master the material; she stopped exercising and she lost weight. I was shocked, especially because the result of her approach mirrored the experience of the physicians with whom I had just worked in Boston. Worse, her test preparation directly preceded the beginning of her third year of medical school, a critical time to begin experiencing clinical medicine and bond to the profession. From my perspective, beginning the third year drained of enthusiasm and energy seemed a tragedy.

When I saw how worn down she was becoming, I suggested that a residency basing recruitment decisions primarily on test scores was not a program she should choose. As a former program director and chief of medicine, I never noted any meaningful correlation between test scores and physician success in practice. But she soldiered on with increasingly longer study days. To her, the culture demanded a level of commitment that required unhealthy inattention to self-care.

This perplexing situation brought me back to the experiences of my Boston colleagues, and ultimately to my own behavior. I realized that the pressure to sublimate one’s needs to accomplish professional goals was something that I had modeled over many years. I have skipped many meals, passed on countless opportunities to unwind, and slept less because of my commitment to “professionalism.” A commitment to serve our patients is certainly a central component of the job—and I have loved this job—but we have to avoid romanticizing an unhealthy level of giving and develop more successful approaches to delivering effective patient-centered care. Perhaps if I had more successfully integrated self-care, I would not have needed that stent placed in my right coronary artery when I was 52 years old.

I consulted with colleagues to find out if my daughter’s experience was unusual and found that, to the contrary, being a resident or fellow is associated with increased burnout, and being a medical student with increased depressive symptoms.7 Fortunately, within minutes of walking out of the Step 1 exam, my daughter returned to her usual self. She scored well on the exam and is relishing her third-year rotations. She calls me frequently to share her clinical cases and to express how thrilled she is to be experiencing and learning so much.

There is a power our medical culture exerts on us all. We complain about the need for more productivity from team members, but we prepare our students for their first clinical year by exhausting and traumatizing them. How early do we create the contradiction between what we recommend to patients and how we care for ourselves? Do we really want to promote unhealthy and unrealistic competition as the primary motivation to excel at doctoring? In the medical home movement, we talk about creating effective teams in order to best treat patients. How do we successfully build that caring culture into medical education as well as into our primary care practices?

List 1 provides a few recommendations about what medical schools, primary care practices, and the medical community could do to positively influence the culture of medicine. Some will disagree, believing that diverting valuable time away from “productive professional activities” is soft, unprofessional, a luxury, or even a waste. But in my 40 years of practicing and teaching, I have witnessed nothing as motivating to trainees and practitioners as sharing the joy of helping diagnose and treat patients in thoughtful and caring ways. I am convinced that to be better, we have to treat ourselves as we hope to treat our patients.

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List 1 Suggested Strategies to Increase Resilience Among Current and Future Primary Care Practitioners Cited Here...

  1. Make student, practitioner, and staff wellness a dashboard metric of success for medical schools, primary care practices, and health care systems.8
  2. Increase availability of Balint8 or narrative/reflection groups6,9 which allow participants to explore concepts such as realism, self-awareness,10 conflicting time demands, talking about stressors, acknowledging limitations of roles and skills, fear of failure, making mistakes, what one enjoys in medical education or practice, etc.
  3. Implement mindfulness training for medical students, practitioners, and staff.5,11
  4. Enhance trainee mentoring by resilient mentors12; encourage taking guilt-free time for self-care,6,7 including the pursuit of interests outside of medicine; use reflective questions9; acknowledge and reflect on what is satisfying and enjoyable; and encourage proactive solutions to identified stressful situations.
  5. Develop curricula to teach learners how to manage patients’ requests for availablilty.7
  6. Promote self-care in training, primary care practices, and academic units by providing a broader cadre of realistic, available role models.
  7. Make an online self-care package available to help students manage stresses of student life.13
  8. Build short periods of time for movement, relaxation, yoga, or meditation into the workday.

Acknowledgments: Thanks to Ron Epstein, MD, for his thoughtful, informed feedback, to Ellen Leopold for her valuable editing of the manuscript, and to the Academic Medicine reviewers for their most thoughtful comments.

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References

1. Bodenheimer T. Primary care—will it survive? N Engl J Med. 2006;355:861–864
2. Shachak A, Reis S. The impact of electronic medical records on patient–doctor communication during consultation: A narrative literature review. J Eval Clin Pract. 2009;15:641–649
3. Christino MA, Matson AP, Fischer SA, Reinert SE, Digiovanni CW, Fadale PD. Paperwork versus patient care: A nationwide survey of residents’ perceptions of clinical documentation requirements and patient care. J Grad Med Educ. 2013;5:600–604
4. Beckman H. Three degrees of separation. Ann Intern Med. 2009;151:890–891
5. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302:1284–1293
6. Beckman HB, Wendland M, Mooney C, et al. The impact of a program in mindful communication on primary care physicians. Acad Med. 2012;87:815–819
7. Drybye LN, West CP, Satele D, et al. Burnout among U.S, medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89:443–451 References cited in List 1 only
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References cited in List 1 only

8. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: A missing quality indicator. Lancet. 2009;374:1714–1721
9. Charon R Narrative Stories: Honoring the Stories of Illness. 2006 Oxford, UK Oxford University Press
10. Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med. 2013;88:382–389
11. Epstein RM, Krasner MS. Physician resilience: What it means, why it matters, and how to promote it. Acad Med. 2013;88:301–303
12. Hales J. Senior lecturer, Department of Medical and Social Care Education, University of Leicester, UK. Personal communication with H. Beckman October 23, 2014
13. Fernando AT, Moir FM, Davis PG, Kumar S, Dorehty I. CALM: Computer Assisted Learning for the Mind 2010 Auckland, New Zealand University of Auckland https://researchspace.auckland.ac.nz/handle/2292/17073. Accessed February 9, 2015
© 2015 by the Association of American Medical Colleges