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Leading by Example: Role Modeling Resilience Helps Our Learners and Ourselves

Abaza, Mona M. MD, MS; Nelson, Kathleen G. MD

doi: 10.1097/ACM.0000000000001936
Invited Commentaries

The issues of burnout and its consequences are some of the most prevalent topics in conversations about the practice of medicine today. Many reports have focused on the contributors that fuel this epidemic, but the time has come to begin to focus on solutions. Prominent national efforts, including a National Academy of Medicine collaborative task force and the 2017 Accreditation Council for Graduate Medical Education common program requirements’ focus on wellness, are presenting opportunities for academic medicine faculty to take the lead in turning this tide. While solutions to the burnout crisis are complex, the foundations of improving this epidemic lie in restoring a sense of purpose and balance in the lives of those who work in academic medicine. The inherent value of academic medicine to improve others’ lives through patient care, the advancement of knowledge, and the education of the next generation is a unique opportunity that many other professions do not share. On the best days, academic medicine faculty must remember to look for that joy and to express it to learners, and, on the worst, they must demonstrate to learners how to practice self-care and how to create personal resilience. By taking on the role of becoming resilient, faculty start to foster a culture of well-being rather than burnout and can begin to find solutions instead of continuing to describe the problem.

M.M. Abaza is professor of otolaryngology, University of Colorado School of Medicine, Aurora, Colorado.

K.G. Nelson is clinical professor of pediatrics, Keck School of Medicine of USC, Los Angeles, California.

Funding/Support: None reported.

Other disclosures: M.M. Abaza is a member of the Accreditation Council for Graduate Medical Education Board of Directors.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Mona M. Abaza, 12631 E. 17th Ave., Room 3004, Aurora, CO 80045; telephone: (303) 724-1950; e-mail: mona.abaza@ucdenver.edu.

The issue of physician burnout and its consequences is reaching endemic proportions. From the 2017 Medscape data1 showing that 51% of physicians report burnout, up from 40% just four years ago, to the disturbing reports of student, resident, and faculty suicide, academic medicine can no longer afford to not address this issue head on. While no one can argue that systemic contributors to this problem abound, from electronic health records and increasing administrative burdens to the loss of individual physician autonomy, the culture of medical training is also to blame. National efforts to take on this crisis are evolving. The National Academy of Medicine’s Collaborative on Physician Wellbeing2 is an important step for our collective organizations to help address the larger systemic issues. But, waiting for the “systems” to fix the problem is not enough either. The areas measured by the Maslach Burnout Inventory3—emotional exhaustion, depersonalization, and personal accomplishment—are expressions of this crisis we see every day.

Faculty serve many roles for their trainees: They may be mentors, sponsors, colleagues, and teachers, but they are, above all, models of behavior, both positive and negative, for those with whom they work. When we faculty members display our vulnerability and our methods of dealing with difficult situations, we can be at our best or our worst. Because our trainees are observing us in these situations, we have the opportunity to influence them. Faculty role models demonstrate aspects of professionalism to their trainees. These traits are often observed rather than specifically taught, and the power of faculty to influence and develop positive traits in their trainees should not be underestimated. Understanding this makes it easy to see how, as faculty, finding, demonstrating, and pointing out positive values including compassion, empathy, altruism, honesty, ethics, responsible behavior, respect for patients and colleagues, and self-care, for both ourselves and our learners, is critical. Unfortunately, faculty may also model undesirable practices and, through the “hidden curriculum,” turn the learning environment into a competitive, possibly humiliating, exhausting, and discriminatory atmosphere.

Our residents and students are already thinking about how to change this culture. The Accreditation Council for Graduate Medical Education (ACGME) resident council described several themes to help increase meaning in work.4 Four of the five themes had nothing to do with systemic burden issues. From providing more direct patient care, to a shared sense of teamwork, to a supportive, collegial work environment and a learning environment of progressive autonomy and clinical mastery, they talked about concepts that present daily opportunities in our health care systems. These ideas, found on almost every residency application essay ever written, are why most of us entered medicine.

This Invited Commentary is not about faculty adding “cheerleader” to their ever-growing to-do list but, rather, remembering that we are in a position to demonstrate the accomplishments that being a health care provider can bring us. Acknowledging the patient encounter that made us feel like we made a difference for another human being that day, showing visible expressions of the joy and satisfaction in helping a learner grasp a complicated concept or procedure, and marveling at the wonder we feel in discovering a new piece of scientific knowledge are unique opportunities in academic medicine. These are the gifts of medicine that are not found in many other professions. The daily opportunity to make a difference in people’s lives is a large part of the “calling” of medicine, and paying attention to it is a critical step to improve our learners’ as well as our own sense of accomplishment. Doing so will foster resilience, not burnout.

The need for this culture change is not just critical to our survival, it is also essential to the training of future physicians. This is underscored by the ACGME’s new common program requirements,5 which took effect July 1, 2017. They state:

Psychological, emotional, and physical well-being are critical in the development of the competent, caring, and resilient physician. Self-care is an important component of professionalism; it is also a skill that must be learned and nurtured in the context of other aspects of residency training.

The point that self-care is a skill to be learned is not to be taken lightly. We can be the role models who demonstrate this skill. More than just being understanding and supportive of our learners’ self-care needs, this means providing the role modeling they need to see to understand the relevance of self-care. We need to tell them that we are going to our own care appointments and not “to a meeting.” We need to openly talk about the dilemmas we face in making choices between our needs, our family’s needs, and our patients’ needs. Although faculty often have more flexibility in their schedules, we should discuss that flexibility does not mean more hours, just more options. When faculty choose to go to their child’s grade school presentation, it sometimes means needing to come to work early to see patients or reschedule meetings or work after everyone goes to bed. Balance does not mean forgoing responsibility for obligations but finding ways, to the best of one’s ability that day, to accomplish them within a reasonable framework.

Faculty should not expect to be perfect at this, nor should their learners expect them to be perfect. Role modeling resilience means being honest about when we are not succeeding at it. When we are less than our best because we did not sleep, have a cold, or had an argument with someone, we have to own our limitations. If we are not brave enough to tell ourselves, let alone our peers, that we are not at our best and we need help, how can we expect our learners to do so? If we only demonstrate the “perfect” us to them, how can we expect them to acknowledge they are less than perfect themselves? Isn’t resilience about adaptability, not perfection? This demonstration of the ability to adapt and show vulnerability is not an “easy ask” of faculty, but it is within our ability.

Cultural change is defined as the modification of a society through innovation, invention, discovery, or contact with other societies. Although we do this every day in education, science, and service in the larger world, the self-effacing aspect of being a health care provider has made this harder for us to do in our own narrower personal world. We must take this on with the same passion with which we take on our responsibility to society. By consciously noting and demonstrating our own successes and failures in our personal well-being to our trainees and peers, we as resilient faculty, role modeling our approaches, can help create the culture change we need in academic medicine to create a resilient future for all of us.

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References

1. Peckham CMedscape lifestyle report 2017: Race and ethnicity, bias and burnout. http://www.medscape.com/features/slideshow/lifestyle/2017/overview. Published January 11, 2017. Accessed July 21, 2017.
2. National Academy of Medicine. Action Collaborative on Clinician Well-Being and Resilience. https://nam.edu/initiatives/clinician-resilience-and-well-being/. Accessed July 21, 2017
3. Maslach C, Jackson SE, Leiter MPMaslach Burnout Inventory Manual. 1996.3rd ed. Palo Alto, CA: Consulting Psychologists Press;
4. Hipp DM, Rialon KL, Nevel K, Kothari AN, Jardine LDA“Back to bedside”: Residents’ and fellows’ perspectives on finding meaning in work. J Grad Med Educ. 2017;9:269–273.
5. Accreditation Council of Graduate Medical Education. Common program requirements: Section VI with background and intent. http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_Section%20VI_with-Background-and-Intent_2017-01.pdf. Published February 2017. Effective July 1, 2017. Accessed July 21, 2017.
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