As increasing attention is being paid to medical student and resident well-being, medical schools and residency programs are examining and implementing many methods to enhance resilience and avoid burnout in medical trainees.1–5 These wellness initiatives often include meditation and other mindfulness activities, self-reflection, journaling, and lectures or workshops on managing stress and building resilience using metacognition and cognitive restructuring. These interventions have in common the creation of opportunities for trainees to focus more intentionally and deliberately on their inner selves to help them become better aware of their experiences, recognize stressors, and regulate their thoughts and feelings so that stressors are less likely to have harmful effects. They also enable trainees to temporarily distance themselves mentally and emotionally from a stressful environment. In this paradigm of resilience enhancement and burnout prevention, the learning environment—and, in particular, the clinical learning environment—is viewed principally as a source of stress rather than as a place that provides social support and connections.
In social psychology, there is an extensive literature on methods of enhancing student well-being and resilience in the face of environmental stress. There is evidence that one important way to reduce the harmful effects of stress is to create a sense in trainees of identification with a group,6 and to enhance social support, social engagement, and meaningful connections with others.7 Although there are several ways in which social support and connections with others are thought to reduce the negative effects of stress, two seem particularly relevant to the medical training environment—namely, social companionship and informational support.8 Affiliation and contact with others (social companionship) allow medical students and residents to discuss events in the training environment that they may perceive as particularly stressful. This social contact may provide useful information (informational support) that allows students and residents to better appraise and cope with potentially stressful events.8 Although turning inward is certainly important to build resilience and avoid burnout, the value of meaningful conversations with others in the clinical learning environment must also be appreciated.
Curiously, opportunities to interact meaningfully with other learners, as well as with faculty, staff, patients, and families, seem to be less common than in years past. Perhaps this is because so much time in the clinical learning environment today is spent in individual activities; in fact, residents now spend nearly half their work hours in front of a computer screen.9 There are few structured opportunities for trainees to gather in the cafeteria, work room, conference room, or library while at work when issues about patient care and the stresses of training might more readily be discussed. It was only a few decades ago that many teaching hospitals provided food for trainees who were in the hospital at night in what was known as the “midnight meal,” a practice memorialized in Lowenstein’s10 book The Midnight Meal and Other Essays About Doctors, Patients, and Medicine. As Markel and Stern note in their foreword to the book:
this midnight meal was much more than a convenience in fast food. Instead, young physicians, many of whom might not communicate with each other during the day because they worked on different services … were forced together at the same time in the same room in the quest of sustenance not only for the body but also for the mind and soul.10
Although the midnight meal no longer exists in most teaching hospitals, modern analogues have been developed and are important for medical schools and residency programs to consider implementing. Schwartz Rounds11—regularly scheduled meetings that provide a forum for open discussion of the social and emotional issues that health care providers face in caring for patients and families—revisit some of the features of midnight meals and add structure. These rounds, developed by the Schwartz Center for Compassionate Healthcare, help participants explore the impact their work has on them. By ensuring dedicated time and a safe space for health care providers to share personal stories, reflect, and voice their feelings, Schwartz Rounds have been shown to give medical students insight into how others feel about caring for patients and a way to process their emotions.12 As noted in a discussion of the value of these rounds, “integral to personal and professional growth is the ability to connect and communicate with each other, to recognize and draw meaning from our daily interactions with patients and colleagues.”13
In a similar vein, Balint group meetings involve structured discussions in which participants make case presentations that focus on patient–provider relationships and are followed by a brief contemplative period to consider responses.14 These meetings, although primarily intended to address patients’ needs, may help teach trainees communication skills.14,15 They also have the potential to reduce burnout among participants by providing a structure and a safe venue for recognizing and discussing emotionally stressful experiences.16 Many medical schools have also created college advisory programs and learning communities, in part to promote student wellness.17,18
So, why should medical schools and residency programs create additional structured opportunities for trainees to establish meaningful connections with others? In part, because these connections provide greater social support for potentially vulnerable individuals. Several studies in the hospital environment have suggested a relationship between poor social support at work (i.e., feeling unable to share experiences and feelings with colleagues) and burnout, as well as the potential for high levels of social support to reduce burnout.19–22 Not surprisingly, García-Sierra et al19 report that for nurses working in a hospital setting, job demands are positively related to burnout. Importantly, however, high levels of work engagement (i.e., a sense of connection with, and fulfillment in, work activities23) can moderate this relationship. Social support increases work engagement and reduces burnout even in the face of high work demands.19 Although nursing managers have traditionally focused on reducing work demand as a way to address burnout among their staff, García-Sierra et al19 suggest that a more effective strategy may be increasing work engagement by enhancing social support. There are lessons from these studies for those involved in medical student and resident education, as burnout and depression have, if anything, become greater concerns in the United States since the implementation of duty hours restrictions for trainees.
In summary, there is little doubt that activities like meditation, self-reflection, journaling, and mindful breathing have value in promoting wellness and can help trainees effectively remove themselves from the stressful aspects of the learning and clinical practice environment. However, medical school leaders and residency program directors should also realize the potential for social connection and engagement, as well as group identification, to promote well-being and avoid burnout. In recognition of these benefits, medical schools and residency programs should create structured opportunities for trainees to establish meaningful connections with each other and with others in their learning and work environments.
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