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Creating a Culture of Wellness in Residency

Edmondson, Emma K., MD; Kumar, Anupam A., MD; Smith, Stephanie M., MD, MPH

doi: 10.1097/ACM.0000000000002250
Invited Commentaries
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Despite increased awareness and recognition of the prevalence of physician burnout and the associated risks of depression and suicide, there is a paucity of actionable guidelines for residency programs to mitigate these risks for their residents. In this Invited Commentary, the authors acknowledge that, although there are inherent barriers to resident wellness, there are numerous modifiable barriers that present opportunities for programs to enable culture change and improve resident well-being. The authors frame the discussion with a personal narrative written by a resident in their internal medicine program who experienced burnout, depression, and suicidality during his intern year. They aim to inspire residency programs and hospital leadership to identify and intervene upon the modifiable barriers to wellness for residents in their programs in order to shape meaningful cultural change.

E.K. Edmondson is a third-year internal medicine/pediatrics resident, Hospital of the University of Pennsylvania/Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania.

A.A. Kumar is a postdoctoral research fellow, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

S.M. Smith is a first-year pediatric hematology/oncology fellow, Lucile Packard Children’s Hospital at Stanford, Palo Alto, California.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Emma K. Edmondson, 3400 Spruce St., 100 Centrex, Philadelphia, PA 19104; telephone: (215) 662-2532; e-mail: emma.edmondson@uphs.upenn.edu.

The shade came down sometime around November, like an emotional amaurosis fugax descending upon my life. Everything in my life had suddenly crumbled into nothingness. I went to work during the day, overwhelmed with the weight of my intern incompetence. I came home and somehow it was worse, as if my empty house was a monument to my overwhelming loneliness. The most frightening part of all was the journey to and from work each day. Every car that drove past and every bridge I crossed were tempting vehicles with which I could finally end the pain. I felt totally alone.

—A reflection from a resident wellness exercise

Our internal medicine residency program’s resident-run Wellness Committee created an exercise to share with interns the challenges of being a new physician, and to create an open dialogue about burnout, mental illness, and resilience during residency. As part of this exercise, one resident wrote a reflection about his experience battling burnout, depression, and suicidal thoughts during residency. This essay is punctuated by excerpts from that reflection. He initially shared his experience during a panel discussion organized for the class of 2018’s intern retreat, a one-day workshop held annually in the fall to facilitate camaraderie among the intern class. The excerpts have been reprinted here with his permission.

The panel discussion sent shock waves through our program. We felt paralyzed by profound sadness and by the fact that our friends and colleagues had these thoughts and feelings. Even more paralyzing, however, was how scared we all felt. It was frightening to admit how much we could relate to the thoughts that the panelists so bravely shared. This realization made some of us angry; it made some of us indignant; and it inspired us to start a movement to promote our own wellness and safety.

Wellness, a state of physical and emotional well-being, often feels unattainable during residency. The daily frustrations of navigating a complex system, the personal insecurities, exposure to traumatic experiences, and immense time commitments are overwhelming. These and other barriers can make the pursuit of personal well-being seem futile. A large and growing body of evidence suggests that not only is it difficult to maintain personal wellness during residency but it may be even harder to avoid burnout and the associated risks of medical errors, depersonalization, depression, and even suicide.1–3

Recognizing these challenges, a group of residents in our program has mobilized to call attention to the problem of resident burnout. We have formed a resident-run Wellness Committee, which meets monthly to discuss issues related to our well-being and mental health, and to identify actionable goals to improve the collective wellness of those in our residency program.

One tactic we have taken to combat burnout and promote wellness is to help residents identify things that are out of their control and let them go, focusing instead on factors that we can change. Inspired by the serenity prayer (“Grant us the serenity to accept the things we cannot change, the courage to change the things we can, and the wisdom to know the difference”), we have developed a framework for addressing barriers to wellness during residency. We acknowledge the challenges inherent to resident training and admit that we cannot change some of them. Instead, we focus on identifying barriers to wellness that can—and should—be changed. In medicine, culture change is neither quick nor easy. By partnering with residency program leadership to change the modifiable barriers, we hope to give ourselves and our colleagues the best chance at mental health and happiness during this particularly difficult phase of our careers.

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Background

The barriers to wellness during residency have gained more attention recently, and for good reason. We are encouraged by a general movement to improve the resident experience by regulating duty hours and changing the culture to be kinder and less hierarchical. Yet, despite increased awareness about physician burnout and the creation of residency wellness initiatives to provide explicit support for this problem, the rates of burnout, depression, and suicide amongst physicians are still soaring.

According to a study by Rosen et al4 in 2006, 4.3% of internal medicine residents met criteria for burnout at the beginning of intern year compared with 55.3% by the end of the intern year. Using the Maslach Burnout Inventory, a validated burnout assessment tool, the study showed that residents had significantly more depersonalization and emotional exhaustion by the end of their intern year as well.4 In another study of internal medicine residents conducted at the University of Washington, 76% of residents met criteria for burnout regardless of their year of training.5

Numerous studies have shown that burnout is associated with medical errors and poses a risk to patient safety.6,7 This downstream effect, on its own, is an outcome very much worth preventing. However, on a personal level for physicians, the risk of depression and suicide associated with burnout is just as critical to prevent.

In New York City hospitals alone, there were three resident physician suicides between 2014 and 2016. It is well documented that the risk of death by suicide is higher in doctors than in the general population. In fact, female physicians are more than twice as likely to die by suicide than age-matched women in the general population.8 For male physicians, the rate is 40% higher.8

Recently, Yaghmour et al9 found that suicide was second only to neoplastic disease as the leading cause of death among medical residents. Notably, the risk for death by suicide was highest early in residency, when trainees are still adjusting to their new roles and responsibilities.9 It is important to acknowledge that similarly difficult transitions occur before residency even begins—and there is evidence that burnout and suicidal ideation start as early as medical school.

In a cross-sectional and longitudinal study published in the Annals of Internal Medicine in 2008, Dyrbye et al10 examined the association between burnout and suicidality among medical students in seven prestigious medical schools in the United States. They found that 50% of medical students experienced burnout during medical school and 11.2% experienced suicidal ideation. For comparison, the rate of suicidal ideation among their age-matched cohort (25- to 34-year-olds in the general population) was 6.9%.10 Moreover, the association between burnout and suicidal ideation was large: There was a two- to threefold increased risk of suicidal ideation in medical students experiencing burnout. Also of note, there was a strong dose-dependent relationship: The higher the burnout score a person received, the more likely that person also experienced suicidal ideation.10 Importantly, however, they also found that recovery from burnout was associated with less suicidal ideation.10 This finding gives us reason for hope.

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Barriers to Wellness in Residency

I felt as if I was running nonstop along a hamster wheel, constantly exhausted and fatigued but going nowhere. Every hour of every day was spent fighting and pleading and being yelled at, occasionally by attending physicians and all too often by consulting physicians and other staff who seemed to feel pleasure at making me feel small and wanting me to acknowledge my inexperience with every interaction. On top of that, I was embarrassed by the extent of my depression and afraid to schedule an appointment with a psychiatrist. So, I put on a mask and performed an imitation of a happy, successful young physician while the suffering continued to boil below the surface.

What is it about this career path that predisposes us to feelings of burnout and worthlessness, lack of fulfillment, and even thoughts of suicide? And how can we enable recovery from burnout to prevent suicidal ideation and promote overall wellness?

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Intrinsic barriers to wellness in residency

In an effort to accept the things we cannot change about residency, we have named them (List 1). There are some realities that just cannot be denied—we face emotionally draining circumstances, we make tough decisions, and the stakes are high. Moreover, to see the volume of patients necessary to feel comfortable practicing independently, the hours are long and often irregular. Weekends and holidays with loved ones are not a given. To an extent, we can accept these conditions. We chose this profession knowing much of this (at least intellectually—it does feel different when you’re doing it).

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List 1Intrinsic Barriers to Resident Wellness

Long hours

Inconsistent work environments, changing teams and personal roles

Intense emotional experiences

Exposure to trauma

Missing important life events

Lack of control over schedule, days off, work hours

Less time spent with family, loved ones

High level of responsibility, life-or-death situations

Assuming a new identity

Doctoring one’s own loved ones when they get sick

Grave consequences of mistakes

How to cope then? What can we offer our colleagues and ourselves not only to survive but, in fact, to thrive during our years of residency?

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Modifiable barriers to wellness in residency

For the past several years, our resident Wellness Committee has been working to identify discrete, actionable things that we can do to shape a culture of wellness within our residency program. Table 1 lists barriers that currently exist but that we view as modifiable, along with our suggestions to remove or diminish these barriers. Many of these may seem like small problems, and indeed some are. But when you live at the hospital (it is called “residency,” after all), even the smallest things, like access to water in the resident work room, can greatly affect your quality of life.

Table 1

Table 1

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A Call to Action

We must emphasize that changing the culture of medicine is far-and-away the most important modifiable barrier to wellness. However, it may also be the most difficult factor to change. Convincing physicians that their personal health and well-being are as valuable as their patients’ is no small feat. Some believe it takes generations to change a culture. Luckily, a generation of residents turns over every three to five years.

By bringing attention to the many modifiable barriers to resident wellness, we hope to create a cultural climate that welcomes the next generation of young physicians into this challenging phase of their careers with tools and an environment that will enable them not only to avoid burnout and depression but also to find personal well-being in and out of the hospital. We hope that this framework inspires residents and residency program leadership to focus on this difficult but meaningful work.

I am fortunate, and perhaps still here today, because I had someone in the program leadership with whom I felt comfortable talking about my depression and a program director who understood the seriousness of the situation and had me get help before it was too late.

My biggest piece of advice is to hospital and program leadership: Do more. Create a culture of acceptance throughout the hospitals where your residents work, where depression is destigmatized and systems are in place to help those who are struggling with mental health issues.

To my colleagues who give so much of themselves to take care of others: I hope that you will reach out to those around you when you need help, as hard as that may be. Depression is not something shameful or a sign of personal weakness; it is an all-too-common and unfortunate consequence of the pressure and uncertainty that comes with being a young physician.

I hope that we can continue to create an environment where all physicians can do the important work of helping the sickest among us while keeping themselves well.

Acknowledgments: The authors wish to thank the University of Pennsylvania Internal Medicine residency program for their support of the Resident Wellness Initiative; Dr. Oana Tomescu and Dr. Amber Bird for their dedication to the mission of resident wellness; and Dr. Oana Tomescu and Dr. Dava Szalda for their critical review of this manuscript.

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References

1. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet. 2016;388:2272–2281.
2. Dyrbye 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.
3. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work–life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600–1613.
4. Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med. 2006;81:82–85.
5. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358–367.
6. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251:995–1000.
7. Hall LH, Johnson J, Watt I, Tsipa A, O’Connor DB. Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PLoS One. 2016;11:e0159015.
8. Schernhammer ES, Colditz GA. Suicide rates among physicians: A quantitative and gender assessment (meta-analysis). Am J Psychol. 2004;161(12):2295–2302.
9. Yaghmour NA, Brigham TP, Richter T, et al. Causes of death of residents in ACGME-accredited programs 2000 through 2014: Implications for the learning environment. Acad Med. 2017;92:976–983.
10. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149:334–341.
© 2018 by the Association of American Medical Colleges