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Invited Commentaries

Redesigning the Learning Environment to Promote Learner Well-Being and Professional Development

Dyrbye, Liselotte N. MD, MHPE; Lipscomb, Wanda PhD; Thibault, George MD

Author Information
doi: 10.1097/ACM.0000000000003094

Abstract

Numerous studies have documented a high prevalence of burnout and depression among medical students and residents (or learners).1–3 Existing data suggest medical students matriculate with a lower prevalence of burnout and depressive symptoms and better quality of life across multiple domains than similarly aged college graduates who pursue other careers.4 These data provide at least some evidence that matriculating medical students have well-developed abilities to manage the stress that often comes with a rigorous college education and the competitive process for gaining entrance into medical school. Once in medical school, however, this profile appears to change, with data suggesting that medical students and residents become more likely to have symptoms of burnout and depressive symptoms than their peers who pursued other careers.1–3

Approximately 44%–55% of medical students and more than 60% of residents have symptoms of burnout.1–3 Nearly a third of medical students and residents have depressive symptoms, and 1 in 10 medical students become suicidal.1,2 Data suggest that approximately 3 out of every 200 medical school matriculates drop out due to a nonacademic reason.5 Although some had a change of career interest, others reported that they could no longer pursue their goal due to burnout or depressive symptoms.3 Similarly, among residents, personal health reasons (such as burnout or depressive symptoms) contribute to residents leaving their training programs.6 Burnout may also increase the risk of learners having an alcohol use disorder, becoming involved in a motor vehicle incident, or having a blood or body fluid exposure.3

Beyond these personal impacts, learner well-being can affect the care provided to patients and learners’ professional development. Medical students with burnout may be more likely to engage in unprofessional conduct, have lower empathy and altruism, and endorse inappropriate attitudes about how to manage conflicts of interest with industry, illness in a family member, and impaired colleagues.3 Residents with burnout may be more likely to report providing suboptimal care to patients, committing a medical error, and struggling with concentrating at work.3 They may also be more likely to perform worse on standardized examinations and high-fidelity simulation scenarios, suggesting that poor well-being negatively impacts their professional development.3,7 Residents with burnout may also have greater racial biases toward black patients, which could contribute to disparities in care.8 Evidence suggests burnout may also increase the likelihood of career and specialty choice regret9 and may influence specialty choice,3 potentially adding to physician shortages in certain specialties.

Educators have a collective responsibility for the system-level factors that influence learners’ well-being as stewards of their professional development (Table 1). Some of these system-level factors also impact physicians’ professional well-being, while others are unique to learners. Effectively addressing these factors will be complex, and although some is known about evidence-based strategies to address these, much still needs to be learned. In the National Academies of Sciences, Engineering, and Medicine consensus study, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being, which we coauthored, a recommended goal was to “transform health professions education and training to optimize learning environments that prevent and reduce burnout and foster professional well-being.”10 Below we outline 10 strategies—based on our collective experience, discussions with fellow consensus study coauthors, and the literature (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A777 for a list of suggested readings)—to help guide efforts to redesign the learning environment to promote learner well-being and professional development.

Table 1
Table 1:
System-Level Factors That Influence Learner Well-Being

1. Commit leadership

Leaders of the institutions and affiliated clinical training sites that accept the responsibility of educating the next generation of physicians must commit to addressing system-level factors that hinder the well-being and professional development of learners. Similar to addressing the well-being of practicing physicians,11 such a commitment willneed to be manifested through (1) allocating resources needed topromote a positive learning environment, (2) holding educational leaders responsible for the state of the learning environment, and (3) having an individual clearly in charge of facilitating, coordinating, and overseeing efforts to improve the learning environment and address learner well-being across the undergraduate–graduate medical education spectrum. This individual should meet regularly with decanal staff, residency program directors, designated institutional officers, individuals responsible for faculty well-being and professional development, and leaders from clinical training sites to leverage opportunities for greater impact. These duties should not be tacked onto someone’s existing role and responsibilities. Rather, an individual with leadership skills and relevant content knowledge (e.g., learner well-being, learning environment, assessment, accreditation rules) should be selected and appointed, provided resources, and empowered to influence change.

2. Empower and equip the teaching faculty

The professional well-being of the faculty, as well as their priorities, goals, and competencies as educators, appear to be tightly intertwined with the well-being of learners.3 For example, residency training programs with the highest prevalence of burnout largely mirror the specialties with the highest prevalence of burnout among physicians in practice.9 In longitudinal studies, medical students who report negative faculty role modeling have a higher risk of developing depressive symptoms, while those who report education is a priority for faculty members have a lower risk of developing burnout.3 Other faculty behaviors such as providing little support, having high demands, providing inadequate autonomy, and being hostile or harassing are associated with learner burnout and depression.3,12,13 In contrast, timely feedback, direct observation, explicit teaching on difficult topics, and provision of mutual support are teachable behaviors that improve learners’ experiences and well-being.3,14

As such, organizations that host learners should ensure the work demands on the faculty and the resources provided to them enable, optimize, and equip them to be positive role models who can effectively teach, coach, and support learners. Doing so will require addressing factors that contribute to faculty burnout, not tolerating harassing behaviors, the alignment of rewards and incentives with educational goals, and effective faculty development.

3. Ensure learner workload is manageable and conducive to learning

With medical knowledge doubling every few days, there is no shortage of information to teach learners. This explosion is coupled with calls for expanded physician competencies in systems and improvement science,15 among other fields. It is expected that medical students—who are often already assigned more reading than can possibly be completed in the time allotted and who are pursuing a parallel United States Medical Licensing Examination (USMLE) preparation curriculum—learn about an ever broader range of topics, and in some situations, in 3 rather than 4 years, while also adding value to the health system.16 The lack of substantial, incremental improvements in resident well-being as duty hours restrictions have been rolled out over the past 2 decades3,17 points to a multitude of factors influencing work stress, including work compression and the tediousness of tasks related to the electronic health record.

Leaders in academic medicine must work together across disciplines to ensure the total clinical and academic workload expected of learners, including preparation for licensure examinations and required institutional learning activities, is manageable. Making a concerted effort to measure the total workload is a necessary first step. Next, educational leaders will need to make hard decisions about trade-offs, sequencing, and individualizing curricula across the undergraduate and graduate medical education continuum.

4. Optimize clinical experiences

The apprenticeship model of medical education requires learners rotate through a series of clinical experiences across departmental boundaries, health care settings, and, often, geographic locations. With each new opportunity for professional development comes a series of challenges that extend beyond the new medical content knowledge to be learned, including different faculty expectations, work flows, electronic health record systems, cultures, and facilities. How well learners acclimate depends on their adaptability, as well as on how well faculty have oriented and prepared them, organized the rotation, and developed a nurturing learning environment.3,18

Rotational and program-level factors can contribute to the well-being of learners. For example, poorly organized clinical rotations and limited exposure to a range of medical problems may increase the risk of burnout among medical students.3 Data support that the well-being of residents within training programs is relatively stable across independent cohorts and that poor learning experiences during inpatient rotations may predict depressive symptoms among interns.14 This must be fixed. How best to optimize clinical experiences, however, remains somewhat elusive and warrants further study. For example, it is unknown if longitudinal clerkships or continuity of supervision—both of which offer the promise of enhanced faculty–learner relationships—improve learner well-being. These have been shown to have several positive effects on learner attitudes and behaviors19,20 and should be studied for their effect on learner well-being.

Strategies that support learners involved in medical errors, leverage team-based care, consider the complexity of a patient when deciding if learners should be involved in his/her care, ensure clinical rotations are well-organized, assist learners during personal life events, and provide opportunities for learners to contribute meaningfully to patient care are likely to support learner well-being.3,21–23

5. Foster social relationships

Social support is a well-recognized protective factor against a range of psychological burdens. Several studies report associations between learners’ social support and their risk of burnout.3 Factors that may hinder social support include away rotations, norm-based grading, poor mentoring and advising relationships, and unfriendly peers.10

Strategies should be implemented to intentionally promote and build relationships among learners and between learners and faculty and remove barriers to meaningful human connections in the learning environment. Structured mentorship programs that also help learners navigate career decision making along with extramural club activities, physical spaces designed for gathering, and learning communities to break big, unwieldy groups into smaller, more cohesive units are some promising strategies to consider.3 How best to promote social support when learners scatter across large geographic distances for clinical rotations remains a challenge to solve.

6. Consider evaluation strategies

It is difficult for learners to build social support and a cohesive, collaborative environment, let alone effectively learn how to work in teams, if they are put into a competitive environment. Norm-based grading supports decisions about conferring honors and ranking students for residency applications but may not support learner well-being.10 In contrast, pass–fail grading in the preclinical years of medical school is associated with improved learner well-being and has been demonstrated to not adversely impact future performance, including on standardized assessments.3 High-stakes assessments, such as the USMLEs, are well-recognized sources of stress, and historical studies suggest depressive symptoms among medical students peak coinciding with the USMLE Step 1.24,25 Although the impact of high-stakes assessments on learner well-being warrants further study, calls have been made to address the unintended uses and consequences of such assessments.

There is evidence to support making the preclinical years pass–fail at all medical schools.10 Beyond that, evaluation specialists should create new ways to fairly and humanly assess learners’ competencies. Additionally, criterion-based grading should be implemented across the continuum of medical education. To build a collaborative learning environment, the academic community should embrace the premise that truly outstanding Medical Student Performance Evaluation letters or letters of recommendation for honor societies or fellowships should rest on demonstrated competencies against established benchmarks, rather than performance in comparison to peers.

7. Promote self-care behaviors

Learner well-being and professional development are a shared responsibility between the individual learner, the faculty, the institutions and affiliated clinical training sites responsible for their education, and the larger house of medicine. Educating learners about the prevalence, contributing factors, and consequences of burnout and depressive symptoms among learners and physicians in practice and about evidence-based strategies to mitigate risk is worthwhile. This should be done in a way that does not add required content to already busy schedules or encroach on personal time. Providing resources for self-care and personal development without being overly prescriptive about what to do (e.g., mindfulness, physical activity, Balint group) is likely to be the most effective and well received.26 Offering tools that allow for self-assessment of well-being and providing access to resources inside and outside the health care system associated with the training environment can help lower barriers for learners to access care for emotional concerns. Several schools and residency programs have implemented a variety of strategies in these directions.27–29 To help ensure resources are allocated most effectively, outcomes of initiatives should be evaluated to ensure progress is being made toward the goal of improving learner well-being.

8. Engage in continuous learning and improvement

Liaison Committee on Medical Education and Accreditation Council for Graduate Medical Education accreditation processes require a system of regular curricula evaluation and improvement. These well-established processes of continuous improvement should fold in measures of learner well-being, the learning environment, and factors that facilitate and hinder learner well-being. Such data can be obtained from surveys, focus groups, and novel metrics, such as those generated by electronic health record systems. Surveys should include standardized validated measurement tools, preferably with national benchmarks, and be administered in a manner to ensure confidentiality and choice and to minimize responder burden. Passive measures of workload and other contributing factors need to be developed and incorporated into evaluation plans. Aggregated, deidentified survey results and other related metrics should be shared annually with learners, faculty, and leaders of institutions and affiliated training sites responsible for residents’ and medical students’ education and used to inform system-oriented efforts to optimize the learning environment, reduce learner burnout, and improve professional well-being and development.

9. Curb educational debt

The educational debt of many learners is staggering. High educational debt is associated with a higher risk of burnout, as well as with a higher risk of substance use disorder among learners.3,30,31 Educational debt also influences learners’ specialty choice, placing them at risk for a long-term commitment to a field that does not align with their passion and may not meet societal needs. As evidence suggests that meaning in work can be a critical protective factor against burnout and essential to career satisfaction and retention in medicine,10 deans of student affairs and academic advisors need to help learners to make the best long-term decisions in their career choices. It is unfortunate that residents are now often required to make loan payments, which can add financial strain—particularly for residents with children and other dependents and for those who live in costly geographical areas of the country. Academic medicine needs to do its part to reduce the cost of medical education, pursue philanthropic partnerships to offset tuition costs, improve access to scholarships and affordable loans, and advocate for more robust loan forgiveness systems. Novel approaches that address needs in health care shortage areas, offset educational debt, and support the professional development of early-career physicians are worth pursuing.

10. Facilitate discovery of evidence-based approaches

Despite decades of research and hundreds of articles on burnout, little empiric work has been done to identify evidence-based approaches to reduce the risk of learner burnout, promote recovery when it does occur, and optimize learning environments.18 The vast majority of studies conducted to date have focused on individual strategies, such as mindfulness, or evaluating changes in duty hours requirements. Ideally, future studies should include methodologically rigorous interventions (i.e., randomized controlled or cohort study designs with crossover or appropriate comparison group and evaluation of postintervention effects) focused both on the individual and on their learning environment. The primary aim should be to identify evidence-based system solutions to improve the learning environment to enhance learner well-being and professional development and to assist learners in refining their ability to monitor their own level of well-being, respond appropriately if it declines, and promote self-compassion and self-care behaviors. In addition to intervention studies, research is needed to enhance understanding of how faculty-level interventions impact learners and the relationship between learner burnout and learners’ professional development and the quality of care they deliver to patients. Longitudinal studies are needed to better identify factors that contribute to poor learner well-being and to identify predictors of optimal professional well-being among learners. Additional studies are needed to better understand the relationship between learners’ well-being and their future experiences and behaviors as physicians.

Educating the physicians of tomorrow is a privilege and with it comes responsibility and duty to both learners and society. Given the moral imperative of reducing learner burnout and depression, actions, such as those outlined above, are needed—for the sake of society and the patients to whom these learners will provide care.

Acknowledgments:

The authors thank members of the National Academies of Sciences, Engineering, and Medicine consensus study System Approaches to Improve Patient Care by Supporting Clinician Well-Being who collaboratively worked together to write the report, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.

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