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Perspectives

Should Wellness Be a Core Competency for Physicians?

Stergiopoulos, Erene MD, MA; Hodges, Brian MD, PhD, FRCPC; Martimianakis, Maria Athina (Tina) MA, MEd, PhD

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doi: 10.1097/ACM.0000000000003280
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Abstract

The concept of “physician wellness” represents one of the biggest shifts in medical culture in recent memory. Over the past few years, local committees, national task forces, and international conferences on physician health and wellness have emerged and have called for action, challenging the medical profession’s traditional stoicism while promoting previously unheard conversations about the well-being of its providers.1–3 In October 2018, the International Conference on Physician Health convened more than 500 attendees to discuss individual- and systems-level strategies for improving physician wellness.4 The conference—a partnership of the American, Canadian, and British Medical Associations—called for physicians and leaders to champion wellness as medicine’s new priority. Its plenary panel on medical education, “Wellness as a Competency in Medical Training,” added another dimension to the already complicated landscape of meanings associated with “wellness.”

The concept of “wellness as a competency” for physicians holds profound implications for curricula, evaluations, admissions, and licensure, and for teachers and learners. Introducing a new required core competency to medical education means adding new topics to the didactic agenda, new responsibilities for the doctor-in-training, and new criteria for evaluation and for admission into the profession.

Yet the idea of wellness as a competency is not entirely new. As early as 1999, the Accreditation Council for Graduate Medical Education (ACGME) defined 6 core competencies for residents in the United States. The sixth competency, professionalism, includes the subcompetency of “maintaining emotional, physical, and mental health and pursu[ing] continual personal and professional growth”5 and tasks the physician with becoming a role model who can “set an example for their patients” by “maintaining their own healthy lifestyle.”5

Similarly, the Royal College of Physicians and Surgeons of Canada has outlined 7 CanMEDS roles or core physician competencies. The third edition of the CanMEDS Physician Competency Framework, released in 2015, notably places an increased emphasis on physician well-being within the role of professional, in which doctors must “demonstrate a commitment to physician health and well-being to foster optimal patient care.”6 The expected behaviors under the subcompetency of physician well-being include the physician’s ability to self-regulate, exhibit self-awareness, use appropriate self-care, and mitigate negative effects of physical and environmental factors on wellness.6

A shift toward framing wellness as a competency has also taken place at the level of medical school curricula. In a national survey, Dyrbye et al found that 6 U.S. medical schools with structured wellness programs in 2016 identified well-being as a specific competency, with dedicated curriculum time devoted to didactic or social activities related to wellness.7

It is unclear how medical schools and residency programs will operationalize wellness into evaluations to assess learners’ competence in this domain. Therefore, as we consider the implications for admissions, curricula, evaluation, and licensure, it is important to ask, what happens to medical education if wellness becomes a core competency for physicians? And what would it mean, then, for a learner to be labeled “unwell”?

Medical Learners With Disabilities and Challenges to Defining “Wellness”

In 2018, the Association of American Medical Colleges released a groundbreaking report on learners and doctors with disabilities.8 These include individuals with psychological, mental health, chronic health, sensory, learning, and mobility-related disabilities. In 2019, 4.6% of U.S. medical students self-disclosed a disability to their school and registered for accommodations, an increase from 2.7% in 2016, though this is still likely underreported given existing barriers to disclosure.9 While the experiences of students with different disabilities—for example, mobility-related disabilities and mental health issues—can differ significantly, these students become administratively and conceptually grouped together under the mantle of disability, perhaps because they are seen to deviate from the perceived norm of “wellness.” Personalized accommodations, which allow students with disabilities to participate and perform in their academic and clinical roles, are typically the purview of dedicated accessibility services offices at medical schools—which are often the same offices that promote “wellness” among all students. Approaching wellness as a way to remove barriers to participation and performance has the potential to benefit all learners, including those learners with disclosed or undisclosed disabilities.

Yet accommodations for learners with disabilities are often absent from conversations about wellness, which tend to focus on healthy eating, regular exercise, and activities for self-care. In the AAMC’s 2018 report, interviews with learners across the country revealed educational environments where disability is often stigmatized by supervisors and peers and where learners are hesitant to disclose their need for accommodations. Indeed, reports from conferences and working groups over the last 2 decades have highlighted a medical culture where doctors and learners with disabilities feel pressured to not take time off, get discouraged from asking for help, and face stigma from widely held beliefs in medicine that illness reflects an inability to cope properly with the demands of training.10–12 These barriers to disclosure and support-seeking reflect a prevailing “culture of perfection”13 in medicine, where learners hesitate to ask for help based on perceived ideals of how a doctor should perform and behave.13,14

We worry, then, that framing wellness as a competency may perpetuate stigma against learners with disabilities. That is, by setting standardized expectations for “well” and “unwell,” we may inadvertently be repackaging the notion that learners with disabilities are unsuitable to practice medicine—this time, by labeling them as “not competent.”

But this depends on how we define “competency” and what we mean by “wellness.” In a recent study,14 2 of us (E.S., M.A.T.M.) explored the experiences of medical students with disabilities at English-speaking Canadian medical schools, using in-depth interviews and analysis of university policies, institutional wellness and student affairs services websites, and student blogs related to wellness. We observed how various discourses of wellness framed trainees’ perceived expectations for the “ideal” medical student. In some cases, wellness was framed as a means to achieve balance—a desirable end unto itself. In other cases—both in institutional services websites and student blogs—wellness was framed as a means to achieve peak academic performance, to minimize distractions, to cope with academic challenges, and to increase efficiency. Wellness became a method to achieve “ideal” student status—something that learners with disabilities found nearly impossible, given the competing demands of managing both their academic performance and their health. Indeed, defining “wellness” in this way might lead these learners to be evaluated as not competent.

Yet students participating in the study described experiences as both learners and patients that created opportunities for in-depth learning beyond the traditional medical school curriculum. Their lived experiences gave them insights into what compassionate, high-quality patient care looks like, based on the care they themselves had received. The learners also revealed how much work they had done in their roles as patients to prioritize and manage their own health, while learning how and when to seek extra support. Their experiences became a strength, helping them understand and manage their own health and that of their patients.

Many of the definitions of “wellness” that learners encounter in medical education do not reinforce this strength, however. Dyrbye et al’s national survey of U.S. medical schools found that among schools that had implemented well-being curricula, the most common offerings included mindfulness meditation training, organized events for physical activity, lectures or meetings related to finances, and organized social activities.7 Schools typically offer a combination of mandatory and nonmandatory activities,7 and learners can often select from a menu of self-care activities like yoga, meditation, student-led socials, and meetings with dedicated counselors.15 However, defining “wellness” as participation in these self-care activities risks singling out learners who cannot spend time on such activities because of the demands of living with a disability and managing their personal health. And if we then add “competency” to the mix, “wellness” transforms from a vague ideal into a series of standardized expectations, with profound implications for evaluation and licensure.

The Question of Competency

“Competency,” like “wellness” and “disability,” has many meanings. That is, what counts as competency varies by clinical, cultural, and geographic context.16,17 Drawing from the international medical literature, one of us (B.H.) has shown how different discourses of competency imply different inherent values with material effects for the structure and content of training and evaluation.16 For example, if we view competency as knowledge, we can determine a learner’s competence through their ability to accumulate facts, which we might measure via a multiple-choice test. If we view competency as a performance, in contrast, we must identify specific behaviors performed by the learner to achieve competence, usually evaluated via simulations and observed encounters.

In other words, the way we define “competency” determines what we evaluate in our learners, how we evaluate it, and who is considered competent. The student who achieves a good grade on a multiple-choice test may be competent in one sense, but not competent in another, such as when faced with an objective structured clinical examination. When we apply the discourses of competency to wellness, the challenge becomes ascertaining what, exactly, we want learners to accomplish. Should all learners be able to recite lists of techniques for avoiding burnout? Should they be required to exercise regularly? Should their scores on self-reported burnout scales be used to assess whether they are “well” or “unwell”? Would these tasks and scores reflect what we really intend to teach when we talk about wellness? And, importantly, what effect would these definitions of “wellness” and “competency” have on students with chronic health, mental health, learning, sensory, or mobility-related disabilities?

Wellness as a Competency: Where Do We Go From Here?

There are clear benefits to emphasizing wellness early in learners’ medical careers. Indeed, framing wellness as a competency could be a way of legitimizing personal health as a priority for all physicians. It has the potential to challenge the existing culture of perfection in medical education and to encourage more learners to seek support when in distress. It is critical, though, that institutions involve learners and faculty with disabilities in the development, definition, and execution of wellness goals and strategies. Doing so will ensure that people with disabilities can help define “wellness” relative to their own needs. Moreover, international networks like the Coalition for Disability Access in Health Science Education18 can serve as resources for establishing best practices to support and include doctors and learners with disabilities in the medical profession.

Alternative models of wellness in medical education, beyond yoga classes and student socials, are also possible. As Bodenheimer and Sinsky19 suggest in their “quadruple aim,” health organizations should work at a systems level to improve the work–life and well-being of clinicians and health care staff to improve health care overall. Rather than adding new resources to improve wellness, they propose removing the barriers that impede wellness in the first place. In particular, they argue that health care organizations should commit to practical workplace strategies to decrease administrative burdens and thus improve the work–life of clinicians and staff.

Applying this systems-level approach to medical education would mean applying concepts of universal design: What barriers to wellness could we remove, and how might removing these barriers benefit all learners?20 Universal design approaches in the medical education setting might include flexibility in the curriculum to adjust schedules, with blank space allotted to allow learners to attend appointments or attend to their health needs. Critically, universal design approaches to wellness would benefit all learners; they would not single out or exclude students or residents with disabilities.

Ultimately, in the current era of competency-based medical education, we must be careful to take stock of the shifting meanings of “wellness” and “competency” and understand which among these are dominant. We must also pay attention to the ways in which new learning activities and evaluations of wellness articulate a new “ideal” student and perhaps create unintended barriers for some learners. In the end, these meanings may determine who is considered a competent physician—and who may be inadvertently excluded from the profession.

Acknowledgments:

The authors wish to acknowledge Dr. Lisa Meeks for her leadership, research, and advocacy for physicians and learners with disabilities and for her thoughtful comments that contributed to the development of this article.

References

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