Reimagining Well-Being Initiatives in Medical Education: Shifting From Promoting Wellness to Increasing Satisfaction

Abstract

The well-being movement in medical education has been underway for over a decade. It seems appropriate to examine and evaluate these efforts to support the mental health needs of learners, faculty, and staff as medicine and medical education evolve in response to the COVID-19 pandemic and beyond.

To date, most interventions intended to promote well-being have focused on individual strategies rather than environmental drivers of distress, and the primary offerings have comprised strategies such as mindfulness, meditation, yoga, nutrition, exercise, and sleep. Responses to this programming from medical learners have primarily ranged from ambivalence to resentment, with many feeling that the programming failed to adequately address their particular needs and the challenges they were experiencing.

In this commentary, the author challenges the assumption that well-being per se should be the ideal target or goal. Learners and faculty may be better served by considering other goals—those that do not focus directly on well-being but that are instead foundational for well-being in that they directly address the challenges that students, residents, and faculty are facing. In other words, goals and associated interventions would focus on the experience of school and work rather than focusing primarily on encouraging healthy practices outside of school and work. The author proposes using the lens of satisfaction through which to view and assess progress toward well-being, increasing satisfaction within 3 interconnected domains: (1) school and/or work, (2) self, and (3) life in general. Attention to these domains may be more likely to produce improvements in well-being that have been sought for years but that remain elusive.

A movement to improve well-being in medical education and medicine has been underway for a number of years, with attention to the issue having been elevated since the mid-to-late 2000s. ^1,2 Most medical schools across the country have promoted the well-being of students for at least the past 5 years, and programs developed at Vanderbilt University School of Medicine and Saint Louis University School of Medicine have been in place for more than a decade. ^3,4 Residency programs have been engaged in the movement over a similar time frame, initially driven by debates about duty hours; more recently, efforts at the residency program level have been accelerated by the addition of well-being requirements to the Accreditation Council for Graduate Medical Education (ACGME) common program requirements in 2017. ⁵ Given this proliferation of activities to promote well-being among medical trainees, it seems appropriate to take stock of these efforts so that we are best able to support the mental health needs of our learners, faculty, and staff as medicine and medical education evolve in response to the COVID-19 pandemic and beyond.

This essay will explore what is known about the current state of well-being efforts in academic medicine, how effective these efforts appear to be, how well they are being received, and finally, how we may look to expand upon current initiatives and programming to enhance the well-being and mental health of learners across the medical education continuum. These views will be drawn not only from the medical education literature wherever possible but also from my own somewhat unique experience, before the pandemic, of visiting 30 academic medical centers and medical schools and giving presentations at a dozen national medical education and clinical specialty meetings over a 2-year period. During these travels, I had the opportunity to converse with numerous medical students, residents, fellows, faculty, staff, administrators, and mental health providers and hear about the range of well-being interventions and how they were viewed and received. I was also able to gather insights from interactions during dozens of my presentations and workshops, seeing and hearing from countless learners how various concepts and ideas related to well-being resonated with them.

Well-Being Outcomes

National medical student well-being data can be found in the Association of American Medical Colleges Graduation Questionnaire (GQ) ⁶ and Year 2 Questionnaire (Y2Q) ⁷ reports. The GQ and Y2Q ask respondents to rate aspects of their overall stress, burnout, and the learning environment. From 2016 to 2019, these measures showed no sign of improvement and in some areas declined slightly. In the GQ, burnout subscales of disengagement and exhaustion showed no improvement, perceptions of the emotional climate fell slightly, and overall satisfaction with well-being programming declined during this period. In the Y2Q survey, perceived stress, disengagement, and exhaustion all worsened slightly over the 4-year time span.

Questions about well-being were added to the ACGME annual survey of residents and faculty in 2018, but a change in the core questions and the onset of the pandemic make comparisons over time impossible so far. My impression, however, from conversations with many people in graduate medical education from across the country is that the well-being of residents before the pandemic was not improving.

The Nature and Perception of Interventions

At this point, most of the interventions designed to promote well-being have focused on individual strategies rather than on environmental drivers that contribute to distress. The primary well-being offerings mirror those found in the broader societal well-being industry, with an emphasis on mindfulness, meditation, yoga, nutrition, exercise, and sleep. And while significant well-being interventions and programming for medical students and residents have been put in place, far fewer have focused on faculty.

Responses to this programming from medical students and residents have typically ranged from ambivalence to outright resentment, with many expressing to me that the programming felt unresponsive to their needs and the challenges they were experiencing, both in work and in life. Some of the specific criticisms of well-being programming included that well-being was too often treated as a knowledge deficit. As one fellow put it, “We don’t need more lectures on nutrition; we need access to healthy, nutritious food in the hospital.” Another told of having an hour-long presentation on breathing that was interrupted multiple times by phone calls and pages. Others complained of toxic positivity—feeling pressured to be happy all the time. And many were frustrated by the sheer length of well-being programming, as well as by recommendations for time-intensive strategies such as meditation, which felt like yet another addition to an already too-long to-do list. For some, it represented another way to feel disappointed in themselves if they were not able to follow through with the recommended practices.

Given widespread perceptions that well-being programming often falls short of the mark, we need to consider what elements we have been missing and how, going forward, we can expand our efforts to craft more effective initiatives.

Is Well-Being the Ideal Goal?

It may be reasonable to start by asking whether well-being itself is the ideal target or goal. When well-being is identified as the primary target, it is not surprising that programs associated with conventional well-being initiatives become the most widely adopted interventions. Our learners and faculty may be better served if we consider other goals that do not focus directly on well-being per se but that are instead supportive of and foundational for well-being and which directly address the problems and challenges that students, residents, and faculty are facing. In other words, goals and associated interventions would focus on the experience of school and work rather than focusing primarily on encouraging healthy practices outside of school and work. One way to achieve this would be through a lens of satisfaction as an alternative to well-being—specifically, increasing satisfaction within the 3 interconnected domains of (1) school and/or work, (2) self, and (3) life in general.

Satisfiers and Dissatisfiers Across the Medical Education Continuum and Implications for Interventions

Satisfaction with school or work

Dissatisfiers in the preclerkship curriculum include content overload, excess contact hours, competition for grades (in graded curricula), and rigid policies. Some of these elements are being addressed by medical schools. For example, in recent years, many schools have adopted pass/fail grading in the preclerkship years. Problems of content overload, however, have not been nearly as widely addressed, and with the move of many schools to shorten this curriculum phase, the material that students must master has been compressed into shorter time periods.

In the clerkship year, dissatisfiers include working with dispirited faculty and residents, subjectivity and unfairness of grading, and excess time demands on some clerkships (not only clinical demands but also add-on assignments and study time required for end-of-clerkship exams). For students who are at risk for marginalization or targeting (including but not limited to Black, Latinx, LGBTQ+, female, and Muslim students), this toxicity is greater and surpasses that seen in the more controlled environment typical of the preclerkship years. Some efforts are being made to address these deeply rooted problems, but much more is needed.

In graduate medical education and within the clinical learning environment, much of the discussion and focus has been on workload, administrative burden, and the electronic health record (EHR). Many residents whom I spoke with felt that some issues that seriously impact faculty, such as challenges with the EHR, were less significant for them. Residents voiced dissatisfaction about various elements within the overall culture of the clinical learning environment, including inadequate emphasis on education, infrequent and insufficient feedback, feeling undervalued and underappreciated, inadequate involvement in program decision making, working with dispirited and demoralized faculty, and a seemingly endless stream of add-ons, such as online trainings, quality improvement projects, didactic presentations, and more—all to be accomplished on personal time. Improving satisfaction within these areas is warranted and, in many cases, would require little to no funding. What it does require is an understanding of how these factors undermine resident satisfaction and a resolute commitment to act upon them.

Satisfaction with self

Many medical students, residents, and faculty struggle with satisfaction with self, yet we too rarely offer programming to help them manage this problem. A number of factors contribute to dissatisfaction with self. The fact that half of medical students will be below average and 90% will not be in the top 10% threatens many students’ sense of satisfaction with self.

Multiple mindsets and mental filters also contribute significantly to distress. Two that have been most studied are maladaptive perfectionism (repeatedly setting the bar for yourself so high that you are repeatedly disappointed in yourself) and impostor phenomenon (feeling, despite objective evidence to the contrary, that you are a fraud, an impostor). These conditions have been found to be associated with depression and anxiety in medical students and with burnout in residents and faculty. ^8,9 Other mindsets and thought patterns have not been similarly studied but appear to be prevalent and likely undermine many learners’ satisfaction with self. These include

• Viewing performance as identity (feeling that you are your high-stakes exam score, not that you got that score),
• Comparison (only feeling good about yourself if you are performing better than others),
• Personalization and self-blame (heaping all of the blame on yourself when your performance is not ideal), and
• Cognitive distortions, including magnification, all-or-none thinking, and catastrophization.

The gold-standard treatment for maladaptive perfectionism and impostor phenomenon is cognitive behavioral therapy; however, we cannot wait until learners develop mental illness and need therapists. Cognitive behavioral techniques can be easily and efficiently taught and have been found to be associated with significant drops in depression, anxiety, and suicidal ideation in medical students and residents. ^10,11 These techniques should be taught in some form to all students and residents and should be reinforced across the educational continuum.

Satisfaction with life in general

A second group of mindsets appears to be contributing to dissatisfaction with life in medicine. I witnessed high rates of cynicism, pessimism, negativity, and, increasingly, anger, particularly in residents and faculty. These feelings are understandable given the challenges that residents and faculty face, but the question that needs to be asked is whether people want to live in frustration, cynicism, and anger. These emotions do not tend to help change the system or the culture in positive ways but rather inflict damage on those who hold them and, in turn, on those around them. A number of tools can be used to manage, rather than eliminate, these feelings, including cultivating positive emotions, reducing emotional reactivity, and promoting self-calm. In addition, appreciative inquiry can be used in a variety of settings to change the narratives we tell ourselves and each other, moving from stories primarily of frustration and anger to those of meaning, grace, and beauty.

Attention to Those Who Are Marginalized in the System

To a great degree, well-being programming has been a one-size-fits-all approach and has not adequately acknowledged and addressed the additional threats to well-being and satisfaction faced by many in our community. These include those who are underrepresented in medicine, LGBTQ+, women, Muslims, and others, who daily deal with offensive behaviors on the micro and macro levels. We must, as a medical education community, begin to acknowledge and reduce the extra burdens and challenges to well-being that individuals in these groups experience.

Conclusion

Greater awareness and acknowledgment of the problem of poor mental health of medical students, residents, and faculty have resulted in a proliferation of programs to address this issue. This is a hugely important accomplishment: the planting of a flag at medical schools and teaching hospitals across the country to signal that student, resident, and faculty wellness matters and that it needs to be a priority. These programs have primarily focused directly on well-being, and while the programs are undoubtedly useful for many individuals, they have not rendered the kind of improvements in well-being that have been sought and hoped for. We need to push further to address systemic threats to trainees’ and faculty members’ satisfaction with the school or work environment, with self, and with life—threats which have too often been accepted as conditions of the medical education environment, but need not be. By undertaking measures that more directly target the stressors, both external and internal, that learners and faculty face, significant improvements in well-being may be achieved.

Acknowledgments:

The author thanks the many students, residents, and faculty who have contributed to the ideas in this commentary. He also thanks the Scholars group at the Accreditation Council for Graduate Medical Education for their ongoing wisdom and counsel.