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Wellness in Residency Training

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Northeast Florida Medicine, Vol. 68, No. 4, Winter 2017

Promoting Wellness in Residency Training

Monia E. Werlang, MD,2
 
Chrysanthe M. Yates, BA,3
and  
Michelle D. Lewis, MD4
1Assistant Professor of Medicine, Mayo Clinic College of Medicine, Community Internal Medicine and Associate Program Director, Internal Medicine Residency, Mayo Clinic, Jacksonville, Florida

2Chief Medical Resident, Internal Medicine Residency, Mayo Clinic, Jacksonville, Florida

3Program Director, Mayo Clinic Lyndra P. Daniel Center for Humanities in Medicine, Jacksonville, Florida

4Assistant Professor of Medicine, Mayo Clinic College of Medicine, Department of Gastroenterology and Program Director, Internal Medicine Residency, Mayo Clinic, Jacksonville Florida

Address Correspondence to:

Mary S. Hedges, MD
Mayo Clinic
4500 San Pablo Road, Jacksonville, FL 32224
Phone: (904) 953-2000
Fax: (904) 953-0655
Email: Hedges.Mary@mayo.edu

Date of Release: December 1, 2017
Date Credit Expires: December 1, 2019
Estimated Completion Time: 1 hour
Background:

The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). This issue of Northeast Florida Medicine includes an article, “Promoting Wellness in Residency Training” authored by Mary S. Hedges, MD, Monia E. Werlang, MD, Chrysanthe M. Yates, BA, and Michele D. Lewis, MD, which has been approved for 1 AMA PRA Category 1 credit.TM For a full description of CME requirements for Florida physicians, please visit www.dcmsonline.org.

Faculty/Credentials:

Mary Hedges, MD, Associate Program Director, Internal Medicine Residency at Mayo Clinic Florida. Michele Lewis, MD, Program Director, Internal Medicine Residency, Mayo Clinic Florida. Monia Elisa Werlang, MD, Assistant Professor of Medicine/Gastroenterology and Hepatology Fellow, Mayo Clinic Florida. Chrysante Yates, BA, Program Director, Mayo Clinic Florida’s Lyndra P. Daniel Center for Humanities in Medicine.

Needs Assessment:

Increasing physician burnout, depression, and suicide reports have recently led to a lot of media attention, but often without clarity or detail. It is important for physicians to better understand where the medical community can best intervene. It is also critical for physicians to learn strategies to address these very concerning trends, which can hopefully lead to improvement in physician mental health and wellness.

Objectives:

1. Understand the current data as it relates to physician burnout, depression, and suicide.
2. Identify barriers to physicians seeking mental health services.
3. Identify strategies to promote wellness among resident and faculty physicians.

CME Credit Eligibility:

A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. If you take your test online, a certificate of credit/completion will be automatically downloaded to your DCMS member profile. If you submit your test by mail, a certificate of credit/completion will be emailed within 4 weeks of submission. If you have any questions, please contact Kristy Williford at 904-355-6561 or kristy@dcmsonline.org. 

Faculty Disclosure:

Mary Hedges, MD, Michele Lewis, MD, Monia Elise Werlang, MD, and Chrysante Yates, BA report no significant relations to disclose, financial or otherwise, with an commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest:

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement:

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit.TM Physicians should only claim credit commensurate with the extent of their participation in the activity.

Physician burnout levels have become alarmingly high is recent years. At the same time, physician depression and suicide completion rates are increasing, with recent data showing that the risk of suicide among physicians is significantly higher than their non-physician age matched controls. The tendency towards depressive symptoms and suicidal ideation appears to start early in medical training, and accelerate through medical school and residency. To address burnout, depression, and suicide risk during residency, Mayo Clinic Florida has initiated a multifaceted wellness approach. Identifying wellness champions with leadership interest is important to implement specific wellness initiatives. Wellness initiatives include: resident wellness education, duty hour and fatigue mitigation, arts and humanities, pet therapy, nutrition, counseling services, social gatherings, resilience training, access to medical care, nutritious food, and ongoing monitoring for burnout among residency programs. To lower the rates of physician burnout, depression, and suicide, it is imperative that the medical community be proactive.

Physician wellness strategies are becoming highly publicized and promoted in response to recent studies that show burnout rates of over 50 percent among physicians nationwide.1 Additionally, there is concerning data regarding depression in up to 30 percent of medical students and residents, as well as notably higher rates of suicide in all physicians compared to the general population (relative risk of suicide among physicians compared to the general population: 1.1-3.4 in men, and 2.5-5.7 in women).2,3,4,5 Approaches from an institutional level have been recently outlined,6 but challenges remain in promoting wellness in both medical trainees and the faculty physicians who teach them. The Accreditation Council for Graduate Medical Education (ACGME) has made physician wellness a high-priority initiative in response to the reports of increasing suicide rates.7

Physician Burnout

Physician burnout has notably increased nationwide in recent years. A study reporting on data from a nationwide survey of 6,800 physicians showed that 45.5 percent of physicians reported at least one symptom of burnout in 2011. Subsequently, when re-surveyed in 2014, the reported burnout symptom rate had increased to 54.4 percent.1 This increase in burnout was noted in all 24 medical specialties studied, with some specialties increasing by more than 10 percent during the study period. The highest increases in burnout were reported in family medicine (51 percent in 2011 to 63 percent in 2014), general pediatrics (35 percent to 46 percent), urology (41 percent to 63 percent), orthopedic surgery (48 percent to 59 percent), dermatology (31 percent to 56 percent), physical medicine and rehabilitation (47 percent to 63 percent), pathology (37 percent to 52 percent), radiology (47 percent to 61 percent), and general surgery subspecialties (42 percent to 52 percent).1,2 Physician burnout is strikingly higher than the U.S. working adult population, which has a reported burnout rate of 28 percent.1 Even when adjusted for confounding variables (such as age, gender, relationship status, and hours worked), physicians remained almost twice as likely to suffer burnout compared to the U.S. working population (odds ratio of 1.97).1 Physicians are also less likely to be satisfied with work life balance, declining from 48 percent satisfaction level in 2011 to 40 percent in 2014, both of which are notably lower than the U.S. working population (odds ratio of 0.68).1 This concerning trend has been published in the general media as physician burnout not only affects physicians, but also affects patient quality, safety, and access to care.8 Physicians with a higher burnout rate are more likely to make medical errors.2 In response to high rates of burnout in residency training, there has been a recent call to action in the medical education community with new requirements at a program level through regulatory bodies.9

 

Physician Depression

Physician depression rates have remained disturbingly high. Among physicians nationally, based on a two-question primary care depression screen, depression rates were found to be 39.2 percent in 2011 and overall unchanged at 39.8 percent in 2014.1,2 Depression rates in medical students is 15-30 percent,3 and this rate appears to rise throughout the medical education years when followed longitudinally.10 Residents suffering with depression were over six times more likely to make medication errors than residents without depression.11 Compounding this problem further, studies show that physicians are much less likely to seek or receive treatment for depression than their non-physician counterparts.3 

This disparity is significant when compared to the general population rates of depression.  The National Institute of Health (NIH) and World Health Organization (WHO) report the prevalence of depression among U.S. adults as 6.7 percent.12 Similarly, the Centers for Disease Control and Prevention (CDC) reported U.S. population depression rates in 2009-2012 of 7.6 percent.13 In 1999, the self-reported lifetime prevalence of depression among physicians was 13 percent in men, and 20 percent in women, a rate already above that of non-physicians, and that has only increased further in the last two decades.14

 

Physician Suicide

Unfortunately, insufficient mental healthcare begins early in the medical career. Of medical students who reported suicidal ideation, only 42 percent received treatment.15 This disparity appears to continue to increase with seniority. Physician suicidal ideation rates nationally were self-reported over a 12-month period to be 6.4 percent in both 2011 and 2014.1,2 A study of U.S. surgeons reported suicidal ideation rate of similar numbers (6 percent) in the preceding 12 months, and most notably, only 26 percent of those reporting suicidal ideation had sought psychiatric or psychological help. Over half reported reluctance to seek help due to medical licensure concerns that require reporting of mental health history regardless of impairment.16,17  

Completed suicides are higher among physicians than non-physician peers and the physician suicide numbers are increasing. It was estimated in 1977 that the U.S. lost 150 doctors per year to suicide, the equivalent of one medical school class per year.17,18 The published estimation in 2017 is that the U.S. loses 400 physicians to suicide per year, equivalent to two to three medical school classes dying by suicide yearly.8,17 In medical students, after accidents, suicide is the most common cause of death.18 In residency training, the leading cause of death is neoplastic disease and suicide.19 Data stratified by gender shows for male residents, the leading cause of death was suicide, then neoplastic disease second. For female residents, the leading cause of death was neoplasm, with suicide a close second. Patterns show higher rates of death early in residency training and also highest during the first and third quarters of the academic year.19

For physicians beyond medical training, the completed suicide rate continues to rise.  Female physicians appear to attempt suicide less often than the general U.S. female population, but have a much higher completion rate of suicide- over 250-400 percent higher than the female general population (relative risk 2.4-4.0).14,17 For male physicians, the suicide completion rate is about 70 percent higher than the general male population.15 The overall suicide completion rates appear to be similar between male physicians and female physicians.20 Physicians of both genders have a much higher suicide completion rate than the general public, which appears to be due to greater knowledge of anatomy and increased access to lethal means.

Wellness is more than the absence of depression or suicidality, but conversely, a person who is depressed or suicidal is not in a state of wellness. The American Medical Association (AMA) website has a helpful framework for approaching wellness for residents and fellows.21 The Mayo Clinic has also created a wellness initiative, including a resource webpage for employees and the opportunity to train as a Wellness Champion (published on institutional internal webpage). The frameworks are similar and both are listed in Table 1.

To address resident wellness, initial steps include identifying trainees and faculty with knowledge or interest in wellness initiatives to provide leadership and reviewing institutional resources available. Each residency program has unique challenges and assets in this regard. At the Mayo Clinic, some of the wellness initiatives already existed in other formats, and these were adapted for residents. New initiatives were developed to address the unique stressors and schedule of medical training.   

 

Specific wellness initiatives implemented for Mayo Clinic Residents:

  1. Wellness education discussions – For trainees in all specialties, the institution offers an annual education day, which includes a wellness education lecture.  Institutional resources and wellness strategies are shared.  Beyond the details of what is shared in the lecture, this raises awareness among residents and faculty and hopefully lessens the stigma in addressing future concerns when they arise. 

  2. Arts and Humanities – In 2014, the Mayo Clinic Internal Medicine residency started a pilot program called FERHAWI (Fellows and Residents Health and Wellness Initiative). This has been implemented with the Mayo Clinic Center for Humanities in Medicine. Specifically, one conference per month is protected for residents to participate in an arts or humanities project together, rather than a traditional lecture. This has included activities in self-care and creative expression such as watercolor painting (Figure 1), drawing, photography (Figure 2), mixed media, movement, dance, music, yoga, guided visual imagery (Figure 3), meditation, narrative and reflective writing, poetry, art analysis and interpretation, medical improvisation, and museum visits. The preliminary data has shown reduced fatigue and increased motivation compared to a regular didactic lecture. This program has been featured on the AMA website.21

    Figure 1: Creative expression watercolor painting - Arts and Humanities FERHAWI pilot program for residents.

    Figure 2: "Just breathe"mindfulness photography project - Residents aimed cameras at the sky for 30 second exposure while breathing to create visual oscillation of the images, unique to each individual. The portraits were assembled into a greater wall installation display.

    Figure 3: Guided visual imagery - Resident meditation with flute player.

  3. Caring Canines – Much has been published on the benefits of canines to human health and stress relief.22 The Mayo Clinic has a Registered Pet Therapy team for animal-assisted activities for the benefit of patients. Recently, the Internal Medicine chief medical residents initiated Caring Canine Fridays, scheduling the Registered Pet Therapy team to spend time with the residents during a 45-minute debrief session on the last Friday of the rotation. During that same time, the chiefs solicit feedback from the residents on recent rotations, didactics, and their overall training experience (Figure 4).

    Figure 4: Caring Canines - Internal Medicine residents during debrief morning report session.

  4. Fatigue management - ACGME requires a fatigue policy be in place for all trainees. The Mayo Clinic makes every effort to ensure this is shared at orientation and several conferences throughout the year, and that this information is prominently posted on the Internal Medicine residency website. Education is provided regarding the significant adverse mental and physical effects of sleep deprivation. If a resident is too fatigued to work, coverage for clinical responsibilities will be arranged, and roundtrip taxi service will be reimbursed. Adequate call room space is also essential for overnight or extended shifts.

  5. Nutrition – In promoting wellness, residents need access to healthy food choices. To promote this, there is a new resident lounge area that has a stocked refrigerator with healthy, nutritious snacks like fresh fruits, cereal, milk, granola bars and sandwiches. This helps to ensure healthy foods are available when working night shifts and weekends, even when the cafeteria is closed.

  6. Gathering institutional resources - A Resident Wellness link is available on our Internal Medicine residency webpage providing institutional resources in a central location that is easily accessible to residents. With new trainees entering residency programs each year, keeping a wellness webpage up-to-date helps share resources that new trainees might otherwise overlook. This includes listing a residency ombudsperson, instructions on how to establish a primary care doctor within the insurance network, local gym membership discounts, employee resource groups, and Employee Assistance Program (EAP) information. Our EAP, which provides free counseling in times of crisis, is available to all employees anonymously and can be accessed without prior authorization from employer or health insurance.

  7. Monitor for burnout – The education department has implemented semi-annual surveys of all residents and fellows of all specialties. The survey results are anonymous and grouped by specialty to evaluate for systems issues that may need to be addressed at the program level. These survey results are compared to national norms by specialty, and if there is an outlier residency with a higher burnout rate than the national average, this is addressed further at the program level. This allows for early intervention and the opportunity to be proactive in addressing resident wellness.

  8. Social gatherings through resident-led groups – The Mayo Clinic Fellows Association (comprised of residents, fellows, and scientists-in-training) is a very active group, coordinating winter and summer socials, community outreach programs (Figure 5), co-ed intramural sports teams (Figure 6), and an Annual Wellness Day event. Annual Wellness Day offers several different activities to trainees in all specialties and fellowships, including free massages, guided yoga and stretching exercises, music, healthy food options, and the presence of the Caring Canines. The goals of the Annual Wellness Day are to show appreciation to the trainees’ hard work, provide the opportunity to relax and interact with peers during the workday, and expose trainees to new alternatives for cultivating wellness. The Mayo Clinic also supports and encourages participation in Employee Resource Groups, which are very active and diverse on campus.

    Figure 5: Community Outreach - Residents volunteering at a local magnet school to increase awareness about heart disease.

    Figure 6: Soccer - Promoted by the Fellows Association, trainees play soccer regularly and compete with other teams in the Jacksonville area.

  9. Resilience building initiatives – The Mayo Clinic Fellows Association established bimonthly talks in which any employee can voluntarily share a past struggle and how they coped with it. Featured topics include, but are not limited to personal or family members’ drug addiction, failing important exams during training, dealing with immigration and cultural barriers, death of loved ones, divorce, depression, etc. While it is common to publicly praise each other’s well deserved successes, wellness is also promoted through sharing failures and how they can be overcome. By seeing vulnerability in others, especially a person who one admires, one can gain perspective on their own struggles. This initiative also aims to create new beneficial mentorship relationships.

 

Physicians historically have taken upon themselves the characteristic of invincibility. This mentality has been passed on by generations of physician faculty to trainees. This can be a paradoxical and detrimental reality. While we work to destigmatize mental health conditions to help our patients, physicians often do not apply the same wellness standards to themselves. This is unfortunately reinforced when physicians are required by state medical boards to report mental health histories and treatments to keep active medical licenses, regardless of any associated impairment.23 While the intention of this practice is aimed at patient safety, it can prevent physicians from seeking the help they need.

Some of the Mayo Clinic wellness initiatives have been in response to the tragic suicide reports from other residency training programs.24 It is important to implement lifelong wellness habits and awareness in medical trainees. For improved physician wellness and resiliency training, personalizing the approach in medical education should include understanding individual backgrounds, traits and coping mechanisms. The medical community needs to be more proactive going forward, rather than reactive, and to destigmatize getting help when needed.

One of the greatest challenges facing training programs is the lack of faculty awareness or wellness. Without specific leadership and wellness initiatives, this becomes “the blind leading the blind” as most faculty received no wellness training during their own medical education. Thus, wellness initiatives are important for physicians at all levels of seniority, which in turn, will best help future physicians.

Well physicians provide better patient care, have fewer medical errors, and receive higher patient satisfaction scores.25 Today’s residents are tomorrow’s practicing physicians and faculty. High physician burnout, depression, and suicidality put an overly burdened healthcare system at risk.  It also puts physicians personally at risk of the adverse and dangerous effects of untreated depression. When it comes to residency training, trainees will learn from example. Physicians must be well to teach well.

 

1. 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 Dec;90(12):1600-13.

2. Ariely D, Lanier WL. Disturbing trends in physician burnout and satisfaction with work-life balance: dealing with malady among the nation's healers. Mayo Clin Proc. 2015 Dec;90(12):1593-6.

3. Bright RP, Krahn L. Depression and suicide among physicians. Curr Psychiatr. 2011 April;10(4):16-30.

4. Wible P. Physician suicide letters answered. Eugene (OR): Pamela Wible, MD Publishing; 2016. 187 p.

5. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004 Dec;161(12):2295-302.

6. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017 Jan;92(1):129-46.

7. Accreditation Council for Graduate Medical Education. Physician well-being [Internet]. Chicago (IL): ACGME [cited 2017 Apr 25]. Available from: http://www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being.

8. Oaklander M. Life/Support: inside the movement to save the mental health of America’s doctors. TIME Magazine. 2015 Sep;186(9-10):42-51.

9. Ripp JA, Privitera MR, West C, et al. Well-Being in Graduate Medical Education: A Call for Action. Acad Med. 2017 Jul;92(7):914-17.

10. Givens JL, Tijia J. Depressed medical students’ use of mental health services and barriers to use. Acad Med. 2002 Sep;77(9):918-21.

11. Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depresssed and burnt out residents: prospective cohort study. BMJ. 2008 Mar 1;336(7642):488-91.

12. National Institute of Mental Health. Major depression among adults [Internet]. NIH; 2015 [cited 2017 Jul]. Available from: https://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml.

13. Pratt LA, Brody DJ. Depression in the US household population. [Internet]. Center for Disease Control and Prevention; 2014 Dec [cited 2017 Jul]. Available from: https://www.cdc.gov/nchs/data/databriefs/db172.htm.

14. Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry. 1999 Dec;156(12):1887-94.

15. Glaser G. Unforunately doctors are pretty good at suicide [Internet]. National College of Physicians, Journal of Medicine; 2015 Aug 15 [cited 2015 Jul]. Available from: https://www.ncnp.org/journal-of-medicine/1601-unfortunately-doctors-are-pretty-good-at-suicide.html.

16. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among american surgeons. Arch Surg. 2011 Jan;146(1):54-62.

17. Andrew LB. Physician Suicide [Internet]. Medscape; 2017 Jun 12 [cited 2017 Jul]. Available from: http://emedicine.medscape.com/article/806779-overview.

18. Sargent DA, Jensen VW, Petty TA, et al. Preventing physician suicide. The role of family, colleagues, and organized medicine. JAMA. 1977 Jan 10;237(2):143-5.

19. Yaghmour NA, Brigham TP, Nasca TJ et al. Causes of death of residents in ACGME-accredited programs 2000 to 2014: implications for the learning environment. Acad Med. 2017 Jul;92(7):976-83.

20. Lindeman S, Laara E, Hakko H, et al. A systemic review on gender-specifc suicide mortality in medical doctors. Br J Psychiatry. 1996 Mar;168:274-9.

21. Okanlawon T. Physician wellness: preventing resident and fellow burnout: Creating a holistic, supportive culture of wellness [Internet]. American Medical Association and STEPSforward; 2015 [cited 2017 Apr 25]. Available from: https://www.stepsforward.org/Static/images/modules/23/downloadable/resident_wellness.pdf.

22. Freeman WD, Vatz KA. The future of health care: going to the dogs? Front Neurol. 2015 May 8;6:87.

23. Hill AB. Breaking the Stigma - A Physician's perspective on self-care and recovery. N Engl J Med. 2017 Mar 23;376(12):1103-5.

24. White T. Surgical residents play hooky to keep healthy [Internet]. Stanford Medicine; 2014 Sep 17 [cited 2017 Apr 25]. Available from: http://med.stanford.edu/news/all-news/2014/09/surgical-residents-play-hooky-to-keep-healthy.html.

25. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010 Jun;251(6):995-1000.