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|Wellness in Residency Training|
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Northeast Florida Medicine, Vol. 68, No. 4, Winter 2017
Date of Release: December 1, 2017
Date Credit Expires: December 1, 2019
Estimated Completion Time: 1 hour
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.
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.
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.
1. Understand the current data as it relates to physician burnout, depression, and suicide.
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 the DCMS at 904-355-6561 or firstname.lastname@example.org.
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 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 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
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:
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.