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Focus on physician health, wellness should start during training :

January 22, 2016

Dr. McClaffertyDr. McClaffertyThe topic of physician health and wellness has come into sharp focus recently as research accrues on the connection between physician health and patient outcomes and medical organizations’ fiscal health.

Although results of studies detailing high rates of physician burnout and depression are distressing, each sheds light onto a topic historically shrouded by a culture of stoicism that has contributed to significant morbidity and mortality among physicians.

All physicians stand to benefit from the attention being directed to this topic, but young physicians may gain the most. It has been shown that serious symptoms of burnout, including suicidal ideation, start early — even in premedical training (Fang DZ, et al. Acad Psychiatry. 2012;36:11-16). Research on the condition of young physicians entering internship and their high rates of depression and burnout (Pantaleoni J, et al. Acad Pediatr. 2014;14:167-172) should catalyze immediate change in our medical culture. This is easier said than done, yet it is unrealistic to expect young physicians to practice consistent self-care in a culture that remains resistant to change.

To be sustainable, change must occur simultaneously at the individual, organizational and cultural levels. It also requires leaders who are comfortable admitting their own vulnerability and are determined to leave the field a better place for those coming after them.

Fortunately, a blueprint exists to guide progress. The classic article by Maslach and Leiter outlines factors associated with lower rates of individual burnout, including a sense of personal control, absence of role conflict, feeling of being fairly treated, social support, alignment of individual and workplace values, and appropriate reward (financial as well as institutional and social recognition for contributions) (Maslach C, Leiter MP. J Appl Psychol. 2008;93:498-512).

Another study showed that physician supervisors’ leadership qualities were highly predictive of burnout and sense of personal well-being among the physicians they supervised independent of salary, workload, specialty and opportunities for professional development, among other factors (Shanafelt TD, et al. Mayo Clin Proc. 2015;90:432-440). Positive leadership attributes were summarized as the ability to “inform, engage, inspire, develop, and recognize,” qualities that are applicable to the skillful mentorship of young physicians.

Culture change also is beginning on a national level in pediatrics. Among the positive developments are the revised Accreditation Council for Graduate Medical Education core competencies in professionalism and personal development, which call for attention to a civil culture in the practice of medicine. The core competencies also position self-care and mindful practice as expectations of the well-rounded physician rather than signs of weakness.

Other initiatives underway include the Pediatric Resident Burnout-Resilience Study Consortium led by Maneesh Batra, M.D., FAAP (Seattle Children’s Hospital), and John Mahan, M.D., and Kathi J. Kemper, M.D., M.P.H., FAAP (Nationwide Children’s Hospital). The consortium includes more than 30 pediatric residency programs committed to the well-being of their trainees. In addition, the Pediatric Integrative Medicine in Residency program through the University of Arizona Center for Integrative Medicine includes more than 500 pediatric residents and embeds a unit on self-care into residency training (McClafferty H, et al. Children. 2015;2:98-107).

Immediate steps that can be taken by pediatricians at all levels of training and practice include the normalization of self-care and modeling of one’s humanity. Young physicians also would benefit from introduction to evidence-based coping skills, such as mindfulness and cognitively based compassion training to navigate the challenges inherent in a medical career. These approaches have been associated with improved attention, emotional regulation and cognitive flexibility linked to reduced burnout and depressive symptoms, higher levels of engagement in work and improved quality of life (West CP, et al. JAMA Intern Med. 2014;174:527-533).

Involvement of colleagues and leaders at all levels is required to dissolve the culture of silence and move our field forward. The AAP Physician Wellness Special Interest Group is committed to this mission.

Dr. McClafferty is chair of the AAP Section on Integrative Medicine Executive Committee and leads the Physician Wellness Special Interest Group.

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