One Size Does Not Fit All: The Current State of Wellness in Pediatrics Free

Not every experience that detracts from well-being is burnout. Vicarious traumatization, moral distress, compassion fatigue, ethical dilemmas, mental health conditions, and secondary trauma all have overlapping features with burnout.⁴  Although seemingly nuanced, appreciation of the differences is critical because various conditions, such as depression and posttraumatic stress, require a more targeted and sometimes pharmacologic approach. It is essential that physicians learn how to distinguish these symptoms in themselves and their colleagues for early use of resources. We encourage organizations to consider making specific evidence-based training, such as stress first aid, peer support, coaching, and suicide prevention, available to their employees.^7–10 

National measurements of burnout have been published year after year for each specialty, but for individual children’s hospitals, it is a corporate imperative to measure the scope of the problem in their own institutions in a nonpunitive manner. The AAP report recommends physicians and organizations consider routine monitoring for burnout symptoms using validated assessment tools. Focusing exclusively on assessing physician burnout, however, overlooks other critical components that contribute to physician well-being. For example, work engagement, a positive psychology construct related to work, is a metric associated with increased job satisfaction, retention, and quality of care.¹¹  The National Academy of Medicine has created a summary of valid and reliable instruments that measure various work-related dimensions of well-being.¹²  Although we acknowledge the value of measuring key facets of well-being and providing data to organizational leaders, measurement is just the tip of the iceberg. Quantifying the problem without explicit organizational follow-up or change can paradoxically result in mistrust toward leadership and a lack of feeling valued.

To make meaningful impacts on physician well-being, we need to identify and acknowledge the key drivers of physician engagement. How does 1 physician have the capacity to spend 16 hours at work while another is exhausted after 8? What is it that makes some want to come to work each day, and how does that desire evolve as some advance through their career? There is a deafening silence of physician voices that echoes in the literature, highlighting the obvious gap of the frontline perspective. Well-being is heterogeneous, it is generational, and funded efforts are needed to ultimately develop interventions “by and for physicians.”⁴  Sinsky et al outline a 7-step approach encouraging organizational leaders to start by soliciting ideas from all stakeholders.¹⁰  The Listen-Act-Develop model is an additional means of seeking physician viewpoints to foster healthy relationships between leadership and physicians and further promote physician engagement.¹³ 

Trainees compose a particularly vulnerable population, with symptoms of burnout shown to peak during a physician’s formative training years. Kemper et al report a troubling statistic from a national pediatric residency consortium that more than 50% of residents were burned out across all years of training from 2016 to 2018.¹⁴  National data on fellowship trainees are significantly lacking. Downstream effects of burnout included worsened mental health, lower levels of empathy and resilience, increased sleepiness, and greater perceived stress, but these effects are likely bidirectional.¹⁴  Bullying, discrimination, sexual harassment, and even physical violence in the workplace were more commonly experienced by burned-out trainees, with clinical staff being identified as a primary source for much of the mistreatment.¹⁵  Pediatric hospitalists often serve as primary educators for trainees in the inpatient setting and have prominent roles in medical education, uniquely positioning them to act as upstanders to support trainees against professionalism violations. Medical education leaders must work diligently to dismantle the hierarchical structure that lends itself to historical power imbalances that in turn stifles trainees from speaking out about incivility from fear of retribution. Strategies to create a psychologically safe environment include ensuring easy access to a system for anonymous and confidential reporting, faculty training focused on fostering positive interpersonal relationships within the health care team, and clear communication of antiprofessionalism policies with staff.

The consequences of inaction are dire. Every day, on average, 1 physician dies from suicide in the United States.¹⁶  In 2017, 1 in 15 physicians reported having suicidal thoughts.¹⁷  Statistics are important but should not be the emphasis. No life should be lost as a result of occupational stressors, toxic work culture, and system issues. Although burnout recognition and reduction among the medical community have become a national priority in the past decade, challenges are growing and solutions are trailing. When reviewing targeted initiatives summarized by Tawfik et al, efforts to date have focused heavily on assessment and data collection.⁴  Although this is progress, assessment itself does nothing to effectively tackle the pervasive “unwellness” that is plaguing our medical community. We must move beyond just knowing to doing, from awareness to tangible action. Our field must seek to unravel the fabric of heroic stoicism that has been deeply woven within our medical culture and activate toward sustaining a healthier, more fulfilled physician workforce.

We need to push past the stigma surrounding mental illness and advocate to reform intrusive medical licensure questions about mental health that preclude physicians from seeking help because of a fear of losing their ability to practice medicine. We must expand access to affordable mental health support for trainees and practicing physicians, supporting large-scale initiatives such as an annual opt-out mental health screening and virtual counseling at a subsidized cost. We need to invest, support, and promote future studies in this area, with special consideration for research that aims to directly amplify the physician’s voice. Organizations must prioritize creating infrastructure to centralize organizational wellness efforts by creating executive roles such as chief wellness officers and providing the appropriate funding and team to support it. These roles seek not only to lead the efforts of change, but also serve as a reminder for organizations to have accountability in communication with their active workforce. We must actively change key drivers of burnout that have been extensively identified in the literature, such as decreasing the burden of electronic health records, delegating clerical tasks, and optimizing shift-based schedules.⁹  Last, we must leverage the power of vulnerability and recognize the impact individuals have to model humanistic behavior that promotes a psychologically safe and inclusive environment.

Physicians cannot keep pouring from an empty cup because of a service-driven calling. This report charges leaders to reimagine a culture that values humanity over invincibility and emphasizes the critical need to support individual and organizational well-being. It summarizes the encouraging work that has been done in the field of physician wellness in the past decade, while highlighting many contributing factors and opportunities for improvement that organizations and individuals can continue to work on. We applaud the AAP for setting the example and committing to the holistic health and support of pediatricians regardless of sex, race, training level, or specialty. An investment in the well-being of pediatricians is an investment in the future of our children, our communities, and the health of our nation.