By VA WEST HAVEN COE CLINIC
On a sunny New England morning at a secluded guest house with a perfectly manicured lawn, medical residents, each with their own brightly colored yoga mat, were getting ready to assume the downward dog position. They were on an annual retreat organized by their residency program to promote wellness. One embraced the opportunity with delight, smiling through every pose. Another grimaced as his back spasmed. And yet another wandered off towards a lake to find his own kind of respite.
Physician wellness has become something of a buzzword in recent years, and rightfully so considering that the rates of burnout and suicide within medicine are rising. Individual residency programs have found burnout rates between 55% and 76%. Such burnout erodes well-being over time and may be contributing to suicide, which is now the second leading cause of death among residents nationwide. In 2014, the suicides of two medical interns in New York prompted the American College of Graduate Medical Education to take action. A series of initiatives to combat burnout were rolled out, including the consideration of wellness in its review of residency programs during site visits. In 2017, emergency medicine physicians convened the first Residency Wellness Consensus Summit to devise a module-based curriculum on wellness. Hospital systems have attempted to respond as well, through the hiring of chief wellness officers.
It is unsurprising that the medical community has taken such an analytical approach towards diagnosing burnout, much as we do with other diseases, in search for a cure. But perhaps such a prescriptive approach fails to capture the highly individualized and somewhat abstract concept of wellness. The reasons for resident burnout are personal and vast. Decreased wellness has been attributed to the lack of time for self-care, inadequate sleep, social isolation, negative work environments, excessive paperwork, long work hours, poor relationships with colleagues, and insufficient mentorship, among others in a lengthy list. Any attempt to standardize the definition of wellness should be met with caution.
So how do we as a society go forward in ensuring our resident physicians are well?
While some of the initiatives mentioned above are sure to help, perhaps residency programs can take a cue from educational psychology, where unstructured time for school-aged children has been linked to greater social success in adulthood. The Montessori educational approach to early schooling was developed in the early 20th century and is largely based on providing unstructured time. In this educational model, children are encouraged to actively explore the classroom and engage in self-directed activities. Montessori schooling has been shown to build a stronger sense of community, creativity, and response to social dilemmas among children. The approach has also been widely adopted by the business and tech industries as a method for promoting innovation, teamwork, and productivity. Why should a similar approach to wellness not be attempted in residency?
To be sure, many residencies are already being proactive about implementing changes in favor of wellness. Our own residency program ensures that each resident individually meets with a psychologist during the first week on the job and checks in with faculty at least twice a year in an attempt to catch a resident who may fall through the cracks. A new Call-a-Friend program provides all residents with a list of colleagues who are willing to be called at any time. But while we appreciate the intent behind free laser tag, massages, spinning classes, and raffles, we should not expect that these changes will make us all well.
During our long journey from college to residency, where overachievement is expected and 80-hour work weeks are the norm, some of us may have forgotten what makes us well. And we must keep in mind that what may have kept us well in the past may no longer be applicable in the present. We need self-discovery that comes with unstructured time to become better and make ourselves truly well.
Wellness is not a one-size-fits-all concept. What resident physicians need is the unstructured time to define for themselves what wellness is, to seek it out, and to feel guilt-free in doing so.
The authors of this piece are Eugenia Betz, Caroline Falker, Leila Haghighat, Sumit R. Kumar, Mona Lalehzari, Benjamin Y. Lu, J. Nicholas Pumilia, Jonathan Stock, MD & Anna Reisman. They are all MDs from the VA Centers of Excellence in Primary Care Education, West Haven Veterans Affairs Hospital, West Haven, CT & the Department of Internal Medicine, Yale School of Medicine