Stay Out of my Wellness


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

5 replies »

  1. It seems to me that the attempts by the “Human Resources” folks to associate “professional development” with an employment evaluation focused on salary, benefits or institutional advancement have NOT led to any true improvement of Human Capital as an asset ( aka its economic appreciation ). So, what could represent a process to improve the person’s accommodation to all of the distractions that might interfere with a professional career?

    The book “First things first” by Steven Covey describes a process that, annually reviewed, might create a structure to periodically describe in writing a means to mitigate the lack of clarity that a highly professional person encounters daily. My adaptation of the process begins with a professional mission statement (usually takes 2-3 years to “get it right” ). Then using an array of VALUES ( such as Altruism, Excellence, Trust, Cooperation and Reciprocity ), the evaluation begins with a brief analysis of the concordance and dissonance that exists between the person’s and their employer’s MISSION STATEMENT. The third portion of the process should involve a written PLAN using the Values structure to ameliorate their own Mission Self-evaluation for the coming year including a date to for its re-evaluation. The PLAN elements might include stress management processes but avoid the personal aspects of professional development (usually a difficult distinction). At least 1/2 of the Plan’s elements should be accurately measurable and one of the elements should relate to the employer’s institutional VISION (however remote that might be). Finally, the person’s supervisor (or mentor) agrees to take certain steps to facilitate the PLAN including an effort in 11 months to verify the f/u review date in advance. As an aside, I am not in favor of using mealtime or “after hours” for these conversations AND more than 40 minutes rarely adds any value.

    As an aside, this process was the most important strategy for building a Team level of function during my active practice years. During our 13 years with a gatekeeper, capitated and an all-other “stop-loss protected” 50% risk-sharing fund, we never had a negative risk sharing year.

  2. Count me just a bit skeptical. Hours are much more limited than we had in training. We just don’t tolerate the really awful, aberrant behavior on the par to staff that used to be so common, maybe even the norm, especially in the surgical specialties. Training needs to be at least a bit stressful. So, if someone isn’t coping well in training I doubt that is really burnout but just a lack of the skills/native talent/personality needed for the job.

    “I know of no medical school, hospital enterprise, or outpatient system that has an active professional development process.”

    That made me think. In our department we conduct classes in leadership with formal readings and a weekly class. We have very active mentoring. But professional development for everyone? I am not really sure what this would look like. We have education classes on a regular basis and active PI, but for most of our advanced practice nurses and docs, they aren’t really going up the ladder anywhere from where they are. Truth be told, a lot of days I am not so sure that doing administrative work is real a move up anyway. We do allow time, with pay, for people to work on projects that we think might improve pt care. What were you thinking about?


  3. I suspect that entry students for healthcare bring a different skill-set as compared 40-50 years ago. My ancient bias goes like this: people who grew up “closer to the land” were more resilient, applicable to patients as well as students.

  4. How can anyone be sick if the courses are exciting and the teacong is superlative? Impossible.

  5. The Grand Marshall of institutional management, Peter Drucker, wrote a book titled “Post-industrialist Society” published in 1993. As large industrial institutions that produced capital goods (steel, aluminum, bricks, pipes) began to be less prevalent, large institutions that managed information began appear. As opposed to capital goods, the value added for information transformation became much more difficult to assess and evaluate. Indirectly, this posed a dilemma for information based institutions represented by the need to improve their professional assets as a means for institutional growth. The usual investment strategies to increase the profits for capital goods did not apply. Peter Drucker’s answer was a need to invest in the professional assets of its professional employees through professional development. His assertion was that information management institutions eventually would not survive very well without an on-going investment in their professional Human Capital.
    So, 24 years later there is no evolving set of strategies for a commitment to invest in the Lynch-pin Human Capital required for healthcare: its physicians. I know of no medical school, hospital enterprise, or outpatient system that has an active professional development process. One year after the book written by Peter Drucker was published, Steven Covey et al published their book, “First Things First” in 1994. It is easily the best of their publications. I might add that a Social Capital investment strategy might be considered as well. Physician suicide is a terrible tragedy, especially for their families.