Medical education research

March 4, 2020


          Part of the CEEP selective involves exploring an aspect of medical education research. This was something that I was also very excited about as I had relatively recently become interested in medical education after working on a project to improve our advocacy curriculum. Something that has crossed my mind in the past few years is the topic of physician burnout. During clerkship, burnout seemed to be prevalent no matter where I went. Sadly, it seems that there is no real intervention in place to help with this. The topic of resiliency came up a lot during these conversations, often accompanied by some measure of contempt. As a medical student who will be entering residency training soon, I became concerned about how I would personally manage burnout but also how could we improve the system to support wellness in the future.

          As I delved into the literature, there has been a huge number of studies studying physician burnout. Burnout is a widespread phenomenon that affects approximately 30-50% of physicians, and is particularly prevalent during residency training (1,2). Burnout is a response from exposure to chronic stress that results in a syndrome involving exhaustion, depersonalization, and a sense of low personal accomplishment (3). This has been linked to medical errors, unprofessional conduct, and decreased altruism, which can be detrimental to patient care as well as compromising the physicians’ own well-being and safety associated with substance use and suicide (4). Unfortunately, there continues to be stigma and normalization associated with burnout that makes burnout challenging to address (5). Given that professionalism is one of the core competencies of the CanMEDS Physician Competency Framework, which includes a “responsibility to self, including personal care, in order to serve others,” tackling burnout is important to ensuring both physician and patient safety (6).

There are many factors that contribute to burnout, including: long hours, heavy workloads, sleep deprivation, exposure to intense emotional experiences, poor control over scheduling, changing work environments, and a high burden of administrative tasks (7). Additionally, the culture of medicine itself has been found to be a barrier to physician wellness as there is a strong expectation to be a “superhuman” and to prioritize work over personal time and self-care (5).

            Many studies investigating ways to manage physician burnout focus on improving resiliency training (8). Resiliency can be described in many ways but essentially allows one to thrive in the face of adversity. In order to implement resiliency strategies, there needs to be self-awareness to recognize the need for self-care. Formalized resiliency curriculum involves skill-building workshops on topics such as meditation, mindfulness, and managing expectations (9).

            A randomized clinical trial of 74 practicing physicians found that participation in biweekly facilitated discussion groups incorporating elements of mindfulness, reflection, shared experience, and small-group learning during 1 hour of protected time resulted in significantly improved empowerment and engagement at work, decreased depersonalization, emotional exhaustion and overall burnout (10). Another study found that a resiliency curriculum with sessions on setting realistic goals, managing expectations, letting go of medical errors, and finding gratitude was considered very valuable to interns to mitigate stress (11).

The discourse around well-being focuses on training individuals to have the skills in resiliency to combat adversity. However, there has been criticism to this approach as it places a strong responsibility on individuals to manage their burnout as if this was a result of a personal deficiency in resiliency rather than external barriers to wellness such as systemic organizational issues. Although addressing systemic issues is a daunting task, it can be guided based on the six categories of work stress by Maslach and Leiter: 1) workload, 2) control, 3) balance between effort and reward, 4) community, 5) fairness, and 6) values (12,13).

-JT-

References:

1.        Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med. 2006;81(1):82–5.

2.        Thomas NK. Resident burnout. Vol. 292, Journal of the American Medical Association. American Medical Association; 2004. p. 2880–9.

3.        Maslach C, Leiter MP. Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry. 2016 Jun 1;15(2):103–11.

4.        Dyrbye LN, Massie FS, Eacker A, Harper W, Power D, Durning SJ, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA - J Am Med Assoc. 2010 Sep 15;304(11):1173–80.

5.        Ironside K, Becker D, Chen I, Daniyan A, Kian A, Saheba N, et al. Resident and Faculty Perspectives on Prevention of Resident Burnout: A Focus Group Study. Perm J. 2019;23.

6.        The Royal College of Physicians and Surgeons of Canada :: CanMEDS Role: Professional [Internet]. [cited 2020 Mar 1]. Available from: http://www.royalcollege.ca/rcsite/canmeds/framework/canmeds-role-professional-e

7.        Edmondson EK, Kumar AA, Smith SM. Creating a Culture of Wellness in Residency. Acad Med [Internet]. 2018 Jul 1 [cited 2020 Mar 1];93(7):966–8. Available from: http://insights.ovid.com/crossref?an=00001888-201807000-00010

8.        West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016 Nov 5;388(10057):2272–81.

9.        Bird A, Pincavage A. A Curriculum to Foster Resident Resilience. MedEdPORTAL Publ. 2016;12(12).

10.      West CP, Dyrbye LN, Rabatin JT, Call TG, Davidson JH, Multari A, et al. Intervention to promote physician well-being, job satisfaction, and professionalism a randomized clinical trial. JAMA Intern Med. 2014 Apr 1;174(4):527–33.

11.      Bird A-N, Martinchek M, Pincavage AT. A Curriculum to Enhance Resilience in Internal Medicine Interns. [cited 2020 Mar 1]; Available from: http://dx.doi.org/10.4300/JGME-D-16-00554.1

12.      Jennings ML, Slavin SJ. Resident Wellness Matters. Acad Med [Internet]. 2015 Sep 1 [cited 2020 Mar 1];90(9):1246–50. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00001888-201509000-00024

13.      The Truth About Burnout: How Organizations Cause Personal Stress and What to ... - Christina Maslach, Michael P. Leiter - Google Books [Internet]. [cited 2020 Mar 1].