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Trainee Well-Being

More Important Than Ever
  • Colin P. West
    Correspondence
    Correspondence: Address to Colin P. West, MD, PhD, Divisions of General Internal Medicine and Biomedical Statistics and Informatics, Departments of Medicine and Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 (
    Affiliations
    Division of General Internal Medicine, Department of Medicine, Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
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      Physician well-being is a major concern in modern medicine. The unacceptably high prevalence of distress among physicians is well documented, as are its drivers.
      • West C.P.
      • Dyrbye L.N.
      • Shanafelt T.D.
      Physician burnout: contributors, consequences and solutions.
      ,
      National Academies of Sciences, Engineering, and Medicine
      Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.
      These largely reside within the work environment, and include excessive workload, inefficient work processes, suboptimal work-home integration, lack of workplace control and autonomy, and loss of meaning from work. In short, burnout and other forms of distress result when job demands chronically exceed job resources.
      Increasingly, guidance on solutions is also available, although widespread adoption of effective approaches to promote well-being and help physicians thrive in their careers has been limited to date. Individual-focused strategies such as mindfulness and stress management training offer documented benefit.
      • West C.P.
      • Dyrbye L.N.
      • Erwin P.J.
      • Shanafelt T.D.
      Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.
      ,
      • Panagioti M.
      • Panagopoulou E.
      • Bower P.
      • et al.
      Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis.
      However, it is important to recognize that physicians are more resilient than the general population on average,
      • West C.P.
      • Dyrbye L.N.
      • Sinsky C.
      • et al.
      Resilience and burnout among physicians and the general US working population.
      supporting the primary importance of organizational and structural solutions to promote well-being.
      Trainees are particularly vulnerable to experiencing distress.
      National Academies of Sciences, Engineering, and Medicine
      Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.
      Just as the main drivers of distress for practicing physicians involve conditions within the work environment; the main drivers of distress among learners involve conditions within the learning environment. Factors more uniquely relevant to trainees include grading and assessment stressors, workplace bullying and discrimination, and stigma around mental health concerns, exacerbated by learners’ common sense of being powerless to improve their situation given their place in the traditional medical hierarchy. However, these challenges present an opportunity for training programs to help residents toward professional fulfillment and establish the roots of a new, more positive culture for the future. The Mayo Clinic neurology residency and associated fellowship training programs have a long history of excellence and innovation,
      • Boes C.J.
      • Burkholder D.B.
      • Coon E.A.
      • Cusforth-Gregory J.K.
      • Klaas J.P.
      • Jones L.K.
      Reciprocal development and progressive responsibility: the history of the Mayo Clinic neurology residency.
      and in this issue of Mayo Clinic Proceedings: Innovations, Quality & Outcomes Ramanan et al
      • Ramanan V.K.
      • Inbarasu J.D.
      • Jackson L.M.
      • Jones L.K.
      • Klaas J.P.
      Promoting well-being among neurology residents: a data-driven approach.
      report on a structure to promote well-being for learners at these critical stages of their career development.
      Briefly, in response to recognition of high burnout rates in neurology as a field, the authors established a volunteer-driven Resident Wellness Committee with both resident and staff neurologist representation. This committee was organized to develop and advance interventions to promote resident well-being based on national and local evidence. To regularly assess and inform initiatives, the committee also developed a plan for repeated web-based surveys to measure well-being and related issues. As simple as this structure may seem, it illustrates several key features of successful efforts to promote resident well-being.
      First, direct resident involvement in all aspects of the process is crucial. Locally informed solutions have shown effectiveness in practicing physicians.
      • Linzer M.
      • Poplau S.
      • Grossman E.
      • et al.
      A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study.
      Representation is necessary to ensure that solutions address the real issues affecting a work group, as leaders and others outside a team may not have full insight into what the key drivers are for specific teams or individuals. Efforts by well-intentioned leaders to address well-being challenges “from a distance” often result in solutions those on the front lines view as missing the mark, and can unfortunately erode trust and a sense that leaders are listening with care. These risks can be avoided by ensuring that those most affected by problems and solutions are directly involved in the development, implementation, and assessment of approaches to promote well-being.
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      Second, supplementation of direct resident involvement with faculty representatives can offer important added benefits. This assumes that residents can maintain a safe space to share concerns, discuss issues, and openly weigh the merits of proposed approaches without fear of reprisal. If these aspects of the work and learning environment can be assured, inclusive representation of faculty and administrators may facilitate action steps. Faculty can develop a deeper understanding of the underlying issues and why proposed solutions align with resident needs, and can use this understanding to more effectively advocate for necessary implementation efforts. Faculty will often have more direct access to levers of change as well, including both financial resources and connections with organizational leadership. This partnership can demonstrate to residents that the faculty members they admire and seek to emulate are deeply and genuinely invested in optimizing the residents’ experiences and want to help them thrive in their training.
      Third, assessment is critical. Baseline measurement provides a reference point against which to gauge progress, and provides insight into what residents identify as the most important problems, barriers, and paths forward. Periodic reassessment can inform perceived and actual advances in well-being, and identify persistent and new areas requiring improvement. In crafting these assessments, teams should use interpretable, well-validated instruments where possible.
      National Academy of Medicine
      Valid and reliable survey instruments to measure burnout, well-being, and other work-related dimensions.
      As identified by Ramanan et al,
      • Ramanan V.K.
      • Inbarasu J.D.
      • Jackson L.M.
      • Jones L.K.
      • Klaas J.P.
      Promoting well-being among neurology residents: a data-driven approach.
      wide variability in approaches to measurement of well-being domains has been problematic, hampering our ability to consistently describe training environments and identify effective interventions.
      Finally, the initial solutions identified and developed through the structure described by Ramanan et al
      • Ramanan V.K.
      • Inbarasu J.D.
      • Jackson L.M.
      • Jones L.K.
      • Klaas J.P.
      Promoting well-being among neurology residents: a data-driven approach.
      align well with current knowledge of how best to promote physician well-being. Effectively addressing physician distress and promoting well-being requires a menu diverse enough to offer something for every resident and every faculty member. It is easy to overlook the importance of basic needs, but regular access to high-quality nutrition, exercise, and rest is key. In addition, residency training is a time when trainees often feel little or no control over how their days are spent, so efforts to provide schedule flexibility and dialogue with residents about their individual needs can minimize work-home interference. Perhaps most importantly, medicine is an inherently social profession, and we must commit to building strong communities to learn from and support each other. This is even truer in the coronavirus disease 2019 era of physical distancing, when direct personal contact and connection has been challenged and limited in a way modern medicine has never before experienced.
      Physicians must be well to offer the best possible care to our patients. Medical training affords us with an opportunity to model and inculcate the importance of attention to well-being in the interests of our patients from the earliest stages of each physician’s career development. Models such as that described by Ramanan et al
      • Ramanan V.K.
      • Inbarasu J.D.
      • Jackson L.M.
      • Jones L.K.
      • Klaas J.P.
      Promoting well-being among neurology residents: a data-driven approach.
      provide guidance toward achieving these goals.

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        Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.
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        Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.
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        Resilience and burnout among physicians and the general US working population.
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        Reciprocal development and progressive responsibility: the history of the Mayo Clinic neurology residency.
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        • Jones L.K.
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        Promoting well-being among neurology residents: a data-driven approach.
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        • Poplau S.
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        J Gen Intern Med. 2015; 30: 1105-1111
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        Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
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        Valid and reliable survey instruments to measure burnout, well-being, and other work-related dimensions.

      Linked Article

      • Promoting Well-being Among Neurology Residents: A Data-Driven Approach
        Mayo Clinic Proceedings: Innovations, Quality & Outcomes Vol. 4Issue 5
        • Preview
          To assess whether the creation of a formal structure to measure and promote wellness among neurology residents would facilitate the development of interventions associated with measurable improvements.
        • Full-Text
        • PDF
        Open Access
      • Reciprocal Development and Progressive Responsibility: The History of the Mayo Clinic Neurology Residency
        Mayo Clinic Proceedings: Innovations, Quality & Outcomes Vol. 4Issue 5
        • Preview
          The first Mayo Clinic neurology resident began training approximately 1 century ago. Over the subsequent 100 years, 639 budding specialists in diseases of the nervous system graduated from the Mayo Clinic Neurology Residency in Rochester, Minnesota. The history of the American residency has been thoroughly covered by Ludmerer in his 2014 book Let Me Heal,1 and a history of the Mayo Clinic Otolaryngology Residency Program was published in 2020.2 Mulder discussed education in the Mayo Clinic Department of Neurology as part of an overview of the history of the department in 1971.
        • Full-Text
        • PDF
        Open Access