Burnout: Is Medical School the Staging Area?
Burnout prevention starts in medical school
Burnout is typically not a rapid onset condition and for many there are signs of the condition as early as medical school or post-graduate training.
In recognition of this, some medical schools and residency programs are taking steps to address burnout as an early career issue. "You might not be able to change the clinical environment, but you can change their response and the choices they make," said Vineet Arora, MD, a faculty physician and assistant dean at the University of Chicago Pritzker School of Medicine.
A New Curriculum
One way to do this is to induce a greater resiliency in physicians in training. The Association of American Medical Colleges is now encouraging schools and residency programs to cultivate resilience in young physicians. Among its "intrapersonal competencies" for entering residents the AAMC includes "resilience and adaptability." That is, a doctor who can demonstrate tolerance of stressful or changing environments or situations and adapt effectively to them.
"While most of us would say that medicine is the most gratifying, stimulating, and noble career a person can pursue, many of our colleagues are in genuine distress," said AAMC President Darrell G. Kirch, MD, last year. "Resilience is what drives us forward and inspires us to take on difficult challenges and to keep trying in the face of doubt and failure."
Studies show that about a quarter of medical students are depressed, half of them experience burnout, and most of them report quality of life substantially worse than the same-age general population. To screen for distress among medical students Lotte N. Dyrbye, MD, and colleagues at the Mayo Clinic developed a Medical Student Well-Being Index. The index correlates with quality of life, fatigue, recent suicidal ideation, burnout, and the likelihood of seriously considering dropping out of medical school.
It is easy and convenient to think that people who go into medicine have a certain kind of perfectionist personality that predisposes them toward burnout, Dyrbye said. Her research into what kind of person enters medical school convinced her the opposite was true. "When they come in the door, medical students have better or similar levels of mental health than others," with lower prevalence of depression and a higher quality of life reported in most arenas, she said.
Wellness and Resilience
The University of Chicago has incorporated wellness and resilience into the undergraduate and graduate medical curricula. Wei Wei Lee, MD, is assistant dean of students and directs the wellness program at Pritzker. "One of the domains of competency is professionalism," she toldMedPage Today. Medical students need to recognize personal and professional development as a skill. That means they must acquire healthy coping mechanisms, become aware of stress, and learn to be flexible and mature and adjust to change.
She has assembled a student committee on wellness, with four representatives from each class, that meets monthly. The committee develops programs to address burnout and holds social events to build student camaraderie. The school is building a portfolio for the students on teamwork and leadership skills as well.
Students do a self-assessment twice a year of their physical well-being, mental well-being, and health-seeking behaviors. They set specific goals they want to work on in the next 6 months. This becomes part of their personal and professional development portfolio. The committee then develops events around the themes that the students are interested in.
"Out of these self assessments, we're now putting together mandatory session on mental health in the medical profession," Lee said. The school wants to destigmatize issues around mental health, and talk about it in an open atmosphere. "We want to normalize that health seeking is not punitive, that there is a supportive community of faculty staff and peers out there." Since the program started in the 2014-15 academic year, student engagement has been high, she said.
The program on resiliency for residents at Chicago was led byAmber-Nicole Bird, MD, now an assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine. A survey of residents at the University of Chicago Medical Center revealed that all of them had experienced it in their training but the majority felt they had no outlet to discuss the issue.
"We felt like there were plenty of interventions available that focused on wellness: healthy eating, sleep management, taking care of yourself," Bird said. But residents didn't think those worked. "We thought, what if we could look at a different marker, say, resilience? Those individuals with lower resilience look at it in a different way, or have more downstream consequences. Maybe we could train them to be more resilient."
The team leaders used the Connor-Davidson Resilience Scale to quantify resilience in residents. They divided the scores between low, intermediate, and high. The average was 70 out of 100. Those who scored lower than 40 were deemed to be at high risk in managing stress. A program was created emphasizing setting realistic goals, managing expectations, processing and letting go after stressful clinical events, and finding gratitude.
From August to March of the 2014-15 school year, small group sessions were held to introduce the main skill, for example, managing and letting go after stressful clinical events. Students were invited to discuss why it was stressful, what it felt like, how they managed it.
Gratitude
Then came a skill building exercise for letting go, including a systems analysis of medical error. "We would have the residents write a narrative of an episode they were involved in that was stressful," Bird said. "We would then have them rewrite the story, remove the 'I', tell the story from the third person as it occurred. Then we asked them to identify where there were other actors at play that contributed to the error."
A similar exercise was created around finding gratitude.
Residents at first were skeptical of the program's value, Bird recalled, but that evaporated as the year progressed. "At the end, we had great feedback. Just under 70 percent of the residents who went through the program wanted it to be continued," she said.
The qualitative feedback showed that the program fostered a sense of shared experience. That was important for the residents, because it "gave them time to process an experience where they felt alone," Bird said. "It was therapeutic."
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