The Pitfalls of Wellness Programs and What We Can Do About It: A Resident Perspective

Shilpa Krishnan, D.O., PGY-2

Atrium Health Sandra and Leon Levine Psychiatry Residency in Charlotte, NC

 

Laura Williams, D.O., PGY-3

Cape Fear Valley Residency Program in Fayetteville, NC

 

“Burnout” is often the term used to describe the mental exhaustion that health professionals face, sometimes manifested as depersonalization and low sense of professional efficacy. According to the Medscape 2021 Physician Burnout and Suicide Report, 41% of psychiatrists reported burnout; across all specialties the rate was 42%.1 Among resident physicians in particular, existing data shows a significant prevalence of mental distress. A national study of U.S. internal medicine residents from the 2008-2009 academic year showed an overall burnout rate of 51.5%.2 A more recent systematic review of resident physicians done in 2015 found an overall prevalence of a major depressive episode among residents to be 28%.3

The COVID pandemic has created additional stresses, emotional exhaustion, and dissatisfaction. Residency, by its very nature, is difficult; residency during a pandemic is even harder. For residents, healthcare workers, and all hospital employees infected with COVID, they experience the stress of the infection, and then the stress of returning to work while recovering. Their colleagues experience pressure to keep up with the workload as COVID spreads. This stress, this pressure, continues to mount as it seeps through hospital systems.  The stress is palpable at every level of care and a stressed leadership affects all those beneath them.

As of early January, we are faced with not just the normal stressors of residency, or the “normal” stressors of the pandemic, but the mounting stressors of government systems that increasingly treat healthcare personnel as expendable. Facebook groups consisting of healthcare workers are filled with posts and memes using humor as a defense mechanism to show just how much the CDC guidelines have made employees feel disposable. And we cannot fault the administration or the hospital for just following federal guidelines.

Naturally, the conversation turns to wellness – a word that we value in psychiatry and try to emphasize the importance of to our patients. Perhaps more than most specialties, we care for both the bodies and minds of our patients. But we are also physicians, notorious for, “do as I say, not as I do.” Nationwide, it’s estimated that roughly 300-400 physicians die by suicide every year.4 A 2013 study using data collected from the United States National Violent Death Reporting System found that physicians who died by suicide were less likely to have received mental health treatment compared with nonphysicians who took their lives.5

Dr. Pamela Wible, activist, and author of Physician Suicide Letters—Answered, has stated that medical education is, “a profoundly dehumanizing experience and it’s drilled into you: ‘Do not show your heart or tears to anyone, ever again.’” To be fair, we have turned a major corner away from the “work until you drop” mentality that was seen for decades within medical education. In recent years the Accreditation Council for Graduate Medical Education (ACGME) has made a push to encourage and prioritize wellness in medical schools and residencies more than ever.

 As a result, wellness initiatives within residency programs have grown in the last several years. Consisting largely of lectures on improving wellness, scheduled group activities, and creating so- called “wellness committees,” these initiatives aim to reduce overall stress. The programs are conducted with good intention, and sure, it is nice every now and then to participate in a yoga session or attend an organized social event. However, these initiatives are not what physicians are asking for and do not provide a solution. The Medscape 2021 Physician Burnout and Suicide Report shows that physicians do not want more education on the importance of wellness, sleep, diet, mindfulness, etc. The top four recommendations made by physicians are: 45% want increased compensation to avoid financial stress, 42% want more manageable work and scheduling, 39% want respect from administration/colleagues/staff, and 35% want increased control and autonomy.1

These wellness initiatives as they are currently conducted, do not address more severe forms of mental illness that many residents suffer from. There are resident physicians who have major depression, bipolar disorder, substance dependence, anxiety with panic, post-traumatic stress, obsessive compulsive disorder, and may even experience episodes of psychosis. We are all human after all. Unfortunately, the stigma of mental illness among physicians persists. For fear of consequence, residents often do not disclose their struggles with mental illness to peers, faculty, or program leadership. This is true within psychiatry as well; for as much as we, as mental health providers, empower our patients and attempt to destigmatize mental illness in the general population, a culture of stigma and silence persists within our community of practitioners.

Considering all of this, what are possible “wellness” solutions? We propose three ideas here.

1. Destigmatize mental illness. As resident physicians, disclosing emotional distress to faculty and program leadership should not count against us. It is imperative that there exists a safe space within every residency program for residents to speak up when they are struggling, without judgment or fear of consequences, personal or professional. Though national bodies such as the ACGME and AMA ask residents annually about wellness through online surveys, these questionnaires can be burdensome and often do not directly lead to sustainable solutions.

2. Shift away from a “work horse” driven model to a work-life integration model. Many hospitals across the country have a resident-dependent care model. In contrast, imagine a residency program/curriculum that prioritizes resident education. It would consist of a robust workforce of attending physicians and faculty members.  It would allow flexibility for residents to obtain varied clinical experiences, explore professional interests, engage in scholarly activities, and be invested in didactic education. It would allow time for doctors’ appointments and taking sick days. It would create a work-life integration that is key to maintaining wellness.

3. Provide necessary mental health and psychiatric services. It is crucial that residents have access to mental health care. With any residency, we would argue this is true. But with psychiatry residency, given the unique emotional weight of patient interactions and psychotherapy training, it is critical. Furthermore, for psychiatry residents, it is not enough that therapy be encouraged; rather, psychotherapy from a licensed professional should be incorporated within the program curriculum itself. Certain North Carolina psychiatry residency programs, such as Atrium Health in Charlotte, pay for their residents to receive psychotherapy for one year. Having residents be therapy patients themselves not only allows for improvements in one’s own mental health, but also expands emotional awareness and insight into the therapeutic process. Having it integrated into training removes the fear and anxiety that one will be viewed negatively for seeking help.

These are necessary steps to take. However, there also needs to be major changes far above the hospital level. We have been bred in this culture of work, work, work – go, go, go. To maintain a healthy mind and body, the culture needs to change – and physicians are demanding it.

References

  1. Kane, L. (2021). Death by 1000 cuts: 2021 Physician Burnout and Suicide Report. Medscape. https://www.medscape.com/slideshow/2021-lifestyle-burnout-6013456#1
  2. West, C. P., Shanafelt, T. D., & Kolars, J. C. (2011). Quality of Life, Burnout, Educational Debt, and Medical Knowledge Among Internal Medicine Residents. JAMA, 306(9). https://doi.org/10.1001/jama.2011.1247
  3. Mata, D. A., Ramos, M. A., Bansal, N., Khan, R., Guille, C., Di Angelantonio, E., & Sen, S. (2015). Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis. JAMA, 314(22), 2373–2383. https://doi.org/10.1001/jama.2015.15845
  4. Kalmoe, M. C., Chapman, M. B., Gold, J. A., & Giedinghagen, A. M. (2019). Physician Suicide: A Call to Action. Missouri medicine, 116(3), 211–216.
  5. Gold, K. J., Sen, A., & Schwenk, T. L. (2013). Details on suicide among US physicians: data from the National Violent Death Reporting System. General hospital psychiatry, 35(1), 45–49. https://doi.org/10.1016/j.genhosppsych.2012.08.005