From burnout to balance

Suck it up.

Is there an EVMS student or resident physician who hasn’t thought that at some point?

The pressures of medical school, the stress of a rigorous health-professions program, the life-and-death decisions residents must make — all bring higher rates of burnout, depression and suicide risk than in the general population. Medical educators nationwide are dealing with the fallout of rising stress and even suicide among students and residents. In 2016, an EVMS resident tragically took his own life.

“Historically, the culture of medicine has included a work ethic of long hours and a commitment to patient care that supersedes self-interest,” says Linda Archer, PhD, Vice Dean for Graduate Medical Education and Professor of Family and Community Medicine. “The public has embraced that work ethic, and it has been an expected role for physicians.

Paradoxically, those long hours and intense commitment can sometimes be detrimental to patients in the form of increased medical errors and a lower quality of care. To address the issue, a new approach is promoting wellness and resiliency among the future healthcare workforce.

“Well-being has to be considered as important as having the technical skills and knowledge to be a medical professional,” says Dr. Allison Knight, Assistant Dean of Student Affairs and Assistant Professor of Psychiatry and Behavioral Sciences. “Medical institutions have an ethical responsibility to provide a culture that supports the well-being of our students.”

Today, EVMS is setting a precedent in establishing values, programs and initiatives to support a culture of wellness and resiliency — and to set up students and residents for long-term success.

The Diagnosis

At any given moment, the United States has more than 40,000 medical students and more than 60,000 resident physicians.

Among students, stress is rampant. In a 2016 study published in the Journal of the American Medical Association, 27 percent of medical students were found to have depression or depressive symptoms, and 11 percent reported suicidal thoughts. Overall, the students were two to five times more likely to have depression than the general population.

One reason is the tough competition for residency programs, training that’s required before physicians can practice medicine. The growing number of medical schools is producing more graduates each year, but the number of residency slots — which are mostly funded by Medicare — hasn’t increased in 20 years. Students are so concerned about this competition that some choose a medical school based on specific programs it has in place to make them highly competitive.

“Before they even arrive on campus,” Dr. Knight says, “students are asking us what we do to help them prep for their national board exams and residency interviews.”

For physicians who do receive residency slots, 28 percent experience a major depressive episode during training, according to the American Foundation for Suicide Prevention.

That’s four times greater than similarly aged individuals in the general population.

For first-year residents, resiliency just became more crucial. As of July 1, the cap of 16-hour shifts for first-years, implemented in 2011, was lifted by the Accreditation Council for Graduate Medical Education. Now they’ve joined all other residents in being allowed to work up to 24 hours in a shift, although some EVMS residency programs have instituted their own lower caps.

The change was made, according to the council, to limit the number of patient handoffs from doctor to doctor and to improve training by enabling new residents to follow patients for longer periods.

But with those kind of hours, residents are often too busy to eat right, work out or spend time with family and friends. And with this training comes their first professional responsibility for patient suffering and death.

Yet despite the high stress levels, residents and students are less likely than others to seek treatment. According to a recent Mayo Clinic study, only about one-third of their sample students who identified as burned out said they sought help. The major issue for most is the stigma of moving from caregiver to patient.

For medical professionals, talking about their own well-being used to be taboo. They feared being thought of as impaired or not up to the demands of a heavy workload. But that’s changing, says Elza Mylona, PhD, Vice Dean for Faculty Affairs and Professional Development and Professor of Internal Medicine.

“Health professionals who are aware of the importance of stress management and healthier lifestyles are more effective than their peers in successful health counseling,” Dr. Mylona says. “They garner more trust and generate better follow-through from patients.”

The Treatment

Today, EVMS students and residents can access new resources to relieve the pressures that accompany medical education and training.

“With the recognition of the personal and professional toll that this lifestyle has taken,” Dr. Archer says, “we’re now seeing a move toward better work-life integration for physicians. This does not mean that the commitment to patient care is any less important, but that we must train medical professionals how to better integrate work-life needs and provide them with self-care skills.”

After David Taylor was diagnosed with generalized anxiety disorder at age 12, he learned to control it. When he entered EVMS’ Physician Assistant program in 2015, he assumed he could use the same tactics.

“But there’s something unique about medical education — it’s a whole other animal,” Mr. Taylor says. “The level of stress and burnout is intense, especially if you just push the rest of the stuff in your life to the back burner.”

Serina Neumann, PhD, Professor of Psychiatry and Behavioral Sciences and a licensed clinical psychologist, has seen many students adjust well. “But others lose their traction,” she says. “Then they stop doing the activities that help them cope and remain resilient to stress when they begin to feel overwhelmed. They begin to lose confidence in their abilities. I see the same process happening with some of our residents.”

In the Physician Assistant (PA) program, Mr. Taylor was putting in about 60 hours a week. He struggled to balance the work with his personal life. Then a few family members and friends passed away, and his grades began to drop. Mr. Taylor realized he wasn’t dealing appropriately with his stress and anxiety, so he turned to the mental-health and academic resources available at EVMS.

Some of the newest wellness resources came with EVMS’ award-winning CareForward curriculum. Implemented in fall 2016, the four-year longitudinal curriculum integrates student wellness as a guiding principle.

“We’re trying to give students the self-care skills they need to flourish in their careers later on,” Dr. Knight says. “We’re one of the few schools that actually has a true curriculum. There are schools doing a lot of wellness activities, but at EVMS, we’re developing an empirical curriculum that is mandatory for all of our students.”

For residents and fellows, the Accreditation Council for Graduate Medical Education (ACGME), one of EVMS’ accrediting bodies, also has recognized the value of wellness. This past July, the ACGME Common Program Requirements added a well-being category for all residency and fellowship programs. Among the requirements is education in resident burnout and depression, along with a provision for services and resources for care.

Before that well-being requirement was added, EVMS had launched a new resource for residents and fellows called Final Rounds. This monthly meeting, first held in 2016, is a safe space for trainees to explore their feelings after challenging experiences, such as the loss of a patient.

“We’re trying to foster a safe environment for them to talk openly,” says Marissa Galicia-Castillo, MD (MD ’97, Internal Medicine Residency ’00), the Sue Faulkner Scribner Distinguished Professor in Geriatrics, Associate Professor of Internal Medicine and Section Head of Palliative Medicine.

Ami Mehta, MD, Pediatrics Chief Resident 2017, attended Final Rounds every month through her chief-residency year. “I wanted to be able to process feelings I was experiencing,” Dr. Mehta says, “and I wanted my residents to know there was a resource for them.”

Physicians often come to care deeply for their patients, she says, and are devastated when they lose someone. “With Final Rounds, I don’t have to lay that burden on my co-workers or my family. The people in this group understand and have had similar experiences. We teach other.”

Dr. Galicia-Castillo says resources like Final Rounds and wellness programs are needed to create a culture shift. “If burnout is in the profession, then we’re seeing it in the trainees — because who are their role models?”

Through his recent struggle, PA student David Taylor learned the value of reaching out. “At EVMS, it’s OK to ask for help,” he says. Once his life regained balance, he was able to return to his program and raise his grades.

“Medical education is too fast-paced to hesitate to wave the white flag,” he says. “The reason I talk about this is the stigma needs to be broken, and people need to be healed.

“You can’t help others if you’re not healthy yourself.”

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Need help?

EVMS provides a variety of wellness resources and programs to students, residents and fellows. Here’s a sampling.