47: Trainee Well-Being

Becoming a health professional is a challenging and complex process. Trainees frequently experience stressors that exceed their previous life experience and coping skills. These demands are proportionate to the responsibility and complexity of caring for patients in all their variability and vulnerability. These demands of professional training are enormous, and trainees often neglect their own physical, emotional, relational, and spiritual health; however, a central component of professionalism is awareness of one’s own limits, and mindfulness about the wise allocation of one’s energy in providing quality patient care (see Chapters 6 and 7). Neglect of this awareness may sow the seeds of burnout and lead to poor quality care and medical error (see Chapter 37). Close attention to maintaining well-being, however, can enhance satisfaction with medicine as a career and optimize the clinician–patient relationship. Given that trainees are vulnerable to pressures to postpone their own well-being until training is completed, it is paramount to include promotion of self-care in the formation of health professionals.

A common trait of physicians is compulsivity. Although many attributes of compulsivity—thoroughness, accuracy, second guessing, monitoring changes—are beneficial to patient care and success in medical training, this trait may also erode the personal health, satisfaction, and well-being of the physician. Early in her training, Jill is manifesting many of the associated characteristics of compulsivity that if unchecked by reflection can lead to cynicism and burnout by the time she is a resident. She is beginning to question her competence, in spite of the fact that she is in the top fifth of her class. Ultimately, she is at risk of developing what has been labeled the “imposter syndrome,” in which the individual feels that she has fooled others into thinking she is competent, but the threat of being unmasked lurks at every turn. Jill is also feeling guilt about not having been wiser in her allocation of time. No matter how hard she has worked, it does not seem to be enough. In addition to self-doubt and guilt, Jill is also carrying a burden of responsibility for meeting all her obligations, and she feels alone with that burden. She thinks about her peers enjoying an outing together and envisions continued isolation for herself in the library. This triad of doubt, guilt, and an exaggerated sense of responsibility has been described by Gabbard as constituents of the compulsivity that is a “normal” trait in most physicians.

Jill’s discontent has its roots in the early conditioning of many bright young people in American society that implies that our value or worth as persons is linked to academic success or outward performance. Most of us have an inherent need for love and acceptance, and when children are repeatedly told that they are special and valued only when they are “exceptional,” that is, at the top of their class in grades and stars in various performance endeavors, they begin to link their personal worth to meeting these standards of excellence. This high need for achievement collides with the reality that many of one’s peers in medical school also came from the top of their class and consequently being smart and performing well are not so exceptional. They must work harder to stand out. Being less than outstanding is construed as having failed to meet an essential marker of their worth and value as a person. They are left with the dilemma of backing off from overwork and consequently carrying the self-stigma of being “second best,” “ordinary,” “mediocre,” and unconsciously feeling less lovable; or of working harder to stand out. Paradoxically these efforts to excel and “stand out” can lead to the very isolation and loneliness from which they are trying to escape.

Some trainees may have the nagging thought that overwork is not good for them, that taking care of themselves by getting enough sleep, exercise, eating well, having fun, and spending time with friends are all important; but in the “psychology of postponement” they think, “As soon as this exam is over, then I can unwind.” In addition, their elevated expectation of themselves multiplies this self-bargaining: “As soon as I get into the residency I want, then I can relax;” “as soon as I get accepted for a fellowship, then I can start working out;” “as soon as I start my first real job, then I can have a life.” Thus, early in professional training a habit of postponement can develop that if unchecked can lead to neglecting many of one’s most valued relationships and activities throughout one’s career. Sir William Osler in a commencement address to graduating medical students in 1889 had these words to say about postponement:

Jill’s story also illustrates the insidious manner in which the system of medical education with its overt and covert rewards and punishments can reinforce the student’s inherent compulsivity. Her exceptional performance has been noticed by one of her professors, who asks her to work with him as coauthor on a paper for publication. It is natural for teachers to ask top performers to do more, yet neither the teacher nor the student pauses to reflect on the potential toxicity of rewarding overwork. Medical school traditionally is better at channeling students into ever-refined strata of academic and professional success than at mentoring them into building a career in which their professional endeavors unfold within a context of a healthy life well lived. Unless Jill were to encounter a mentor who has this broader grasp of personal and professional well-being, her role models and professors will continue unwittingly to provide a “hidden curriculum,” in which being a successful physician entails putting one’s own life on hold.

Jill’s chance encounter with Dr. Bennington, along with Ann’s willingness to mentor Jill about the importance of honoring life values in becoming a doctor, shows the powerful influence of senior physicians who have struggled themselves to attain life wisdom in revising the “hidden curriculum” of medical training. In choosing mentors, students would do well to seek out physicians who tolerate the tension of keeping their personal and professional lives in balance and who explicitly honor a variety of values beyond their professional lives, including family relationships, friendships, recreational pursuits, hobbies, and personal self-care. Having a mentor is a critical component of career satisfaction and success in medicine. The mentoring relationship has been described as one of the most complex and developmentally important in a person’s life. Mentors act as teachers, exemplars, and guides for their mentees. On a practical level, medical students and residents who have a mentor report better career preparation than do those without a mentor. Ideally, the mentoring relationship provides some benefits to both mentor and mentee, such as opportunities for collaboration, mutual teaching and learning, and the promotion of self reflection as illustrated by the above vignette.

Among the perspectives worth cultivating is the awareness that becoming a health professional is a process that occurs over several years and that self-perceived imperfection is an inherent part of that process. It is helpful to think of ourselves as “becoming” rather than insisting on holding an image of what we have not yet become, then unfavorably comparing ourselves with that image. Given the continual pressures inherent in medical training to judge our own competence, it is important to cultivate the equally important capacity for “self-appreciation.” When we respond to a sunset, to the first flower blooming in the garden in spring, or to the final movement of Beethoven’s 9th Symphony, this is typically not an act of judgment, but one of appreciation. It is impossible to engage the “judgment” and “appreciation” centers of our minds at the same time.

The exaggerated sense of personal responsibility that is part of the compulsive triad is often reinforced by the competitive climate of getting into medical school and advancing through training. This attitude is frequently carried into residency training and subsequent practice, in which the illusion is maintained that one is a self-sufficient professional, that asking for help is a sign of weakness, and that competency is distinguished by the ability to “go it alone.” Nothing could be further from the way health care is actually delivered, in which systematic attempts to improve quality and reduce error now demand that teams of professionals from various disciplines work cooperatively to provide patient care and promote the health of the community. The best medical schools are beginning to train for this, and the Accreditation Council of Graduate Medical Education (ACGME) states that “systems-based practice,” which largely involves working as part of a team, is one of the core competencies to be mastered during residency (see Chapter 41). Whether or not teamwork is reinforced by one’s medical school or residency, cultivating the practice of working cooperatively with others and committing oneself to helping colleagues succeed can contribute enormously to one’s personal and professional satisfaction.

Bill is showing the classic signs and symptoms of burnout, which consists of emotional exhaustion (including compassion fatigue and dissociation from feelings in general), depersonalization in relationships (treating oneself, patients, coworkers, and family members as objects), and a perceived clinical ineffectiveness. Burnout has been described as “an erosion of the soul,” and it spreads gradually and continually over time, sending people into a downward spiral in which it is difficult to recover if one remains in the circumstances that generated it. Burnout has been associated with impaired job performance and poor health, including headaches, sleep disturbance, irritability, relationship difficulties, fatigue, hypertension, anxiety, depression, myocardial infarction, and chemical dependency. Cognitive performance as well can be compromised by burnout. A national US study of internal medicine residents found that symptoms of burnout, which were associated with higher medical school debt, were also associated with lower In-Training Examination scores. For physicians the seeds of burnout may be sown in medical school and residency training, where fatigue and emotional exhaustion are often the norm. By mid-career, the momentum of this condition is maintained by the subtle reinforcements in the work setting for being a hard worker and placing service to others before self-care.

All too often residents are confronted with the reality of patients who for one reason or another are nonadherent to medical regimens, or who have chronic health problems that are refractory to interventions (see Chapters 4 and 20). Unremitting exposure to cases in which one’s own efforts appear futile can engender frustration and cynicism. Without the opportunity to discuss these common experiences with their peers and faculty, trainees may begin to experience the early symptoms of burnout.

Ward residents like Bill may begin to view their work in terms of the tasks involved in admitting and discharging patients, rather than in terms of the patient’s experience of illness. Terry Mizrahi, a medical anthropologist, spent several months observing teams of ward residents in one training hospital, and through observation of what they did and what they communicated among themselves she concluded that the job of the ward resident is “getting rid of patients.”

Frequently, underlying this detached attitude is “compassion fatigue,” in which an overload of suffering threatens to run our emotional tank dry and lead to dissociation, characterized by a withdrawal of attention from emotions and somatic sensations as we focus cognitively and visually on complex patient care problems or get absorbed in our “to do” list. We become anesthetized to feelings and cannot relate to family and friends once we leave work. The cognitive correlate of dissociation is decontextualization. This involves a habit of thinking of others (and even ourselves) in a utilitarian way that abstracts and constructs persons into categories that have usefulness for our jobs and getting our tasks done in a timely way. This habit of thinking ignores the full life context in which others (and we ourselves) are embedded. Thus, we relate to patients as diagnoses or appointments on the schedule, to coworkers as facilitating or impeding our work, to family and friends as intruding or placing unrealistic demands on our time, and to ourselves as task-processing machines.

Bill understandably feels a disconnect between the sense of vocation he once felt about medicine and the sense of futility about how he spends his working hours. In the absence of time to reflect on what is happening or discuss it with others, he finds himself slipping into disillusionment and cynicism. His job as a resident has begun to feel meaningless.

Carl Rogers once said that “what is most personal is most universal.” Nothing can be so personally isolating as the perception that one has lost one’s way professionally. It is reminiscent of the poignant lament of Dante at the opening of the Divina Comedia:

Nothing can be so healing and reassuring as to know that others have traveled the same road and have emerged as colleagues to admire and emulate. The value of retreats, support groups, or even impromptu discussions during lulls in the pace of work to share common experiences and struggles is to remind trainees that they are part of the human community and that they have the capacity for renewal and change.

Support groups are an especially valuable learning format in residency training programs to help residents navigate personal and professional developmental tasks, learn self-management and emotion management skills, build authentic community with their peers, and promote their well-being. Developmental challenges common to residents include establishing one’s professional identity, developing professional confidence, coping with patient deaths, erosion of an idealized view of medicine, cognitive and behavioral management of stress, assuming the responsibility of a team leader, developing a reflective capacity for self-awareness, finding a career path, and learning self-acceptance and the limitations of personal control. Having a safe and confidential format for sharing these issues with one’s peers is vital to a resident’s professional development, and training programs would be wise to incorporate this into their curricula.

Emotional Intelligence

Among the strategies that trainees can use for restoring a capacity for compassion and enjoyment of work is the cultivation of “emotional intelligence.” Developing self-awareness is essential to emotional intelligence. This is a challenge for clinicians who have been trained to dissociate from their feelings as a way of being “objective” in their professional role with patients. Since the quality of clinicians’ relationships with their patients is a major component of the therapeutic process as well as a major contributor to their own well-being, developing self-awareness to maximize this process is essential (see Chapter 7). Emotional intelligence includes developing a language for one’s emotions and a capacity of self-disclosure to others. The mirror of this process of self-awareness and self-expression is the capacity to recognize emotions in others. We can use our own emotions to develop hypotheses about what the other is feeling. We can learn to check out feelings with others, reflect feelings, comment on what we are observing, and receive the emotional disclosure of others without judgment. It can be helpful to regard emotions as value-neutral information that is passing through our awareness like weather systems, which in themselves are neither right nor wrong. Thus we can think of attending to the patient’s feelings as getting a “weather report” and awareness of our own feelings as “checking the weather.” Accepting our own emotions and those of others can be liberating and allow us to be fully present to others and ourselves (see Chapters 2 and 7).

Other components of emotional intelligence include controlling impulses, especially by delaying our response in conflict situations, delaying gratification for the sake of achieving goals, and using cognitive reframing and self-instructional statements to regulate our moods. We can enhance our emotional intelligence by naming internally what we are feeling at the moment, keeping a journal that captures the predominant feelings we have experienced on a given day, practicing using emotional words with friends and intimate partners, reflecting the feelings that others disclose to us, and in some cases by engaging in psychotherapy to enhance our emotional literacy.

Self-regulation of anxiety and situational stress is a skill that can be learned in the context of training. It is an essential prerequisite for the accurate perception of patients’ distress, which facilitates the use of empathy skills (see Chapter 2). A Belgian study of resident physicians on an inpatient rotation found that their self-reported anxiety and physiologic measures of sympathetic nervous system arousal were inversely related to their ability to detect patients’ distress.

Bill’s feeling of futility in caring for patients who did not get better in spite of his best efforts emanated from his own beliefs and expectations about control. Gaining clarity about the extent to which control is possible in the events of our lives, and in the profession of medicine in particular, is essential to satisfaction with the work of being a doctor. Although people tend to be more satisfied when they perceive a greater control over the events that impact them, most of the outcomes of patient care are multidetermined and to a large extent dependent on many forces beyond the physician’s control, including patient choices as well as genetic and environmental variables. Thinking in terms of “influence” rather than “control” may be more realistic. Within the large array of factors that contribute to illness and health, physicians can have enormous influence, but medical care is only one of several events that contribute to the eventual outcome. Assuming a Zen approach of focusing on “right action” in the moment—whether it is the exercise of empathy, conducting a careful physical examination, engaging clinical reasoning, or performing a procedure—and releasing the need to have the outcome be a marker of one’s competence, can provide a helpful cognitive framework for self-assessment. Other strategies for inoculating ourselves against futility may include finding meaning in small victories, such as preventing a hospitalization for a patient with chronic emphysema; using a recurrent worsening of a condition, such as a patient repeatedly admitted for diabetic ketoacidosis, as an opportunity to learn more about clinical medicine; regarding “difficult patients” as visiting professors because of the learning they can provide about how to manage such patients; focusing on the quality of the relationship with the patient whose condition is worsening; and spending some reflective time recalling the positive connections with patients who appreciate the work we do.

Common to several of the unhealthy habits described above (compulsiveness, the psychology of postponement, dissociation from feelings, and tolerating conditions of burnout) is the notion of work as energy depletion. Hence many physicians, nurses, administrators and others view weekends, vacations, and time with family as the opportunity to recharge and recapture a more expansive awareness. Some seek to expand the time available for recharging by working parttime. The converse of protected “personal time” is the intense compression of “work time” and the density of tasks to be processed in a given day. During this surreal pursuit of the processing of tasks in which “productivity” is equated with “being good,” an altered state of consciousness emerges (see Chapter 5). This is a trance that one enters in the presence of certain ritualistic cues (the door to the office, turning on the computer, checking the schedule, retrieving voice mails) and may include running an incessant “to do” list, looking for brief tasks to process in an illusory pursuit of “closure,” a shortened attention span, irritability in the presence of lengthy or labored conversations, a habit of checking and rechecking one’s work, stewing about difficult interactions in the past, and worrying about future events.

Renewal, Reflection, and Mindfulness

Steve McPhee, a professor of medicine at UCSF, has used the metaphor of solar-powered versus gasoline-powered automobiles to contrast different approaches to human energy in our daily lives. The notion of work as a locus of energy depletion (requiring a leaving of work to find energy renewal) is similar to the nonrenewable dependence of industrial societies on fossil fuels. In the long run, such a view of one’s own energy is unsustainable. An alternative perspective is that energy renewal is continually available as one moves through the day, whether at work or away from work. This is analogous to the solar-powered car, which requires the opening of panels to draw on the renewable energy from the sun. Such a fundamental shift in our thinking about energy may entail reevaluating our notion of who we are. The fossil fuel model represents a view of oneself as an individual source of productivity and accomplishment, acting with agency upon the material world and upon people’s lives to achieve outcomes. The solar panel model suggests a view of oneself as a medium of energy exchange, a self-organizing system much like a candle flame that gives off light in the process of continuous transformation, a system that is embedded within, and a part of, larger self-organizing systems such as a doctor–patient relationship, a health care system, a society, the earth itself.

Trainees should ask themselves: How can we open ourselves to renewal as we move through our days, both at work and at home? What is the psychological equivalent of “opening our solar panels?” One approach is the cultivation of mindfulness, which is the practice of being present to where we are and what we are doing. It is the discipline of living an intentional, conscious life (see Chapter 7). Our stream of consciousness often includes thoughts about the past, sometimes accompanied by regret or resentment, and thoughts and images of the future, sometimes threatening, sometimes escapist. Mindfulness is a counterweight to this enchantment with the “there and then” by increasing our skill at being present in the “here and now.” Mindfulness involves nonjudgmental attention to our emotional and mental states as they pass through awareness. We learn to see ourselves as vessels through which the various feelings of joy, sorrow, anger, affection, peace, and agitation flow without defining who we are in any moment of intensity. Twenty minutes a day practicing mindfulness meditation can enhance our capacity for mindful attention. This practice can help physicians be present to patients without interference from what happens before or after that encounter. Mindfulness is also the gateway to accessing opportunities for personal renewal in the midst of work, where in addition to expending energy, we are also receiving energy from personal interactions or the satisfaction of work well done.

The process of approaching each day with mindfulness and openness to the uncertainty of who will walk in the door next, and nonjudgmental attention to the “weather” of our own emotions and those of others, is captured in this poem by Rumi, the thirteenth-century Sufi mystic whose verses reach across the centuries and cultures to speak to our own experience:

Incorporating a brief period of reflection at the end of each day is one way of conditioning ourselves to perceive the opportunities for personal renewal and meaning contained in various encounters of the day. Using a journal or simply reflecting back for a few minutes on the events of the day can offer a transitional time to let go of the day and absorb the gifts that came our way. Angeles Arrien suggests that we ask ourselves three simple questions: “What surprised me today? What moved me today? What inspired me today?” Sometimes we may find that there has been great meaning in our encounters with the full panoply of human experience, including suffering. A related practice is that of keeping a “gratitude journal,” which can be done at the end of the week. This involves writing down a few things from the week for which one is thankful, from simple events like watching a particularly beautiful sunrise to more profound ones like a satisfying encounter with a patient with whom one had a previously troubling relationship.

Intimacy and Value Clarification

If our relationship commitments are consistently subordinated to work demands, a review and clarification of our values is in order. Although humbling, we can get a glimpse into our value hierarchy by examining how we actually spend our time and energy in any given week. We may find that what our practice reveals is at variance with what we tell ourselves and others about our deepest values. We also may find that much of the way we spend our time is in response to urgent demands that are not that important in the long run.

In addition to the challenge of nurturing our relationships with family and friends when constrained by professional demands, another barrier is posed by a fear of intimacy or the lack of skill in sharing our inner selves with others. Since clinicians spend much of their time on the receiving end of others’ confidences and disclosures, they may have less practice in self-disclosure. It is in relationship with others, however, that we deepen our identity and sense of who we are as persons. This requires not only the presence of close relationships, in and out of medicine, but also time spent with them and the capacity for self-disclosure and intimacy.

• Friends. Given the general erosion of community in American life, we must actively seek connections with others. Sometimes opportunities for forming friendships will arise in the work setting, and there it depends on our willingness to take the initiative. We also can develop hobbies and interests outside of medicine that form natural settings for people with similar interests coming together, whether it is through the arts, volunteer work, political action, a faith community, sports, or engaging in outdoor activities. It is not sufficient to have a network of friends without developing our capacity for self-disclosure. Learning to confide in trusted friends is an essential counterbalance to long hours of receiving the confidences of patients in our professional roles.

• Intimate partners. A love relationship sustained over time can be one of the great spiritual paths to our growth and development as persons. A long-term and even life-long journey with an intimate partner is a cauldron which both tests our identity and expands our capacity to embrace life and endure its stresses and challenges. It is in such a relationship that we can learn acceptance of ourselves with all our flaws and virtues. We also can learn the art of compassion through nurturing our beloved and seeking their well-being. Building and maintaining a successful partnership requires scheduled time. Enhancing our interpersonal communication skills—especially the art of active listening, disclosure of feelings, and negotiating respectfully when there are differences and conflict—is central to an enduring relationship. Other vital intimacy skills include awareness of our family of origin influences on couple communication and expectations; learning to tolerate differences in tastes and preferences; clarifying mutual values as a couple; and negotiating time, sex, money, space, division of labor, and whether and how to raise children. Romance and sex may occur spontaneously in the early stages of a relationship, but over time require our intentional planning to create the time and conditions for this vital component of a relationship to be a lasting source of mutual renewal. Sometimes couples get stuck in stagnating patterns or impasses in their communication, and at such times couple counseling can be a valuable resource.

One constraint to giving ourselves the needed time to honor personal values and relationships may be concern about money. Many physicians at the beginning of their career are understandably worried about paying off medical school debt. This may lead to working longer hours in the earlier years, or even moonlighting, which diminishes time and energy for family, friends, and hobbies. Sometimes material aspirations and the consumer mentality of our culture lead us to encumber more debt than is necessary, and we end up trading valuable time for more money to service those debts. The way money flows through our lives and whether it is a burden or a useful tool will depend on our core philosophy about wealth. Engaging in a process of clarifying our life values and financial goals, either through consultation with a financial planner or reading financial self-help literature, can provide a framework for making wise decisions about what we need to sustain our lives and how much time and energy we will expend in generating an income to support those needs. One physician couple reported a process of reflection they used when they realized they were “sacrificing precious time and earning money to support a lifestyle not worth living.” They engaged in a process of value clarification and financial assessment that eventually led to downsizing their material possessions, eliminating debt, and embracing a path of “voluntary simplicity.” They traded financial wealth for the time to travel, spend more time with their families, and pursue other interests.

Organizations and Trainee Well-Being

Although it is essential to engage in self-reflection, value clarification, and behavior change to move our own lives toward renewal and sustainability, viewing this solely as a personal project will not be sufficient to make meaningful changes. Well-being is not only an individual process, but a political process as well. With the best of intentions we may begin a practice of mindfulness, enhancement of our intimate relationships, and caring for ourselves physically—only to have those intentions evaporate at the next attending rounds or faculty meeting where overwork is reinforced and rewarded with admiration, the esteem of colleagues, and the imperatives of meeting productivity expectations. For the well-being of trainees to thrive, the organizations in which they are trained and work (hospital systems, group practices, academic medical centers, and government institutions) must be sustainable enterprises that value the health and well-being of all their workers. Each of us has a responsibility not only to ourselves but to our colleagues and our profession to engage in the difficult work of changing our organizations—medical schools, residencies, health care systems, and practice settings—so that they allow time and energy for “those gentler influences which make life worth living.”

The woodblock print seen below, The Great Wave off Kanagawa, by the artist Katsushika Hokusai, is from a series entitled “36 Views of Mt. Fuji.” It captures several of the elements of personal and organizational well-being we have discussed above. The first and most obvious element is the waves, which are relentlessly chaotic and threaten to capsize the boats. The waves call to mind the ongoing challenges and uncertainty of clinical training and practice. The second element is the people in the boats, who require cohesion, teamwork, and ongoing communication to keep the boats headed into the waves and moving successfully forward on their journey. Our colleagues and team working alongside us are a vital resource for navigating each day of patient care and the developmental hurdles of professional formation. A healthy organization provides such a disciplined collaboration for its members, so that no one person bears the sole burden of responsibility. The third element is Mt. Fuji, at first indistinguishable from the waves, which in its deeply grounded stability provides the still point in the center of this painting around which the chaos revolves. Mindfulness and self-awareness can provide such an inner stillness allowing us to rest at the deepest center of ourselves as we continually adjust our balance to catch the next wave.

Training health professionals in this complex, information-rich and choice-rich era of human history requires new skills that were not required of previous generations. At the same time, doing so in a way that sustains both educators and trainees as persons requires drawing upon the “practical wisdom” of previous generations. This practical wisdom, what Aristotle called phronesis, incorporates the cognitive, emotional, behavioral, and interpersonal skills to expand our capacity as persons and reduce or eliminate the nonimportant and unnecessary loads that erode our spirits. We also need to develop a practical wisdom of working within health care systems that is mindful of the factors that promote sustainability, such as expanding our capacity for service through teamwork, clarifying the organization’s values, and establishing structures and processes that promote the well-being of health care workers. This perspective is the responsibility of trainees and faculty alike. Developing the practical wisdom to engage in this work in a sustainable way is our personal and collective challenge.

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