Physician wellbeing – what do physicians want?

The often quoted epitaph of an unnamed ancient Athenian physician, “These are the duties of a physician: First… to heal his mind and to give help to himself before giving it to anyone else,” is too often ignored in medical education, medical training, and clinical practice. Despite duty hour restrictions and wellness programs, as well as a plethora of opinions regarding physician wellbeing, we continue to read that “burnout,” depression, and suicide remain areas of grave concern within our profession. We cannot afford to ignore these problems, and research is critical to developing a clearer understanding of what constitutes burnout, how it differs from depression, what the protective factors might be, and which management strategies are most effective. Professional dissatisfaction is not restricted to physicians who are relics of another age, unable or unwilling to adapt to the electronic health record and the touted efficiencies and improvements that accompany our modern health care system. Even medical students and residents are struggling with these issues [1], [2], [3], [4].

In their recent article, “Predictors of emotional wellbeing in osteopathic medical students in a COVID-19 world,” [1] Jacobs, Lanspa, Kane, and Caballero discussed a vexing concept that remains poorly understood and researched – physician wellbeing. The authors addressed factors that appeared to promote emotional wellbeing in a cohort of osteopathic medical students during the early months of the coronavirus 2019 (COVID-19) pandemic [1]. Their cross sectional study included a convenience sample of 1,310 medical students from one medical school who were invited to complete a 56 item questionnaire that the authors developed containing validated measures [1]. Of the medical students invited to participate, 202 (15.4%) fully completed the questionnaire, and the authors found that utilizing a variety of coping strategies, having personal resilience, and taking care of one’s health (specifically not sleeping more or exercising less than they did prior to COVID-19) contributed to maintaining emotional wellbeing among the respondents. Osteopathic physicians – with our focus on the dynamic interaction between body, mind, and spirit – are in an excellent position to study these thorny questions around what contributes to and helps sustain medical student and physician wellbeing, and conversely, what contributes to physicians’ dissatisfaction and unhappiness with their work.

Most medical students are aware well before they begin medical school that they will be tested and pushed to their cognitive and emotional limits, but clearly that has not been a deterrent. In 2021, applications to American Association of Colleges of Osteopathic Medicine (AACOM) schools are up 19% from 2020 and applications to Association of American Medical Colleges (AAMC) schools have increased 18% [5]. However, it also appears from a recent study of 268 medical students [3] that despite entering medical school with eagerness, optimism, and a spirit of idealism, by their final year, some are more depressed, anxious, and “worn out.”

Duty hour restrictions were initially instituted in 2003 to address concerns about medical errors and deaths secondary to resident fatigue, spurred on by a high profile death in which the role of resident fatigue remains debated [6]. Additional duty hour restrictions were introduced for ACGME accredited residencies in 2011, retaining the limit of 80 hours set forth in the 2003 duty hour reforms, ostensibly to decrease medical errors; however, there is a lack of empirical support for either decreases in medical errors or mortality, or improvements in medical knowledge as assessed by board certifying examination scores [7], [8].

So, what’s going on here? Why are medical students and residents experiencing high levels of depression and anxiety, even with duty hour restrictions and wellness programs? The reality is that we really don’t know. Continued research to better define and understand the factors that influence physician wellbeing across our full career lifecycle are critical – and that journey starts in medical school, with our students.

The study from Jacobs et al. [1] is important for several reasons. It is the first to explore emotional wellbeing among the newest members of our osteopathic family during the COVID-19 pandemic. Further, despite an abundance of articles related to physician burnout, there has been comparatively little research on what contributes to physician wellbeing. Given the alarming rates of “burnout” and depression among medical students, residents, and early career physicians, understanding what contributes to emotional wellbeing is critical [2]. An earlier study [9] (prior to COVID-19) of 268 osteopathic medical students found that higher levels of emotional intelligence (EI), which indicates a person’s awareness of and ability to respond to emotions in themselves and others, was correlated with decreased levels of perceived depression, anxiety, and stress. Students in that study who “screened positive for potential anxiety and depression exhibited significantly lower levels of EI than their counterparts showing subclinical symptoms,” indicating that EI might be one contributor to wellbeing [9].

Physician burnout has been defined in a variety of ways (which contributes to difficulties with specificity and measurement) but is typically characterized as a combination of emotional exhaustion, cynicism, and perceived inefficiency or decreased sense of personal accomplishment resulting from work related stress [10], [11]. However, the validity of burnout has been debated, and it is likely conflated with clinical depression [12], [13]. Despite its pervasive use, I struggle with the term burnout itself, as I find it nonspecific, pejorative, and likely inclusive of physicians who actually suffer from a treatable mood disorder. The most accepted and utilized measure of burnout is the two item Maslach Burnout Inventory [10], but in a study of 5,575 schoolteachers, over 90% of respondents who reported being “burned out” actually scored in the moderately severe or severely depressed range on the Patient Health Questionnaire-9, which assesses for major depressive disorder [13].

As a profession, we need to push back against facile explanations and recommendations. Physicians who are overwhelmed, burned out, or suffering from clinical depression are unlikely to respond to exhortations to engage in activities to promote “wellness” and “self care” when they are feeling deluged by the many duties that have been noted to contribute to physician burnout (the electronic health record, the process of insurance denials and preauthorizations, less time with patients, and other forms of administrative “creep”) [14], [15]. A prior systematic review and meta analysis [16] also showed little evidence to indicate that well meaning remedies like wellness programs or self care are actually efficacious [16]. The symptoms of depression (sleep and appetite disturbance; poor concentration; decreased energy and enjoyment of previously enjoyable activities, including professional and leisure pursuits; and feelings of guilt, hopelessness, or helplessness), which overlap with and may be indistinguishable from burnout, likewise require specific interventions. However, medical students (and physicians as a larger group) are often reluctant to seek mental health treatment for a variety of reasons, including stigma, licensing concerns, and fear of other professional repercussions [17].

Healthcare workers, including physicians, have responded to the COVID-19 pandemic with a spirit of altruism and self sacrifice, reinforcing the idea that we see our work as a calling, rather than just a career. However, a recent meta analysis [18] of the prevalence of depression, anxiety, and insomnia in healthcare workers during COVID-19 suggested that the rate of depression in physicians across age groups is 25%.

COVID-19 has presented major challenges to medical education, patient care, and social connectivity, but lessons learned regarding medical student and physician wellbeing during this time should not be considered in a vacuum. For example, prior to COVID-19, women physicians noted higher levels of burnout than men physicians, likely due to the family demands that still fall disproportionately on women [19], [20], [21]. School closures, part time schooling and hybrid schedules, and the loss of prior childcare arrangements have exacerbated the stressors already experienced by many physicians with childcare and eldercare responsibilities [22]; how the compounded effect of these stressors will affect overall burnout and wellbeing rates begs further study.

As Jacobs et al. [1] noted, more focused research on emotional wellbeing is needed. Their data showed that personal resilience contributed to maintaining emotional wellbeing in their convenience sample, but the findings of a national survey study recently published in Journal of the American Medical Association [23] suggested that although resilience was inversely associated with burnout symptoms, burnout rates were still substantial even among the most resilient physicians, and physicians still exhibit higher levels of resilience than the general working population in the US. This speaks to the need for systemic change in the clinical care environments in which physicians practice, as well as to increased attention required to develop and nurture behaviors and skills that promote physician wellbeing from the first day of medical school.