AANS Neurosurgeon | Volume 27, Number 2, 2018

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Physician Heal Thyself

Physician health and wellness is an often-ignored aspect of healthcare, but with burnout transitioning from a buzzword to a harsh reality, the time has come to take a hard look. Current changes in the field of medicine stem from new burdens of bureaucratic inefficiencies and an infusion of new technologies. While physicians have made significant advancements in what can be treated and cured, many feel the physically and psychologically rigorous environment one experiences when practicing medicine has not improved in parellel. Data suggests that the youngest physicians – those still in training – struggle the most, with 47-70 percent of residents reporting burnout during training. Although overall resident attrition rates among clinical specialties remain low at 2-7 percent, the number is 3-5 times higher in general surgery and surgical subspecialties1. Resident depression is also on the rise, with recent studies reporting resident depression rates of 21-43 percent2. The effects of burnout and depression, both strongly tied to deteriorating physical and mental health, can be quite grave – multiple studies demonstrate correlations between these and increased medical errors3-5. The stress, anxiety and unhealthy habits physicians maintain should not be something we simply accept, but actively look to alleviate.

Stanford University Addresses Physical Health

Institutions around the country have made significant efforts to remedy the ominous burnout trend. At Stanford University, Michel Kliot, MD, FAANS, and Gerald Grant, MD, FAANS, of the department of neurosurgery are championing efforts to reduce stress and anxiety to improve the physical and mental health of Stanford neurosurgical residents. A founding principle of their program is to listen, showcasing a concerted effort to understand each individual resident’s personal and professional challenges. Some of the earliest interventions are directed at improving the physical well-being of residents. In a recent internal survey, 80 percent of the residents reported neck or back pain. Interventions implemented include:

  • The introduction of yoga, Pilates and core strengthening classes;
  • A pilot program with a company that makes a device that monitors back posture in real time, which can have significant impact in the OR; and
  • Plans to renovate and augment current hospital gym facilities are being promoted to motivate residents to develop workout regimens.

Last year, Stanford became the first academic medical center in the nation to appoint a chief wellness officer. Tait Shanafeltis, MD, a nationally recognized expert in physician wellness assumed the position in September. After pioneering efforts to combat physician burnout and improve physician satisfaction and fulfillment at the Mayo Clinic, he comes to Stanford to lead the WellMD Center – a program with the sole focus of improving the wellness culture and lifestyles of physicians at Stanford.

Addressing Mental Health Too

Equally apparent are the efforts to improve the mental health of Stanford neurosurgical residents and the professional environments in which they work. Team building activities, where residents can interact in non-clinical settings with other residents and faculty members, are becoming more frequent. Efforts are being made to provide more dedicated mentorship to the residents. Faculty plan to communicate clearly and succinctly with residents on an annual basis sharing clinical neurosurgical milestones that residents are expected to achieve as well as making a concerted effort to ensure residents reach them. It is hoped that the feedback residents receive will be more precise, individualized and clear to reduce their uncertainty and anxiety about their standing in the program. Lectures have been designed on various practice environments residents may choose to go into in an effort to help them achieve their career goals.


Read More

Exercise for the Surgeon: Part 3

Like Aloe for Sunscreen: Harm Reduction & Prevention in Neurosurgery Resident Burnout


Key to Success

The success of these efforts at Stanford lies in its faculty making it a priority to understand the challenges of a modern day neurosurgical resident. It is hoped that, as a result of all these efforts, residents will feel more empowered and fulfilled as they incorporate health-promoting activities into their daily life.

Medical University of South Carolina: Innovators

A similar multi-pronged approach has been used at the Medical University of South Carolina (MUSC) by Raymond Turner, MD, FAANS, and colleagues. In the Department of Neurosurgery at MUSC, faculty members initiated La Sierra – a program that looks to improve several different aspects of resident health6,7. Their efforts have been focused on stress management and combating burnout and fatigue. Innovative efforts include:

  • Implementation of a curriculum of lectures to improve resident fitness, fatigue and communication skills.
  • Planned social activities to improve resident comradery and satisfaction8.

The impact has been positive! After comparing baseline and post-intervention data, the program showed improvements in fitness, decreases in medication use for disorders such as hypertension and dyslipidemia as well as improvements in sleep quality, depression, anxiety and quality of life9. The program also had an effect on resident performance, with improvements in Board scores and interpersonal interactions with other health care providers. After completion of the program, residents were anonymously asked to review the initiative. Participating residents indicated that the program had not interfered with either clinical or academic opportunities, believed it provided significant value to the department of neurosurgery and would recommend other institutions implement a similar program.

Changing Ways for a Changing Time

The efforts, both at Stanford, MUSC and many other institutions around the country showcase a necessary change of perspective in medicine. Physicians, although the champions of improving health and the well-being of others, need also to prioritize their own health – especially those in training, whose passion for clinical excellence and service often come at the cost of their own personal health. Improving the environments in which physicians train, whether that be through improving resident nutrition, fitness, morale or decreasing work anxiety and stress, should be a priority for every program nationwide.

References

1. Ishak, W. W., Lederer, S., Mandili, C., Nikravesh, R., Seligman, L., Vasa, M., . . . Bernstein, C. A. (2009). Burnout During Residency Training: A Literature Review. Journal of Graduate Medical Education, 1(2), 236-242. 

2. Mata, D. A., Ramos, M. A., Bansal, N., Khan, R., Guille, C., Angelantonio, E. D., & Sen, S. (2015). Prevalence of Depression and Depressive Symptoms Among Resident Physicians. Jama, 314(22), 2373.

3. West, C. P., Tan, A. D., Habermann, T. M., Sloan, J. A., & Shanafelt, T. D. (2009). Association of Resident Fatigue and Distress With Perceived Medical Errors. Jama, 302(12), 1294. 

4. Mccormick, F., Kadzielski, J., Landrigan, C. P., Evans, B., Herndon, J. H., & Rubash, H. E. (2012). Surgeon Fatigue. Archives of Surgery, 147(5).

5. Fahrenkopf, A. M., Sectish, T. C., Barger, L. K., Sharek, P. J., Lewin, D., Chiang, V. W., . . . Landrigan, C. P. (2008). Rates of medication errors among depressed and burnt out residents: Prospective cohort study. Bmj, 336(7642), 488-491. 

6. Fargen, K. M., Spiotta, A. M., Turner, R. D., & Patel, S. (2016). The Importance of Exercise in the Well-Rounded Physician: Dialogue for the Inclusion of a Physical Fitness Program in Neurosurgery Resident Training. World Neurosurgery, 90, 380-384. 

7. Fargen, K. M., Spiotta, A. M., Turner, R. D., & Patel, S. (2016). Operation La Sierra: A Novel Wellness Initiative for Neurological Surgery Residents. Journal of Graduate Medical Education,8(3), 457-458.

8. Spiotta, A. M., Fargen, K. M., Denham, S. L., Fulton, M. E., Kellogg, R., Young, E., . . . Turner, R. D. (2016). Incorporation of a Physical Education and Nutrition Program Into Neurosurgery. Neurosurgery, 79(4), 613-619. 

9. Spiotta AM, Patel S, Turner RD. Impact of a Residency-Integrated Wellness Program on Resident Mental Health, Sleepiness, and Quality of Life. Neurosurgery (in press).

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