47: Trainee Well-Being

INTRODUCTION

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.

CASE ILLUSTRATION 1

Jill Rayburn had not slept in 30 hours. She had been studying for her pathophysiology examination for a week, and still she felt ill prepared. As a second-year medical student she was beginning to wonder whether she was cut out for medicine, in spite of the fact that she was in the upper 20% of her class. Many of her classmates seemed to be on top of the material to be mastered for this examination. Some of them had even gone for a hike yesterday afternoon. Last night she declined an invitation to play indoor soccer. It was mid-January and cold outside, and she was tired of being stuck in the library. She was beginning to resent the professor who invited her to coauthor a paper, even though at the time she felt flattered that he had singled her out for this honor. Now she did not feel up to the task, and she wished she had started preparing for this examination earlier rather than working on the paper. She looked back to her days of high school and college, when she was consistently at the top of her class, and remembered many carefree days. She wondered what had happened to that teenager with the sense of humor and the time to hang out with friends. Now as she looked ahead to the remainder of the winter, all she saw were more deadlines and isolated days in the library without respite. She wondered if she would ever have fun again.

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:

Engrossed late and soon in professional cares . . you may so lay waste that you may find, too late, with hearts given way, that there is no place in your habit-stricken souls for those gentler influences which make life worth living.

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.

CASE ILLUSTRATION 1 (CONTD.)

Jill was walking across the quadrangle after her pathophysiology examination and failed to notice Dr. Ann Bennington, her teacher from the previous term in a class on the medical interview. Dr. Bennington noticed Jill’s hunched over posture and drawn facial expression. “Jill, you look like you have the weight of the world on your shoulders and haven’t slept in days. How are you doing?” Jill managed a smile and protested, “I’m fine. I just finished the pathophys exam.” Ann confronted her mildly, “Well you look exhausted. When’s the last time you had an evening off?”

When she noticed a tear forming in Jill’s eyes, Ann replied, “Jill, I suspect you’re carrying more of a burden than you let on to others. I’d really like to talk with you more about this.” She then suggested they meet later that afternoon in her office. At the meeting later in Dr. Bennington’s office, after some initial hesitation Jill opened up with the self-doubt, emptiness, fatigue, and isolation she had been feeling the last few weeks. After a pause, Ann replied, “You know, Jill, you remind me of myself when I was a medical student.” Noticing Jill’s tears, she continued, “The fact that you are one of the brightest people in your class doesn’t seem to matter to you now, and I think I know why. Like me you are perfectionistic, and there are reasons too numerous for us to go into now why we are that way. But one of the effects of that perfectionism is that we never feel we can get enough praise or external validation for our worth. That’s because we weren’t taught to value ourselves from within, that we are lovable and have immense worth before we ever set out to do great things.” She paused to observe Jill’s response. Since she was breathing more freely and seemed curious, Ann continued: “There’s nothing wrong in striving for excellence. In fact that’s desirable. But what we mean by ‘excellence’ needs to be challenged. Your work as a physician, like your work as a student, will always occur within a real world context of the various values you hold and commitments you have made, as well as the limitations of time, personal energy, and competing tasks. Bumping up against these limits can be humbling, but ultimately accepting those limits and allowing your excellence to be contextualized into your life will give you wisdom. Your body, mind, and spirit are giving you feedback that you ignore only at your peril. Rather than anesthetizing yourself to this pain, let it teach you more about yourself and the full context of joy of which you are capable. To the extent you can let your awareness of the origin of this pain lead you to greater self-acceptance, you will be an excellent physician and a healing presence for others.”

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.

CASE ILLUSTRATION 1 (CONTD.)

In April of her fourth year of medical school Jill dropped by Dr. Bennington’s office to let her know she would be going to a family medicine residency in the South. “How are you feeling about the match?” Ann asked. “Well, to tell you the truth,” Jill replied, “my first choice was another program where I could have pursued some work in epidemiology based on that paper I co-authored a couple of years ago. Since the match, however, I’ve thought more about the program I’m going to, and especially about one physician on the faculty there who interviewed me. I was struck by the pictures he had on his wall of his wife and children, his children’s poems and drawings, and what he shared with me about how much their training program valued both professionalism and the personal growth and life satisfaction of their residents.” Ann smiled and nodded. Jill went on, “I have you to thank for reaching out to me at a critical moment a couple of years ago and helping me realize there was more to me than trying to be a star. You helped me realize the value of humility, which includes appreciation of my gifts as well as acceptance of my limitations. You also gave me the greatest gift, which was affirming my own capacity for appreciating my life and for letting that be the ground from which to appreciate others.” In June, after her white coat ceremony Jill opened a card from Dr. Bennington, which contained this poem by Derek Walcott:

Love After Love

The time will come

when, with elation

you will greet yourself arriving

at your own door, in your own mirror,

and each will smile at the other’s welcome,

and say, sit here. Eat.