Endocrine Today, November 2015
Laurence Katznelson, MD; Mickey Trockel, MD PhD
Physicians’ health is important not only for their own quality of life and that of their family, but also for the quality of care they provide patients. From medical school through clinical practice, stress and burnout limit a physician’s well-being and ability to provide optimal care.
Physicians who are well rested and are not struggling with symptoms of burnout are less likely to make mistakes and more likely to attend to nuanced needs of individual patients. One study demonstrated that patients have longer post-hospital recovery times if their physicians score high on a measure of depersonalization, a component of burnout characterized by reduced interest in interacting with and empathy for people at work.
Physicians who are engaged in positive health behaviors are also more likely to advise their patients to do likewise, and those who are engaged in contemplative practices, such as mindfulness meditation, may perform better on measures of patient communication and patient satisfaction.
In the context of mounting evidence for the relationship between physician wellness and the care they provide, it is no surprise that a well-cited review referred to physician wellness as “the missing quality indicator.” Medical specialists, including fellows in training, are potentially at risk for burnout, and interventions that promote wellness should be considered. We propose three components for general physician wellness planning.
Basic self-care: sleep, eat, move
Physicians lead busy and often stressful lives. A large national survey indicated more than 45% are experiencing one or more symptoms of burnout, and internal medicine subspecialists rank modestly lower than average, with more than 40% reporting one or more symptoms of burnout.
Taking time for self-care basics when busy and stressed is analogous to inflating your tires when leaving late on a long commute by bicycle — it takes time from seemingly zero margins but in the end pays off. Adequate sleep improves cognitive and psychomotor performance, elevates mood and increases the likelihood of engaging in other positive health behaviors, such as aerobic exercise. Sleep may be even more important for physicians in training, during a time when inadequate sleep may detract from learning and patient safety. Physicians are susceptible to sleep problems caused by shift work and by anxiety-related and primary insomnia or may simply not allocate sufficient time for sleep due to work demands or devaluation of sleep.
Laurence Katznelson
Each of these causes of poor sleep can be identified, and specific solutions can be provided. Some evidence supports that varying the number of days in a row physicians are required to work when most people sleep may attenuate the adverse impact of working these shifts. Other reports suggest timely use of melatonin and light therapy may lessen the adverse impact of night shift work on sleep health, although more systematic study of these strategies among physicians is needed.
However, ample evidence points to the efficacy of managing insomnia with cognitive behavioral therapy, which in the long term is more effective than and obviates the ill effects of addictive hypnotic medications and, therefore, should be made available to all physicians with symptoms of insomnia. Individuals are often unaware of the impact of sleep on their cognitive performance, which may lead physicians to undervalue sleep. Continued education on the benefits of sleep, coupled with abatement of excessive work hour demands, may help.
Good nutrition is also likely to render short- and long-term benefits to physicians’ personal wellness and clinical efficacy. One study demonstrated that providing good food to physicians where they work improved their cognitive performance on composite measures of speed and accuracy. Increasing evidence indicates good nutrition may have long-term cognitive performance benefits, which may increase the number of years experienced doctors can care competently for their patients.
Aerobic exercise offers similar short- and long-term cognitive performance benefits and may also confer significant mental health benefits. In a study that compared aerobic exercise with use of sertraline as treatment for depression, benefits were comparable in the short term but favored exercise at 10-month follow-up. This demonstrates the clear benefit of regular exercise in maintaining mental health.
Stress reduction, screening for depression
Reports of high rates of burnout and higher than average suicide rates among physicians have prompted efforts to alleviate stress and facilitate early detection and treatment of depression. A growing body of evidence suggests mindfulness meditation may be helpful in mental health promotion and may improve patient outcomes. Peer support programs that train physicians to provide brief compassionate counseling support to colleagues after distressing adverse clinical outcomes is also a promising stress-reduction strategy.
However, even in the context of the best evidence-based general health promotion and primary prevention strategies, some physicians will still experience significant distress and depression. Programs that screen for depression and link to appropriate clinical services for physicians, such as demonstrated at the University of California, San Diego, have been recommended by the U.S. Preventive Services Task Force for all adults and may provide a culture that can screen for and support individuals with distress.
Attention to career transitions
Recent reports of two suicide deaths of physicians early in their first year of postgraduate training point to the need for particular attention to support physicians during potentially stressful career transitions, such as beginning a new training program, starting a new job or shifting to retirement. Moving from residency to fellowship training may provide a particularly difficult transition due to the typically small cohort of fellows in most medical subspecialty training programs, as small numbers of colleagues may impede formation of natural social support networks. Programmatic check-ins with fellows to assess their well-being and careful consideration of ways to increase social interaction with fellows in other subspecialties may help.
Start where we are
Even a cursory review of the topic of physician wellness points to the need for physicians to do more for their own health and the health of their colleagues. The stewardship over physicians in training carries particular responsibility for safeguarding the public good through promoting wellness of budding physicians. The prevailing work culture in medicine, erosion of physician autonomy and financial pressure may make it hard to do all that could be done to promote physician wellness. Nevertheless, we can start where we are and take wellness steps forward.
- References:
- Babyak M, et al. Psychosom Med. 2000;62:633-638.
- Beach MC, et al. Ann Fam Med. 2013;doi:10.1370/afm.1507.
- Halbesleben JR, Rathert C. Health Care Manage Rev. 2008;33:29-39.
- Lemaire JB, et al. BMC Health Serv Res. 2010;doi:10.1186/1472-6963-10-241.
- Morris MC, et al. Alzheimers Dement. 2015;doi:10.1016/j.jalz.2015.04.011.
- Moutier C, et al. Acad Med. 2012;doi:10.1097/ACM.0b013e31824451ad.
- Oberg E, Frank E. J R Coll Physicians Edinb. 2009;doi:10.4997/JRCPE.2009.422.
- Rubin R. JAMA. 2014;doi:10.1001/jama.2014.13505.
- Shanafelt TD, et al. Arch Intern Med. 2012;172:1377-1385.
- Wallace JE, et al. Lancet. 2009;doi:10.1016/S0140-6736(09)61424-0.
- For more information:
- Mickey Trockel, MD, PhD, is clinical assistant professor in the Department of Psychiatry and Behavioral Sciences at Stanford University.
- Laurence Katznelson, MD, is professor in the Departments of Medicine and Neurosurgery and associate dean of Graduate Medical Education at Stanford University, as well as an Endocrine Today Editorial Board member. Katznelson can be reached at 300 Pasteur Drive, Stanford, CA; email: LKatznelson@standford.edu. Trockel and Katznelson report no relevant financial disclosures.
Endocrine Today, November 2015
Laurence Katznelson, MD; Mickey Trockel, MD PhD
Comments