Image1 Awareness is the first important step to enhance resilience and wellness, and mitigate burnout. Although stress is inevitable, burnout can be preventable or mitigated. Through this virtual teaching platform, physicians in training can gather information on the resilience and wellness of residents by adopting creative approaches to teaching, in order to achieve awareness and become active partners in preventive care. We hope that this conveys a clear message that we, as healthcare professionals and educators, do not only care for patients but we are required to care for ourselves. A supportive work environment is important to the resilience and wellness of physician trainees in order to help them thrive. Teaching tools to empower physician trainees to foster personal resilience and wellbeing should be an essential part of residency training programs. We aim to define how to characterize resilience and burnout and thus create a targeted curriculum.

With our online teaching initiative we endeavour to provide trainees with resources and tools to recognize and actively engage in managing stress and burnout. We aim to engage experienced physician trainees to offer advice on what their peers could do to avoid burnout during training and become a more engaged, satisfied, and resilient physician. In striving to create a useful resource, we plan to build a collaboration of educators who are enthusiastic, inspiring, and who support the physician trainee participants in feeling like they, themselves, make a difference through building capacity and enhancing the system to take care of our own.

We face a sustainability challenge in our medical education. Thus, focusing on medical school curriculum on physician resilience in today’s technologically and socially complex and high resource consumptive world is our primary focus. We acknowledge the paradoxical tasks of training competitive and well equipped residents and fellows to practice medicine in this highly intense resource consumptive world while simultaneously building a bridge to a world all but guaranteed to telescope these levels of complexity and consumption with its all inherent stressors based upon the interplay between economic and ecological forces.

It is possible that the change in medical culture may eventually come from medical schools as well, with leading the way by practicing physicians in the field. However, given the serious nature of the problem, a current passive approach to sustainability of medicine is unacceptable and medical schools must acknowledge the problem and begin to act.

Finally, medical educators are increasingly choosing or being required to shift to online teaching (Maggio et al, 2018). We herein provide a conceptual framework for creating an initiative for physicians in training to better understand and improve their experience of wellness, resilience, and burnout during training while transitioning to online teaching.

Some facts about resilience, wellness, and burnout:

Some believe that Maslow’s fifth basic need for self-actualization may be our highest calling (Maslow, 1943), whereas others posit that Viktor Frankl’s creation of a “life of meaning” should be our utmost desire (Frankl, 2006). We know that self-actualizing individuals are self-aware and concerned with personal growth and fulfilling their potential. Thus, burnout can result from a serious investment in one’s work (a desired goal for self-actualization), which transforms into chronic stress under the wrong conditions (Maslach & Leiter, 1997). With chronic stress, the resulting burnout can impair executive function, including difficulties to prioritize. Healthcare leaders must put physician wellbeing at the top of their agenda. They must promote the art and science of medicine for the benefit of the public health. Through concerted efforts to increase resilience and wellness during residency, training sites will produce physicians better equipped to manage stress and provide higher quality care to their patients. Online teaching modules helping to create wellness programs for physician trainees should start with understanding the importance of wellness, as well as with identifying methods to create a sustainable culture of resilience and wellness. There are steps physicians themselves can take to prevent the encumbrances of training and practice from depleting the joy out of medicine.

To learn more about the definition of resilience and burnout, and the manifestations and prevalence of burnout, click on each tab below.

Definition of resilience and burnout. Resilience is our ability to bounce back from challenges or persevere despite disruption or chaos. Resilience is a foundation to wellness. On the other hand, wellness is a multifaceted concept that leads to optimal levels of emotional and social functioning. Wellness is more than the absence of illness. For physician trainees who have a variety of responsibilities and burdens bearing down on them, it is essential to be cognizant of the various elements that contribute to their overall wellbeing. Burnout is a psychological syndrome of overwhelming emotional exhaustion, depersonalization (i.e., feelings of detachment from the job), and decreased sense of accomplishment emerging as a prolonged response to chronic interpersonal stressors on the job (Maslach & Leiter, 2016). Burnout is described as “the index of dislocation between what people are and what they have to do” (Maslach & Leiter, 1997). In other words, it can be the outcome of an imbalance between various dimensions of work output (e.g., type of work, intensity, number of hours) and the opportunity to “recharge the batteries” (e.g., not enough attention paid to basic needs, including rest and reward).

Manifestations of burnout. The three main manifestations of burnout produced by chronic dislocation are: (i) a sense of exhaustion, (ii) cynicism, and (iii) professional ineffectiveness. These can have consequential problems with work satisfaction and professional performance, including patient safety (Tijdink et al, 2014). The research has shown an inverse correlation between the degree of emotional exhaustion and professional engagement (Tijdink et al, 2014). The willingness of physicians to work for the love of their job and not financial compensation or other form of recognition can, eventually, expose them to chronic stress and give rise to compassion fatigue. That is especially true in academic medicine, where there are less explicit limits on the academic and clinical balance of working hours. Many research studies have used the Maslach Burnout Inventory (MBI) as a measure of burnout (Maslach et al, 1996). The MBI tool addresses three dimensions: (a) emotional exhaustion (i.e., feelings of being emotionally exhausted by one’s work); (b) depersonalization (i.e., an impersonal response toward recipients of instruction and care treatment); and (c) sense of lack of personal accomplishment (i.e., feelings of ineffective work achievement and competence) (Maslach et al, 1996).

Prevalence of burnout. Much variability in the prevalence of burnout and its three dimensions has been found among physicians across the world. In a 2011-2012 U.S. national survey, medical students, residents/fellows, and early career physicians (five years or less since residency completion) were more likely to be burned out (all p < 0.0001) compared with the general population (Dyrbye et al, 2014). Burnout is prevalent in medical students (28-45%), residents (27-75%, depending on specialty), as well as specialist physicians (IsHak et al, 2009).

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Because burnout in the medical community is an epidemic that starts early during the medical training and continues to manifest through the career practice years, addressing the physician burnout is the shared responsibility of both the individuals and the institutions in which they train and work. Given the strong association to patient safety, patient satisfaction, and quality of care, there certainly is an imperative for institutions to mitigate physician burnout and promote physician engagement. Although some factors driving burnout are greater than the institutions (see more details in section Integrate New Lifestyles), organizational-level efforts can, and should, have a profound effect on physician wellbeing. A concerted effort of the leadership starting from the highest level of the institution is the key to making meaningful progress.


Institutions need to develop an early active awareness of burnout and incorporate relevant interventions starting during the process of training medical students and resident physicians in order to foster increasing resilience of the medical community. Regarding physician burnout, which of the following statements is correct?

A. Research has shown that American physicians experience lower levels of emotional exhaustion than their European peers
This is incorrect, and this is why. A meta-analysis found that physicians from the Americas experienced higher levels of emotional exhaustion than their European peers when work-life conflict was strong and when they used ineffective coping (Lee et al, 2013). However, American physicians experienced lower levels of emotional exhaustion compared with their European counterparts when quality, safety culture, and career development opportunities were strong. European physicians with positive work attitudes experienced lower emotional exhaustion in comparison with their American counterparts (Lee et al, 2013).
B. In comparison with the general population, burnout rates seem to decline among physicians
This is incorrect since the burnout seems to be on the rise among physicians in comparison with the general population. In a study conducted among U.S. physicians from 2011 through 2014, burnout increased and satisfaction with work-life balance decreased, with an increasing disparity relative to the general working population; there were no changes noted in the general U.S. working population (Shanafelt et al, 2015) (see Figure 1).
Figure 1. Prevalence changes in physician burnout from 2011 to 2014 (Data derived from Shanafelt et al, 2015)
Figure 1. Prevalence changes in physician burnout from 2011 to 2014 (Data derived from Shanafelt et al, 2015)
C. Recent research has shown that more than half of U.S. physicians experience burnout features
This is correct. In an article by Shanafelt et al (2015) evaluating the prevalence of burnout and satisfaction with work-life balance in U.S. physicians and workers in 2014 relative to 2011, more than half of U.S. physicians experienced professional burnout.
D. First year of medical training appears to be the most protected time against burnout
Medical training appears to be, not less, but the most critical time for distress and burnout (Dyrbye et al, 2014). (See Prevalence section above.)

Some facts about resilience, wellness, and burnout:

In a study of U.S. academic otolaryngologists (n = 351 respondents; 68% participation rate), 70% reported moderate to high burnout rates, but women experienced a significantly higher level of emotional exhaustion than men (Golub et al, 2008). In this study, high burnout rate was significantly associated with likelihood to leave academic medicine within the next one to two years (Golub et al, 2008). Similarly, a study conducted among U.S. emergency physicians (n = 1,272 respondents) showed that 60% had moderate to high burnout scores (Goldberg et al, 1996). Projected attrition rates in this study were 7.5% over five years and 25% over 10 years. A Dutch survey of medical professors (n = 437 respondents) at eight academic medical centres has shown that early career medical professors (younger age and fewer years since appointment) and having children living at home were factors significantly associated with higher scores of emotional exhaustion (Tijdink et al, 2014).  

Despite the fact that trainees and academic and practicing physicians have higher rates of burnout than the general population, they are notoriously reluctant to seek help (American Foundation for Suicide Prevention). Although burnout is a rising concern for both female and male physicians, female physicians appear to be predominantly affected (Tijdink et al, 2014). According to the Physician Work Life Study (n = 2,326 respondents; 32% were female; the adjusted response rate was 52%), female physicians reported burnout symptoms 1.6 times more often than their male peers (McMurray et al, 2000). Among female physicians, burnout was typically caused by a perceived lack of workplace control and inability to meet the demands of both work and home life (McMurray et al, 2000). This study added that being a mother with young children significantly increased risk of burnout among female physicians.

Did you know?

Academic women appear to face challenges and barriers to success in comparison to their male peers regarding their struggle to achieve academic advancement and to occupy the highest positions within institutions. This can lead to burnout symptoms and other serious consequences.  

Given the fact that burnout is often a precursor to more serious psychological health problems, a meta-analysis has shown that the suicide rate ratio among female physicians is double compared with the general female population (2.2, 95% CI 1.9-2.7), and greater than their male peers (1.4, 95% CI 1.2-1.6) (Schernhammer & Colditz, 2004).

To learn more about burnout as a systemic problem in academic medicine, particularly for women, click on each tab below.

Publications. Despite the fact that the proportion of women in medicine is approaching that of men, female physicians remain in minority regarding reaching the highest academic positions (Jena et al, 2015). One reason for this disparity between the sexes may be that female physicians, in comparison to their male colleagues, have a lower rate of scientific publishing, which is an important factor affecting promotion in academic medicine (Fridner et al, 2015; Reed et al, 2011). Publication of scientific research is an academic currency for professional advancement, it determines status and prestige, as well as it serves to rank universities and professionals. Having a relatively low Hirsch index for publications was associated with higher scores of emotional exhaustion (Tijdink et al, 2014). A study has shown that 54% of medical professors considered that publication pressure was becoming “excessive” and was statistically associated with burnout (Tijdink et al, 2013). Physicians with more control over their work had a higher publishing rate (Fridner et al, 2015). Interestingly, work-related exhaustion was found to have a significant negative impact on the publishing rate among female physicians (odds ratio 0.2, 95% CI 0.1-0.7), but not in male physicians (Fridner et al, 2015).

Academic citizenship. “Academic citizenship” may be recognized through promotions criteria in the context of an increasingly performative academic culture, which can disadvantage women who publish less than their male counterparts (Macfarlane, 2007). How academic citizenship is rewarded, and how female professors “pay the price” for academic citizenship, are key elements to understand. Good academic citizenship requires an active engagement and participation in the life of the university, awareness of the institution’s strategic goals, and a willingness to integrate meaningfully the demands of the medical field with the needs and expectations of teaching roles and learners’ needs.

Remuneration. Studies suggest that academic women earn less on average than their male peers because they may focus on academic citizenship roles that can go unrewarded and not leading to promotion and, subsequently, pay rises (Macfarlane, 2007). In this vein, a recent study has shown that significant sex differences in salary exist among U.S. academic physicians even after accounting for age, experience, specialty, faculty rank, and measures of research productivity and clinical revenue (Jena et al, 2016). In a 2016 study analyzing sex differences in earnings among 10,241 academic physicians at 24 U.S. public medical schools, female physicians (n = 3,549 subjects) had lower mean unadjusted salaries than male physicians ($206,641 vs $257,957; absolute difference $51,315, 95% CI $46,330-$56,301) (Jena et al, 2016). A significant sex gap in salary remained even at the associate professor level when controlled for human capital, structural factors, and academic and clinical productivity (Claypool et al, 2017). Beyond remuneration, the moments of validation, and opportunities to prove our own self-worth to others and, more importantly, to ourselves, are essential factors to the pledge to mitigate burnout. Continuous efforts of academic institutions to metamorphose into non-gendered settings is a professional imperative.

Some facts about the consequences of untreated burnout in physicians:

Table 1 shows a summary of the consequences of untreated burnout in physicians. Further facts specifically on depression and suicide in physicians are presented below.

Table 1. Key consequences of untreated burnout in physicians
Depressive disorder
Substance use disorder
Interpersonal relationship problems
Physician turnover
Decreased quality of care
Increased medical errors
Decreased patient satisfaction
Decreased professional effort
Compromised role models for trainees
  • A 2010 prospective cohort study of 740 interns across 13 U.S. hospitals found that the incidence of depression increased from 3.9% to 25.7% in the first three months during internship (Sen et al, 2010).
  • A prospective cohort study by Fahrenkopf et al (2008) reported that 20% of 123 pediatrics residents at three U.S. children’s hospitals were depressed and 74% were burned out; these residents made 6.2 times more medical errors per month than non-depressed residents, although burnout in this study did not seem to correlate with an increased rate of medical errors.

  • In a study using aggregated ACGME data on 381,614 residents in training during years 2000 through 2014, suicide in men and malignancies in women were the leading causes of death in residents (Yaghmour et al, 2017).
  • Data for death by suicide in U.S. residents during years 2000 through 2014 suggested an added risk early in residency and during certain months (the first and third quarters) of the academic year (Yaghmour et al, 2017).
  • The increased risk of suicide begins as early as medical school (Schernhammer, 2005).
  • Canadian data is lacking, but in the U.S. about 400 physicians commit suicide each year (American Foundation for Suicide Prevention).
  • Physicians who died by suicide were less likely to receive psychiatric treatment compared with non-physicians who took their lives even though depression was found to be a significant risk factor at approximately the same rate in both groups (Gold et al, 2013).
  • In the Johns Hopkins Precursors Study of 1,153 white male and 108 female physicians compared to the U.S. general population from 1948 to 1998, suicide was the only cause of death where the risk for physicians was higher than for the general public (Torre et al, 2005).
  • As previously stated, the relative risk of suicide among female physicians is 2.27 times greater than the general female population, whereas in male physicians is 1.41 times higher than the general male population (Schernhammer & Colditz, 2004).
  • Interestingly, in the study by Torre et al (2005), the risk of dying by suicide compared to the general public was highest among psychiatrists (standardized mortality ratio 4.46, 95% CI 0.90-13.02).

Did you know?

The causes of suicide among physicians are the same as the general population; 70-90% of suicides are linked to psychiatric disorders. Depressive disorder is a major contributor to suicide, and other factors include bipolar disorder and substance use disorder. Suicide rates are higher among physicians who are divorced, widowed, or never married. Physicians who are at most risk for suicide are driven, competitive, and compulsive. Because of greater knowledge of lethality of drugs and easy access to means, the higher completion-to-attempt ratio for physicians contributes to the problem (Myers, 2017).

Image1 Although the predictive factors for burnout are further discussed in detail in subsequent topics of the section Know Yourself, we herein briefly review the interplay between occupational and individual factors. In order to prevent or mitigate burnout, one must understand its risk factors. The strongest predictors of burnout in the workforce have been inadequate research time, inadequate administration time, low self-efficacy, and dissatisfaction with balancing work and life (Golub et al, 2008). In a cross-sectional survey performed among U.S. emergency physicians between 1992 and 1995, the most highly ranked correlates with burnout were self-recognition of burnout, negative self-assessment of productivity, lack of job involvement, career dissatisfaction, sleep disturbances, increased number of shifts per month, dissatisfaction with specialty services, intent to leave the practice within 10 years, higher levels of alcohol consumption, and lower levels of exercise (Goldberg et al, 1996).

Workplace characteristics that have been found to cause burnout include an overloaded schedule, lack of control over workplace schedule, insufficient reward, absence of fairness, and conflicting values (Maslach & Leiter, 1997). For example, the health care system in the U.S.A. is fragmented, complex and the bureaucratic burden and administrative demands add pressure on the practicing physician. Electronic health records (EHRs) exacerbate the problem when the system is cumbersome and less user-friendly. In a recent pilot study conducted at a U.S. academic medical center, a strong positive correlation between the EHR use and resident physician burnout was found (Domaney et al, 2018). These authors suggested that time spent on EHR use may be an area of importance for medical educators to consider when seeking to minimize burnout and promote wellness. In a large U.S. national study, physicians’ satisfaction with their EHRs and computerized physician order entry was generally low (Shanafelt et al, 2016). Physicians who used EHRs and computerized physician order entry were less satisfied with the amount of time spent on clerical tasks and were at higher risk for burnout (Shanafelt et al, 2016).

In academic medicine, faculty burnout may be inevitable when the institutional culture promotes a model of medical professors as isolated businesspersons, encourages overwork, offers little recognition for good teaching and mentoring of trainees, and allows the faculty members to become “shock absorbers” for institutional stressors. In such environments, it is easy for misconceptions about burnout and depression, and the fear of stigma or consequences from admitting one’s mental health issues to delay help seeking, hence making the symptoms worse. Thus, it is not that some medical academicians just are not cut out for it. Institutions can, and may, cause burnout, and only a concerted effort of an institution can deal with it.

Furthermore, sexual harassment in the workplace certainly adds to the discrimination experiences and burnout. In a 2014 survey of U.S. clinician-researchers (n = 1,066 respondents; 62% response rate), 30% of women reported having experienced sexual harassment compared with 4% of men (Jagsi et al, 2016). Among women reporting harassment, 47% (95% CI 39%-56%) stated that they believed these experiences negatively affected their career advancement, whereas 59% (95% CI 50%-67%) perceived a negative effect on their confidence as professionals (Jagsi et al, 2016).

<strong>Figure 2.</strong> Contributors to physician burnout (Data derived from West et al, 2018)

Figure 2. Contributors to physician burnout (Data derived from West et al, 2018)

Even in the current #MeToo era, reporting sexual harassment can be stressful; women who report sexual harassment may experience retaliation, stigmatization, and marginalization, which can lead to chronic stress and burnout (Jagsi, 2018).

Regarding individual risk factors, a cross-sectional twin study by Mather et al (2014) found that a history of traumatic life events (e.g., abuse, neglect) was associated with burnout. Early childhood trauma affects the stress response systems, which can become hyperactive and create a sense of overwhelm when facing stressors during adulthood. It is often true that people drawn to medicine tend to have traits that make them prone to potential problems (e.g., perfectionism, an exaggerated sense of responsibility, a compulsion for achievement, difficulty asking for help). For those choosing a helping profession like medicine, it is important to identify early on personal resilience factors. Figure 2 summarizes the contributors to burnout.

Summary of burnout key factors

The rates of burnout symptoms that have been associated with adverse effects on patients, physician health, and healthcare workforce exceed 50% in studies of both physicians-in-training and practicing physicians (West et al, 2018). Factors of the physician burnout epidemic are largely embedded within healthcare institutions and systems, however, individual physician-level factors also play a role, with higher rates of burnout commonly reported in female and younger physicians (West et al, 2018) (see Figure 2).

Did you know?

"I would never want to have a mental health diagnosis on my record."
  - Gold et al, 2016

"Let’s talk about the elephant in the room."

Stigma is prevalent among physicians. In a closed Facebook group survey of 2,106 U.S. female physicians who were also mothers, nearly 50% believed they met the criteria for a mental illness at some point in their careers but had not sought treatment due to stigma (Gold et al, 2016).  

In this study, two-thirds reported that fear of stigma inhibited both treatment and disclosure (Gold et al, 2016). Moreover, one in three respondents said they received a formal mental health diagnosis since medical school. Despite this, only 6% of physicians with formal diagnosis or treatment of mental illness had disclosed to their state. These authors showed that stigma and licensing questions, particularly those asking about a diagnosis or treatment rather than functional impairment may contribute to treatment reluctance among suffering physicians (Gold et al, 2016).

QUIZ - Broken heart and moving on!

Dr. A, a second-year neurology resident, became despondent when her 8-month relationship with her boyfriend abruptly terminated. Her text messages and e-mails seeking an explanation were ignored. Dr. A has had a long struggle with self-esteem, and she interpreted this rejection as confirmation of her self-criticism. Because of her work schedule, Dr. A felt that there was impossible to see a psychotherapist or psychiatrist and believed that asking for time off to do so would unfavourably affect her evaluations. She also was afraid she cannot afford these medical services. Moreover, she felt ashamed to disclose her breakup and depression to her colleagues and believed that they would resent having to “bear her burden.” Dr. A thinks it would be “too humiliating” to ask the attending physician for help. She had made a couple of medical errors while on-call last week and it has taken her an increased amount of time recently to complete the electronic medical documentation. The evaluations of her work performance have declined until a couple of days ago when her residency program director compelled her to take a medical leave of absence. Now she worries that she has a record which will create licensing issues in her future practice. Yesterday she started to think that she was an embarrassment to her father (a highly respected surgeon in his community). She reminisced about her father expecting her to “always be the best and be professional.” At the beginning of medical school, Dr. A feared being “found out” that she had a diagnosed anxiety disorder, and avoided treatment for fear that seeking professional help could jeopardize her future medical license. She avoided treatment during residency for those same reasons. Now that she struggles with depressive symptoms as well, she has developed a strong conviction that admitting to “mental illness” seems like admitting to failure. She now feels like the world would be a better place without her.

Click below on all the perceived barriers to treatment in this case.

This is correct. As mentioned previously, in an online survey of 2,106 U.S. female physicians (aged 30-59 years), almost 50% believed they met the criteria for a mental illness at some point in their careers but had not sought treatment (Gold et al, 2016). The key reasons for avoiding care included a belief they could manage independently, limited time, cost, fear of reporting to a medical licensing board, and the belief that diagnosis needs to be kept confidential because of embarrassment or shame.
Confidentiality concerns
This is true.
Time constraints
This is correct.
This evidently is correct.
Fear for documentation on record
This is precisely right.
Self-centredness and narcissistic traits
This is unlikely true. Unlike in this case, self-centred people and narcissistic people crave attention from others, and can reliably find a way to talk about themselves when they begin to feel neglected and less worthy. Unlike Dr. A, the self-centred individuals and narcissistic individuals essentially say, “Notice me and how special and wonderful I am!” Although Dr. A has had a long history of self-esteem problems, there was nothing in the history to indicate a narcissistic rage as a reaction to narcissistic injury after the breakup (which is a perceived threat to a narcissist’s self-esteem or self-worth).
Suicidal ideation
Suicidal ideation is not a barrier to treatment per se but a core symptom of a major depressive episode, unless there is evidence of hopelessness or that cognition, judgment, or memory is impaired, thus undermining one’s ability to appreciate the therapeutic value of treatment.

Although this topic is discussed in detail in section Integrate New Lifestyles, we herein summarize some key elements regarding the foundation and strategy of a healthy lifestyle balance. Table 2 shows the seven rules for promoting physician resilience (see the acronym RESPITE).
Table 2. The 7 rules for physician resilience:   R E S P I T E
REMAIN RESPONSIBLE: Be satisfied with the responsibility you take for your own wellbeing (physically, emotionally, spiritually, and financially)
EXPRESS EMOTIONS: Be satisfied with the way you express and manage your emotions (laughter, sadness, contentment, and anger)
STUDY: Be satisfied with your ability to study and be a student for your entire career
PRIORITIZE: Be satisfied that your life’s priorities are yours and clearly reflect your values
INFLUENCE: Be satisfied with your ability to have a positive influence at work and in life
TRANSFORM: Be satisfied with your commitment to initiate and embrace change and transformation at work and in life
ENCOURAGE: Be satisfied with the way you ask for and receive assistance and encouragement from others (professionally and personally), when in trouble

Self-awareness and the knowledge of one’s own limits is the foundation to a healthy life balance. Professionals should know themselves so that precursor symptoms of exhaustion become clearly identifiable signals that allow prompt adjustment of the workload and coping skills. For example, growing up with an alcoholic parent might make the child unaware of his/her own needs (because of parental neglect) and, as an adult, he/she might continue to put other people’s needs first and ignore signs of exhaustion. Sometimes, a psychotherapeutic process is necessary for the professional to learn more about how the past has affected his/her specific coping under stress, and how to optimize resilience factors to prevent burnout recurrence. Making sure one continues to find meaning in one’s job helps giving a sense of reward and enhancing self-efficacy.

But such individual measures are insufficient without supportive infrastructures and organizations. Institutions must meet the goal of gender equality, with adequate career planning and talent spotting as part of an overall strategy. At an institutional level, modification of risk factors for burnout such as allowing sufficient faculty time for research and administrative activities may prevent or reduce the development of burnout and its deleterious consequences. Setting a series of clear “academic citizenship” expectations should be the goal. An attitude shift should also occur to destigmatize the sufferer (who can often be blamed or perceived as weak, while in fact the issue can be systemic and multi-layered).

Moreover, training gaps in nonclinical skills are still prevalent, with resulting symptoms of burnout and anticipated substantial attrition of physician numbers in the future (Gorelick et al, 2016). Changes in graduate medical education and healthcare delivery are greatly needed and should have important consequences for the workforce in healthcare system. Educating medical trainees early on and allowing for group supports to take place can help decrease isolation and increase empowerment when individuals combine their effort and ideas to create an impact by catalyzing organization change.

A balance between personal and professional lives is essential in order to prevent burnout. Figure 3 illustrates an example of physician self-care toolkit. Physicians often have trouble with finding a balance. They take work home, often do not “switch off” once at home, and often do not take the time to “recharge their batteries.” They should be given permission and encouraged to practice what they preach and make room for mindfulness practices. A life lived as mindfully as possible means being aware of one’s own experience as one experiences it (whether it is an emotion, a thought, a body sensation, or a situation). It increases feelings of wellbeing and decreases distress. Dispositional mindfulness has been shown to have a buffering effect against perceived stress and burnout; it is a resiliency factor and it can be taught (Lebares et al, 2017).

Physicians are never done learning and should expect to always find time to be a student for their entire career, but if they learn or study “mindfully”, one concept at a time, they will be more focused and effective, and generally more satisfied because they will be ruminating less about past mistakes or not worrying so much about the future. Developing a personalized toolkit with activities having a “high mindfulness index” for a specific individual (e.g., colouring, gardening, jogging) could be a strategy developed during a workshop or faculty development seminar.

<strong>Figure 3.</strong> Essentials for physician self-care toolkit

Figure 3. Essentials for physician self-care toolkit

Physicians are expected to be ethical, use good clinical judgment and do what is right and in the best interest of their patients. Being a disciplined decider and doer prevents from becoming a procrastinator and can bring balance to the busy professional. Collaboration and collegiality should be high on everyone’s list. Balint groups, narrative/reflection and interest groups, or specific associations can be created to allow the sharing of resources. Peer conversations centred on the experience of doctoring were found to be beneficial by some physicians (Beckman et al, 2012), and they can start during the training years during Healer’s Art course, for instance.

Good relationships are strengthened when we all do our share of the extra-instructional work. Interdisciplinary collaboration to enrich the educational experience and mostly for the opportunity to collaborate with colleagues is essential and can enhance a sense of agency through the latitude and freedom experienced from pursuing specific interests. Encouraging civil and gracious behaviour in every setting should be on everyone’s minds; kindness breeds kindness. Reports favouring a reflective approach to the year’s work should be considered.

Undertaking new responsibilities should prompt physicians to ask themselves: “Will this commitment enhance my career at the expense of taking away from my time with family/friends, or lead to balance or imbalance in my life?” Setting priorities for personal life and academic and clinical practice is essential. It is important to not lose perspective and stay connected with core values rooted in an authentic sense of self. A quick road to burnout is ensured by taking on too many projects and responsibilities. Henceforth, learning to say no (or yes) to additional work responsibilities is vital.

Although many medical trainees have debt by the time they graduate, they must learn to control their finances from early on. However, physicians should not confuse their net-worth with self-worth. As individuals, social connection is paramount. Finding a lifetime partner or friend is a needed ingredient for wellbeing. Lastly, physicians always take their clinical and academic practice earnestly, but they should also learn to have fun by injecting a dose of humour into their daily activities. Humour is one of our most valuable resources in the efforts to control stress.

Table 3 presents a summary of principles and strategies to promote physician wellness (Kuhn & Flanagan, 2017). Moreover, Thomas et al (2018) have prepared the Charter on Physician Wellbeing and highlight that governing bodies, policy makers, medical organizations, and individual physicians all share a responsibility to proactively support meaningful engagement, vitality, and fulfillment in medicine. They set forth guiding principles and key commitments as a framework for key groups to address physician wellbeing from medical training through an entire career (see Table 4) (Thomas et al, 2018).

Table 3. Principles and strategies to promote physician wellness (Kuhn & Flanagan, 2017)
Individual/professional level Administrative level Institutional level National (policy) level
Lifestyle hygiene (e.g., sleep, diet, exercise, mindfulness, mind-body practices, socialization)
Discussion groups
Shared stories
Peer support and advocacy to challenge stigma
Expanding interests/cultivating hobbies
Developing a toolkit
Utilizing psychotherapy, cognitive restructuring (e.g., “excellence is not perfection”, “be the best you can be” rather than "the best")
Flexible schedules
Less cumbersome electronic health records and billing requirements
Adjusting clinical productivity expectations
Leaders should emulate desired wellness behaviour
Increasing employee satisfaction
Professional development
Screening tools for distress
Education to address misconceptions/prejudices
Sensitizing medical trainees early on during their studies
Mentoring support
Adjusting academic productivity expectations
Educating the public to address barriers to access care
Easing credentialing barriers (focus on functional impairment rather than diagnosis)
Funding research to identify risk and resiliency factors of work-related burnout
Table 4. Key points of the charter on physician wellbeing (Thomas et al, 2018)
Guiding principles Key commitments
Effective patient care promotes and requires physician wellbeing Societal commitments: to foster a trustworthy and supportive culture in medicine; to advocate for policies that enhance wellbeing
Physician wellbeing is related to the wellbeing of all members of the health care team Organizational commitments: to build supportive systems; to develop engaged leadership; to optimize highly functioning interprofessional teams; to appreciate that physician wellbeing is a shared responsibility
Physician wellbeing is a quality marker Interpersonal and individual commitments: to anticipate and respond to inherent emotional challenges of physician's work; to prioritize mental health care; to practice and promote self-care

Test your knowledge on key aspects of resilience, wellbeing, and burnout

1 The symptoms of physician burnout are associated with which of the following consequences?
A. This is only partially correct. Although this is a problem associated with physician burnout, the other presented options are also associated challenges.
B. This is partially correct. Although this is a problem associated with burnout, all the other options are associated challenges among physicians.
C. To a certain degree, this is part of the problem, along with the other presented options.
D. This is only part of the problem, because the other options are also associated with physician burnout.
E. This is correct. It is known that challenges to physician wellness are widespread, including symptoms of burnout, relatively high rates of depression, and increased suicide risk affecting physicians in training through their professional careers. Burnout is associated with suboptimal patient care, lower patient satisfaction, decreased access to care, and increased healthcare costs.

2 What are some effective personal strategies to enhance resilience in your training program?
A. Although this is one personal strategy to enhance resilience, you may know that all the other options are also effective tactics to promote wellness.
B. This is one personal strategy to enhance resilience, but all the other options are also effective tactics to promote wellness.
C. Although this is one strategy to enhance personal resilience, all the remaining options are effective strategies to promote wellness.
D. Once again, this is one strategy to enhance resilience, but so are the other proposed options.
E. That’s right! All the listed options represent personal strategies to enhance resilience. There are many strategies that residents and fellows can use to take wellness into their own hands. Working with other peers and leaders in a respective program can create an environment where wellness strategies can be applied on an individual level.

3 "Our academic physicians are overwhelmed." How can we find time to implement wellness initiatives in our residency training program? What should we do?
A. This is only part of the solution. Although this is one important strategy to implement wellness, all the remaining options are also known to be effective tactics to promote wellness and resilience.
B. This is part of the solution, as this is a strategy that will implement wellness; however, the other listed options are also proven effective strategies to promote wellness and resilience among physicians.
C. You are partially correct here. This is because all the other given options are also effective strategies to promote wellness and resilience.
D. Almost correct, again. Although this is a strategy to implement wellness, the other options are also known to be effective tactics to promote wellness.
E. This is correct! The fact that attending physicians are overwhelmed is attestation for the need to take the time to engage in wellness activities. Indeed, all the listed options represent initiatives to enhance wellness. With strong leadership support of wellness initiatives, time can be found for wellness. Helping physicians in training find time for self-care should be an institutional priority.

  • The concept of physician wellness and burnout is multidimensional and includes factors related to each physician as an individual, as well as to the working environment (Kuhn & Flanagan, 2017).
  • Physicians must actively engage in self-care.
  • Specific practices, academic culture and healthcare organizations should evaluate the balance between demands they place on physicians and the resources provided to sustain an engaged, productive, and satisfied physician workforce.
  • Consistent national efforts are required in order to assist physicians seeking help for physical as well as psychological health problems (Kuhn & Flanagan, 2017). Improving access to services without affecting the physician’s licence status should be prioritized.
  • Workplace efforts to promote non-gendered settings and eliminate inappropriate behaviours are necessary.
  • Efforts to maintain proper physician self-care should always be supported by institutions. Some have recommended that medical leaders find ways to transform the workplace into a place that is “healing for the healer as well as the patient” and to find time asking medical professionals what they believe is working (Eckleberry-Hunt et al, 2018).

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