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Alexander Dufort MD, Lindsay Hasegawa, Tezeta Mitiku MD, Tricia Woo MD, Calvin H. Hirsch MD
Although this will be discussed in more detail in another topic, resilience is the capacity to respond to stress in a healthy way such that goals are achieved at minimal psychological and physical cost; resilient individuals "bounce back" after challenges and grow from these experiences. Resilience has been identified as the key to enhancing quality of care and maintaining a sustainable healthcare workforce. Identifying and promoting resilience is a critical, yet very difficult task, as it depends on the individual, the community, as well as institutional factors (Epstein & Krasner, 2013).
Resiliency and sustainable medicine are intricately linked on the individual level. Residents who are able to work and engage in personal activities that foster resilience are more likely to engage in sustainable medical practice and vice versa. As such, sustainability at the individual level can be defined as a physician’s ability to engage in a form of medical practice which is sustainable over the long term and provides high quality care to patients. There are many aspects of a physician’s life which can impact his/her resiliency and ability to engage in sustainable practice; these will be described extensively throughout this module and only summarized briefly in this section.
Residents/fellows are faced with numerous stressors during their post-graduate medical training; e.g., exposure to suffering and death, long working hours with associated sleep deprivation, high performance expectations and criticism from supervisors, frequent evaluations, and many others (Van Dewark, 2010). Faced with these stressors and poor coping skills, residents can suffer a number of negative consequences (e.g., psychiatric illness, including substance abuse, burnout). In the most extreme cases, physicians may take their own lives (Van Dewark, 2010). Putting these pieces together, it is possible to see how residents working under these types of stresses and developing these negative consequences may not be able to function in the most efficient and sustainable manner.
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As discussed above, residents/fellows who can foster resilience and develop positive mechanisms are more likely to develop in both sustainable self-care practices and a sustainable medical practice. These positively reinforcing behaviours can be implemented by both the individual resident/fellow as well as the wider medical education system. Several individual factors have been identified, which can protect individual residents against burnout and unsustainable practice. These include residents whom are:
On a systematic level, several residency programs have been implementing resiliency training programs with the goal of increasing awareness in regards to burnout and fostering sustainability, often promoting mindfulness and stress management skills (West et al, 2016). In addition, several organizations have mandated maximum working hours for residents as a means to combat burnout.
As we will see in future sections, these factors which can impact individual sustainability and resilience have wide reaching effects, impacting the sustainability of the medical system and global carbon footprint.
The medical system functions in a dynamic equilibrium, relying on employees, resources and, of course, patients, to function. A deficit in any of these fundamental tenets can cause the system to become unsustainable. For example, healthcare professionals must be properly trained, as well as willing to work in the provided environment and culture. A multitude of medical staff with varying responsibilities must collaborate in order to successfully admit, accommodate, treat, and discharge a single patient. Consequently, in order to operate within a medical system, access to various resources is required, from food, linen, and facility services, to imaging and laboratory technologies. Lastly, the system requires patients who both require and are accepting of these services.
The cost of the medical system is increasing due to the aging of the population, new and more expensive treatments, new diagnostic and therapeutic procedures, more demanding patients, newly elaborated diseases, and an increasing prevalence of chronic diseases. Maintaining sustainability as a medical team can help combat the increasing demands on an already fragile system, such as minimizing stress and having adequate supports in place. This promotes a resilient system, and as a result, when challenges emerge the system is capable of responding robustly rather than collapsing or developing dependence (Hassan, 2014).
The carbon footprint is historically defined as the total emissions caused by an individual, event, organization, or product, expressed as carbon dioxide equivalent. Major contributions to the carbon footprint in medicine include fossil fuel, electricity, and water consumption, and overall waste generation. Think of the demands on the environment an average admission to the internal medicine ward can have - transportation to the hospital, clean linens, daily meals, electricity and water, and ongoing facility services. In addition are the medical costs - disposable and sterile instruments for procedures, imaging modalities, and daily laboratory investigations. Although each individual decision a physician makes may seem inconsequential, the sum affects the overall system greatly. A recent increase in awareness of unnecessary tests, treatments, and procedures have led to the development of campaigns such as Choosing Wisely, which recognizes these decisions often result in poor clinical outcomes as well as significant waste in the overall healthcare systems in North America. While appreciating your influence on the carbon footprint, however, it is of utmost importance to maintain quality patient care and safety.
Interestingly, many of the steps we can take to reduce our carbon consumption will also promote health. For example, walking and cycling instead of driving, or increasing plant-based sources in our diets can cut carbon costs as well as promote physical health. As a physician, providing medical care for minor concerns over the phone can eliminate unnecessary travel. Hospitals, in addition to being fiscally expensive, have high carbon costs. Initiatives to keep patients out of hospitals by improving home care and end of life services can greatly decrease these demands (Thompson & Ballard, 2011).
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Sustainable medicine and resiliency permeate through all levels and specialties of medicine. How do the concepts of resiliency and the various forms of sustainable medicine fit into the training of a resident physician? Physicians in training face many of the same challenges across specialties. This section will look at four different aspects of residency and how these relate to sustainability. These are:
A significant challenge which affects all residents is the expectation of long working hours. From 12-hour work days to 24-hour weekend call shifts, residents are expected to not only work long hours but to remain competent and professional while doing so. The expectation of long working hours can affect resiliency and sustainable medicine in a myriad of ways.
Long working hours have been associated with increased stress, sleep deprivation, car accidents, relationship stress and burnout (Fletcher et al, 2005). Shockingly, one study of medical students and residents suffering from burnout demonstrated that 6% of sample population suffered from suicidal ideations (Goebert et al, 2009). All told, these effects of long working hours may lead to residents that are more at risk of burnout and affect the sustainability of their practice, possibly causing them to take a leave of absence.
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The link between long working hours/sleep deprivation and medical errors has been identified for several decades. For example, interns in the ICU have been shown to make 36% more medical errors and nearly six times as many serious diagnostic errors when working a traditional work week (1/3 call shifts) vs. a reduced work week (Landrigan et al, 2004). Medical errors can directly impact the sustainability of healthcare systems through increased cost. This cost is not negligible as the annual cost of medical errors in the United States was estimated to be approximately 17 billion dollars. Therefore, it stands to reason that supporting resiliency and preventing burnout would directly increase the sustainability of medical systems (Van Den Bos et al, 2011).
While no research has specifically focused on the impact of resident working hours on the carbon footprint, it is worthwhile discussing what is known and how this could foreseeably affect sustainability at a global level. As detailed above, long working hours have been associated with increased medical errors and other adverse patient events (Landrigan et al, 2004). In addition, medical errors such as adverse drug events have clearly been shown to lead to increased hospital stays and patient mortality (Classen et al, 1997). Therefore, it is possible to envision that the medical errors arising from resident working hours may lead to increased hospital stay, increased diagnostic tests and other factors which may increase the carbon footprint of hospitals.
These detriments to resident resiliency and sustainability have led to several jurisdictions and organizations, including the Accreditation Council for Graduate Medical Education, mandating a maximum 80-hour work week. As the above example demonstrates, expectations of residents are high and can directly impact sustainability due to a range of factors.
Above we discussed how resident expectations can lead to an unsustainable situation. Often, the effects of these expectations are quite apparent and easy to identify. Another factor which can lead to an unsustainable practice is the culture of medicine, an aspect of residency that is a bit more insidious, but no less pertinent to resilience. Related to the culture of medicine is the idea of the hidden curriculum where this can refer to the “implicit rules to survive the institution such as customs, rituals, and taken for granted aspects” (Lempp & Seale, 2004). It is important to note that some of the aspects of the culture of medicine also intersect with expectations of residents (e.g., long hours being expected).
A number of aspects of the hidden curriculum or culture of medicine can directly affect resident wellbeing. Some examples include the following (Haidet & Stein, 2006):
The above examples are only a snapshot of the hidden curriculum/culture of medicine. This complex process can affect sustainability in numerous ways. One specific aspect of the culture of medicine is intimidation, harassment, and abuse. Intimidation, harassment and abuse can be common experiences in medical education, sometimes even considered a positive teaching tool ingrained into the culture of medicine (Musselman et al, 2005). However, recent focus on this subject has linked these negative behaviours to multiple negative outcomes.
Intimidation, harassment and abuse can be commonly experienced by residents and medical students (Baldwin et al, 1991). In one longitudinal study, 72% of students reported experiencing at least one abusive event throughout their training. These abusive events included among others: gender discrimination, exclusion, and sexual harassment. Harassment and other forms of maltreatment have been associated with suicide attempts, depression and other psychological consequences (Frank & Dingle, 1999; Richman et al, 1992). As such, the widespread nature of harassments can lead to residents whom are more prone to burnout and less likely to sustain their practice.
As detailed above, intimidation, harassment and abuse are associated with depression in medical trainees. Further research has demonstrated that residents suffering from depression are more likely to commit medical errors, with one study estimating this risk to be six-fold (Fahrenkopf et al, 2008). In addition, “disruptive” physician behaviour, which included abusive behaviour, was associated with a cost of over one million dollars at one American hospital (Rawson et al, 2013). This example provides another link between resident resiliency and sustainability as the costs associated with these negative experiences directly impinge on our medical system.
In the previous section, we described how “disruptive” behaviour was associated with significant financial costs. This cost was estimated to be due to staff turnover, medical errors, and procedural complications (Rawson et al, 2013). As we saw when examining the effects of resident working hours, these types of errors and complications can lead to lengthier hospital stays and increased patient mortality (Classen et al, 1997). This can then expand outwards, affecting the carbon footprint of the healthcare system by leading to increased use of medications, electricity, diagnostic tests, and many other tangible and intangible items. This again shows us the links among aspects of the medical system which can affect the resiliency of residents while also impacting the healthcare system’s carbon footprint (see Figure 1).
The scope of practice can be defined as a physician’s area of training and experience. For example, while broadly speaking there are many challenges to all medical residents, there are specific aspects in the scope of practicing psychiatry that can significantly impact resilience and, as such, sustainability. In this subsection, we will review two significant factors. The first involves the use of physical and chemical restraints or isolation to manage acute psychiatric crises, and the second involves coping with patient suicide.
Figure 1. Global sustainable wellbeing
Psychiatry residents are often managing patients in acute psychiatric crises that pose a significant risk to themselves or the public. Residents must quickly learn to manage intense clinical encounters. At times this may require the use of physical or chemical restraints in order to ensure the safety of the patient and public. As a trainee, this can pose a significant psychological burden, impact morale, and contribute to burnout. All of these factors can significantly impact a resident’s resilience and, as such, sustainability.
Psychiatry residents are faced with the particular challenge of managing clinical encounters that fall within the scope of the Mental Health Act. This includes involuntary hospitalizations, capacity assessments, including financial capacity, and community treatment orders. These duties can often place the resident in what may appear to be an adversarial stance with their patient. This can have a negative impact on the therapeutic alliance with the patient and make treatment more challenging. Over time, these types of interactions can also take a toll on the resident’s morale and contribute to causing burnout.
Coping with the suicide of a patient is one of the most challenging aspects of practicing psychiatry. Residents are particularly vulnerable as they have the most direct contact with acutely ill patients. Research has shown that approximately one in three psychiatry residents experience a patient suicide and as many as 9% of residents have experienced more than one (Brown, 1987a; Kleespies et al, 1990). Despite the frequency of completed suicides amongst patients receiving psychiatric treatment, it remains largely a taboo subject as there is a significant amount of shame and guilt associated with these events for clinicians (Bierman, 2003). As residents have limited clinical experience, having a patient complete suicide is often experienced as a personal failure (Brown, 1987b). The impact of a patient suicide can be devastating for a resident. For some it may be as severe as symptoms of posttraumatic stress disorder or a professional crisis that may lead to thoughts of changing career paths (Bierman 2003).
The nature of the physician-patient interaction is unique in medicine. It inherently demands a significant psychological vulnerability on the part of the patient and clinician. There is a key emphasis placed on the physician-patient relationship as an active component of both the diagnostic and treatment process. This establishes an inherent level of intimacy with patient encounters. In this subsection we will briefly discuss two aspects of the physician-patient relationship: countertransference and boundary violations.
Countertransference is broadly defined as the projection of therapist’s emotions towards the patient. This can be challenging for residents to manage as they are early in the training process. It can often be distressing for clinicians to experience an intense emotional reaction to patients as it may be interpreted as a lack of professionalism. However, we know that utilizing countertransference is often an integral part of many diagnostic and therapeutic processes, especially in the psychiatry field. This places a significant psychological burden on residents to “bring themselves” to the therapeutic process. It is critical that residents develop the skills to manage these specific demands in order to build resilience and facilitate sustainability of their practice.
Boundaries define the scope of the physician-patient interaction. Gabbard and Nadelson (1995), defined boundaries as “... the limits of a fiduciary relationship in which one person (a patient) entrusts his or her welfare to another (a physician), to whom a fee is paid for the provision of a service.” Boundary violations can include but are not limited to “sexual contact, giving or accepting inappropriate or elaborate gifts, probing for private information that has no relevance to the clinical issue, acting in a dual capacity, excessive self-disclosure, entering into business relationships with patients, and failing to obtain adequate consent prior to intimate examinations” (CMPA, 2014). While boundary violations can occur in any medical domain, the practice of psychiatry has unique risks because of the nature of physician-patient relationship. This requires clinicians to be particularly vigilant. It is critical for residents to learn early in their careers how to maintain appropriate professional boundaries with patients. Research indicates that education is an important factor in helping physicians to understand and recognize possible boundary crossings and violations before they occur (Gabbard & Nadelson, 1995).
In the above sections we discussed many aspects of medicine and residency that can lead to unsustainable practice on several different levels. It is important to note that much of the above presented research comes from various residency programs and different countries and may not completely reflect your experience. The purpose of this skill building exercise is to focus on your experience and aspects that may make your practice, the hospital system, or the environmental impact unsustainable. Read over the questions on the right side and try to apply your answers to the various levels of sustainability.
Clara, a second year resident on the consultation-liaison psychiatry service, is following a 47-year-old man with angry outbursts and opioid-seeking behaviour who has been admitted for major depression and a suicide gesture involving the consumption of 20 tablets of acetaminophen 325 mg/hydrocodone 5 mg. To the faculty attending, a seasoned white male clinician, he is polite and consistently agrees to the treatment plan. To the resident, an Asian woman, he is surly and demanding, and complains that no one is paying attention to his pain and that she is restricting pain medicines and causing him to suffer, even though he appears comfortable when seen by the attending. He demands that she recommend that he have a regular diet despite his history of heart failure necessitating salt restriction. He also demands that she recommend a second head computed tomography (CT) scan, given his “headaches” and difficulty concentrating, although the first was unremarkable. He claims that the venlafaxine XR she has put him on makes him “crazy” and demands that she switch the antidepressant to the anxiolytic, buspirone, which he claims has worked better for his depression in the past. Clara recommends buspirone 10 mg twice a day, as well as a repeat head CT scan to the primary team, both of which are ordered.
The resident is angry and resentful toward the patient for the way he is behaving toward her, even though she objectively knows that he is splitting (behaving nicely toward the attending and unpleasantly toward her) due to his underlying personality disorder. She feels that counseling and setting limits only exacerbate the abuse she receives from him. As a consequence, she makes recommendations for adjusting his medication dose but otherwise does her best to avoid him beyond a quick daily review of his vital signs. She is frustrated by her inability to manage him and believes that she is perhaps not well-suited to a career in psychiatry.
Clara first needs to have greater self-awareness of her reactions and to be realistic. As much as she resents his discrimination against her, she should realize that his behaviour and prejudices are deep-seated, unlikely to be changed quickly – if ever, and are in part a response to his splitting behaviour, which he uses against the most junior member of the psychiatric team because he believes she is easier to bully. Despite her knowledge of personality disorders and “splitting,” she allows his behaviour to get under her skin. Given the splitting, it would be important for her to discuss the case frankly with her attending so that they could develop a common plan of action that would mitigate the patient’s splitting behaviour and lead to consistent limits on rewarding his demands. Clara’s frustration with the patient has resulted in self-blame for her inability to change his behaviour, leading her to acquiesce to the patient’s demands.
Clara also needs a community of fellow residents who can appreciate her predicament and offer advice, not just be a sounding board for her complaints. It takes time to cultivate the necessary friendships, but talking to peers at her level and above may be easier than admitting her perceived failures to the supervising attending physician. Her reaction is counterproductive by showing to the patient and to herself a loss of empathy and professional competence, which only augments her low self-esteem.
Finally, Clara may benefit from relaxation techniques, ranging from outside activities like going to the gym to formal relaxation methods such as mindful meditation.
Alex is an attending hospitalist at a Californian medical center who is four years out of his residency in internal medicine. On Sunday he picks up a service of 18 patients, including 92-year-old Saul, who was admitted for observation after transport to the ED Friday afternoon following an unwitnessed fall from his wheelchair. The patient suffered no broken bones or a subdural hematoma, although he has a large ecchymosis on his left forehead, with significant periorbital swelling. His past medical history is extensive. Several years ago he fractured his left ankle but delayed seeking medical attention, resulting in fusion of his ankle at an odd angle, impairing ambulation. He has coronary artery disease, paroxysmal atrial fibrillation, diastolic heart failure, foraminal stenosis from C3-C6, spinal stenosis at C3-C4, a new left rotator cuff tear with dislocation of the humeral head following a fall two months earlier, carious and loose lower front teeth, several midbrain lacunar infarcts, and a history of mild cognitive impairment, although he displays a sharp memory for remote events and can usually remember recent events with prompting. He is very hard of hearing. He has a chronic indwelling bladder catheter due to prostatic hypertrophy with obstruction, as well as chronic stage III kidney disease. The computed tomographic scan of his lungs, looking for occult rib fractures, revealed previously undiagnosed, moderate interstitial lung disease. On Wednesday he is scheduled for left cataract removal (his “good” eye), and he has a dense cataract obscuring vision in his right eye. He is legally blind. He becomes mildly delirious Saturday evening, which is attributed to hypovolemic hyponatremia. His delirium resolves with correction of his electrolyte abnormalities.
Saul tends to be cantankerous and demanding. Freeda, his 62-year-old daughter, a former university biochemist, has acknowledged that her father is not a candidate for any major surgery because of his organ-system decompensation; the cataract extractions are being done for quality of life. Nevertheless, she regularly pages Alex and demands consultations from specific specialists in Cardiology, Pulmonary Medicine, Geriatrics, Ophthalmology, Orthopedics, Physical Medicine and Rehabilitation, and Nephrology, although none are on service and are mostly unavailable; by the structure of the medical school, consultants do not have order-writing privileges unless they are explicitly permitted by the primary attending. She also demands regular visits from Speech Therapy, Occupational Therapy, and Physical Therapy, and regularly complains about the food. This is not an academic service, and Alex is the primary provider.
Freeda rarely leaves her father’s bedside. On Monday, she refuses discharge to her house because the patient cannot stand or transfer, and she also refuses discharge to a nursing home for the 1½ days prior to the cataract surgery, after which the plan is to admit him at least overnight. He normally would stay on the hospitalist service with consultation by Ophthalmology.
Alex is frustrated because the initial plan, before he came on service, was to discharge the patient to a nursing home on Day 2, but the daughter refused. Although Alex remains polite, he flat-out refuses Freeda’s demands and replies that the consultations are not appropriate and that he is “[T]he captain of this ship!” Freeda asks to meet with the chief of hospital medicine, who is very solicitous and appears understanding; however, there is no change in management or attending physician.
Freeda telephones the senior academic geriatrician, who is also the patient’s primary care physician. He agrees that Saul is familiar with the staff and his surroundings, and that transfer to the nursing home for just 1½ days would be disruptive and potentially harmful to him. Going home, even with home health ordered, was out of the question; home health would not be able to provide the 24/7 level of care that Saul needed. The geriatrician pages Alex to present his opinions as an experienced geriatrician. He is sympathetic to Alex’s need to deal with a demanding daughter and a complex patient, but strongly advocates that Saul remain in hospital through the cataract surgery.
Subsequently, Alex meets with Freeda in the patient’s room and conveys that he spoke with the geriatrician, and that Saul would in fact be discharged that afternoon, returning Wednesday morning for an outpatient cataract extraction.
Insofar as the specific requested specialists were unavailable, Alex was justified in refusing to contact the individual physicians. The consultations would add to the cost of the admission and undermine the construct of sustainable medicine. Moreover, Freeda had previously stated that her father was not a candidate for non-cataract surgeries and he was now medically stable on his outpatient medications, so little would be gained from the consultations (with the exception of ophthalmology). However, Alex gratuitously added that he was “Captain of this ship!” implying that he wanted Freeda to know that he, Alex, was in control. Although the cataract extraction was scheduled as an outpatient, Saul’s complexity and new periorbital swelling warranted an ophthalmology consultation to make sure he still was a candidate. Alex allowed his desire to exert control over the case to rise above the patient’s welfare and clinical needs. Alex misrepresented the statements from the geriatrician in order to bolster his decision to discharge the patient on Monday. In so doing, he also dismissed the clinical experience and expertise of an expert geriatrician, potentially affecting his standing in the department. Alex’s need to assert control, possibly due to the insecurity of being a young junior faculty member, caused him to ignore recommendations that were both reasonable and justified. Alex also appears to have been stressed out by a large, complex service and likely did not have time to spend reasoning with an obstinate daughter.
Alex is irritated with the family, in addition to being overwhelmed by a busy service with sick patients. He has let his frustrations adversely affect his clinical decision-making and alienate him from the surrogate decision maker (daughter). Alex would have benefited from greater awareness of why he was frustrated. With family members like Freeda, limit-setting must be done by engaging the family in discussions of options that are realistic, and explaining in a kind but succinct manner why the family member’s demands may be unrealistic. The focus has to be on the patient’s welfare. Alex needs to be aware that Freeda, in a maladaptive way, is trying to advocate for her father and is unwilling to face the reality that rehabilitation in a nursing home is a necessary, though less than ideal, setting for him. Resolving this impasse requires that she cultivate her awareness of her father’s needs and her own anxieties and feelings of guilt. This, in turn, can be facilitated by the attending physician acknowledging and sympathizing with her concerns, along with evidence-based presentation of the options. She needs to be emotionally supported for making a decision that is realistic even if it makes her father unhappy. In summary, resilience on the part of the attending physician is enhanced by supporting, not confronting, the family.
Although this is explored in detail in the section Integrate New Lifestyles, topic Practicing Resilience in the Era of Sustainable Medicine, techniques to relieve stress in general are important for Alex, just as they are for Clara (see Case 1). These can take multiple forms (mindfulness, other meditation methods, exercise, diverting entertainment, etc.), but the key factor is finding time and the skill to let go of the worries and anxieties generated by the service, including Saul and his daughter. Support from colleagues, especially his service chief, can help accomplish this goal, but requires that they have training or skills in promoting resilience.
If Alex followed the recommendation of the senior geriatrician, keeping him in the hospital would increase the cost of this hospitalization, which potentially would be inadequately reimbursed because Saul is on “observational” status. However, the “carbon footprint” should not take precedence over quality of care (i.e., doing what’s right). Despite the pressure from the case manager to discharge Saul, Alex should be aware that a premature or inappropriate discharge could result in readmission, increasing the cost of care beyond the expense of keeping him an extra 1 ½ days.