This article is co-authored** by (top row) Christina M. Nowik , Pamela Lai, Thomas McLaughlin, Simon Moore, (bottom row) Gillian Shiau, Natasha Snelgrove, Nureen Sumar, and Jasmin Yee, all of whom previously served on the Resident Doctors of Canada (RDoC) Resiliency Working Group
For Canadian resident doctors, July 1st is more than a national holiday; it represents the day when newly-minted doctors become responsible for decisions in patient care. While this is an exciting day, it can also be fraught with anxiety and stress. Over the course of residency, acute work-related stressors, including traumas and patient deaths, can negatively impact residents’ wellbeing. Additionally, residents endure chronic stressors such as large debts, extended work hours, and isolation from family. These factors predispose residents to burnout. The prevalence of burnout among resident doctors is up to a staggering 75%. Resiliency interventions have been shown to work, and the time to begin implementing them nationwide is now.
Physicians struggling with burnout demonstrate reduced job performance, more difficulty concentrating, decreased creativity, lower job satisfaction, increased presenteeism, and greater absenteeism. Burnout is also associated with increased medical errors. Moreover, patients of burned out physicians are less satisfied with care and less likely to adhere to treatment for chronic disease.
Resident doctors have a high prevalence of depression – nearly 30% according to one recent meta-analysis. Male and female physicians are estimated to complete suicide at a rate up to 70% and 400% higher than males and females in other professions, respectively.
Medical educators are taking action by incorporating wellness into the core principles of Canadian medical education. The CanMEDS frameworks of the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada include key competencies related to managing one’s personal health as a physician.
For over ten years, the Canadian Department of National Defence (DND) has provided resiliency and mental health training to Armed Forces members across the institutional hierarchy and throughout members’ careers. The DND defines resiliency as “the ability to recover quickly, resist, and possibly even thrive in the face of direct/indirect traumatic events and adverse situations.” This concept acknowledges the inevitability of stress, focusing on practical tools to mitigate its impact on wellbeing and performance. The Mental Health Commission of Canada (MHCC) has adapted the DND’s Road to Mental Readiness training (R2MR) for non-military workplaces, including the Ontario Paramedic Association. The MHCC training is called The Working Mind (TWM), which has been delivered to approximately 25,000 participants in just the past 3 years.
R2MR and TWM focus on decreasing stigma and increasing mental health literacy. They introduce participants to the Mental Health Continuum, a reflective tool for familiarising users with early signs of distress and encouraging them to seek early help (Figure 1). Practical skills known as the “Big Four” form another key component; this includes: 1) Tactical breathing, 2) Goal setting, 3) Visualisation, and 4) Positive self-talk. These skills – derived from cognitive behavioural therapy, mindfulness, and performance psychology – are intended to decrease stress and improve performance. R2MR includes Focus and Attention Control training, known as the “+” in the “Big Four+” skills whereby an individual applies the Big Four techniques with selective scrutiny of what he/she is choosing to pay attention to and what he/she is choosing to disregard. This allows users to further improve their performance under trying circumstances by teaching them to select the attentional focus which is most appropriate for a given context.
A decade after the DND began implementing resiliency training, Resident Doctors of Canada (RDoC) undertook the adaptation of this curriculum for postgraduate medical education. To this end, RDoC brought together representatives from national and provincial stakeholders in medical education in an iterative feedback process with the goal of creating a coordinated, national approach to resiliency which is developed and delivered by resident peers. This Resiliency Curriculum is intended to complement existing wellness and professional support programs.
Physican-directed burnout interventions are associated with decreased burnout. Asuero and colleagues showed that primary care physicians who participated in a program consisting of clinical presentations, mindfulness-based training, yoga, and group discussion demonstrated moderate improvement in Maslach Burnout Inventory, while control subjects showed no change. Stress training and visualisation exercises for surgical residents are associated with improved performance. The DND evaluated R2MR with 28,000 Armed Forces personnel and observed a significant increase in knowledge and confidence around mental health and coping strategies, as well as a significant increase in care-seeking behaviour between 2002 and 2013. Organization-directed interventions may produce a greater effect than physician-directed interventions. By providing universal training throughout the organizational hierarchy – such as resiliency training is delivered in the Canadian Armed Forces – the intent of the broader program is to change the organizational culture within postgraduate medical education and ultimately the medical community at large.
As the demonstration of “commitment to physician health and well-being to foster optimal patient care” constitutes a core skill in medicine, there have been calls to implement such training earlier in medical education. Indeed, the ability to assess one’s wellbeing and to respond appropriately, as well as the ability to perform under stress, should be taught from the outset of medical education.
This piece represents a call to action for all physicians, residents, medical students, and educators to recognize and act upon these critical issues. As Resident Doctors of Canada does its part to test and implement a national resiliency curriculum for residents, we call upon all trainees and educators to reflect on how you can best integrate wellness and resiliency into your own programs and own lives.
Currently, the levels of burnout, depression, and suicide among medical trainees are unacceptably high. While the profession of medicine is inherently stressful, the current system of training further facilitates the erosion of empathy and wellness. We must work towards a culture where the well-being of trainees and clinicians is valued and bolstered. Organized resiliency initiatives for medical trainees must be implemented to ensure a physician workforce which is healthy and able to provide excellent patient care.
Christina Nowik is starting a fellowship in Maternal-Fetal Medicine at the University of British Columbia and has a special interest in health policy.
Pamela Lai is a family physician in Ottawa with a special interest in physician wellness.
Thomas McLaughlin is a pediatrician at the University of British Columbia with special interests in child health policy and medical education.
Simon Moore is a family physician in British Columbia and Northwest Territories with a special interest in medical education.
Gillian Shiau is a vascular and interventional radiologist at the University of Alberta with a special interest in medical education.
Natasha Snelgrove is a psychiatrist at McMaster University and the University of Toronto with a special interest in physician mental health.
Nureen Sumar is a family physician practicing in Primary Care Oncology and Palliative Care in Calgary with a special interest in physician wellness.
Jasmin Yee is the Resiliency Project Coordinator at RDoC.
Financial support for the development of the Resiliency Curriculum has been provided by Resident Doctors of Canada.
Simon Moore is the founder of The Review Course in Family Medicine.
The authors graciously thank Dr. Andrew Szeto from the Mental Health Commission of Canada and Lieutenant-Colonel Suzanne Bailey from the Canadian Armed Forces for sharing the successes of resiliency training delivered by their respective organisations.
I am re reading about resiliency teaching in medical school and residency; a CMAJ article from March 2018.
We need to move beyond studies and advice to students and clinicians to hydrate, take a break, and carry a fruit or granola bar in your pocket. (Urgent hospital calls or CODE Blue will take precedence)!
Rural MD groups are often understaffed. Perhaps the CMA can join with Health Canada to fund/ create an extra position (or short term rural ‘locum’) to reduce the on-call burden for rural and northern regions.
For urban MDs, the CMA could fund MD ‘locums’ to
cover on-call shifts, hospital coverage, or relief for residents. (Assuming that there’s a hard cap on the number of hours a trainee will work per day).
Can Nurse practitioners play a role?
Perhaps staff Surgeons & hospital MDs can return to doing on-call shifts, to reduce burn out among residents. (Spread out the on-call burden).
The CMA has resources to return monies to MDs to reduce their debt load/ financial pressure to work long hours. (Or CMA partnership with the Federal government).
We need to see tangible steps, and the CMA has new resources.
Thanks for addressing this important topic.
One of my frustrations is the imbalance that exists in terms of the emphasis placed on individual physician responsibility for wellness as opposed to addressing systemic and organizational contributors to burnout. Too often, it seems the easiest way to appear to be addressing the problem is to build in more lectures that place the onus on the individual – an overly simplistic approach to a complicated issues driven largely by increased system pressures, constantly rotating teams, increasing patient and family complexity/demands and lack of control over scheduling.
On an unrelated note, I was interested to learn that the OMA now screens for depression/mental illness on its medical student disability insurance questionnaire (a new addition in the past 3 years). Clearly they have recognized the growing prevalence of mental illness in medical trainees and are trying to insulate themselves from the cost.
Great to see some work being done to address physician burnout at the resident training level.
One point of discussion: I would be cautious with some of the conclusions in your article based on the actual evidence from the articles. For example your statement that ‘Stress training and visualisation exercises for surgical residents are associated with improved performance’ should be assessed for its validity given that the study in question was 1. likely under-powered; 2. flawed as the two groups were statistically different in their previous surgical exposure; 3. and was based on a model, so to extrapolate that to real work surgical performance is foolish. In regards to the single article by Asuero and colleagues, a recent meta-analysis (including the said article) of physician and organization-led interventions published in JAMA in 2016 by Panagioti et al. concluded that there is a large amount of heterogeneity in the data, and that overall the improvement on the Maslach Burnout Inventory was only 3 points; to put this in perspective the score for the above test can range anywhere from 22-88; and sometimes more. So to make the conclusion that “resiliency interventions work,” is rather premature, especially because of the lack of literature in medical training.
Finally, in my opinion, none of the evidence that was provided compared resiliency interventions to simply putting a hard limit on working hours. I won’t quote one of the many methodologically flawed studies in regards to duty hour restrictions and pretend it will solve all our problems; however, if we are going to actually practice evidence based interventions we should be comparing what you intend to do with resiliency training to something that has been advocated for by residents for many years.
Just my two cents.