Dr. Brigham started with Lewin’s equation: B = f(P, E). It states that behavior is a function of a person and his or her environment. He then pointed to its implications for physicians and physician well-being. “Think about what we expose our residents to: death and dying, other people’s secrets, other people’s sickness, depression and anxiety. But it’s not all depressing.”
Timothy Brigham, MDiv, PhD, chief of staff and senior vice president in the Department of Education at the Accreditation Council for Graduate Medical Education (ACGME), was speaking to representatives from the 32 member schools of the AMA’s Accelerating Change in Medical Education Consortium at the 2016 consortium meeting in Chicago. His keynote, which focused on physician well-being, referenced what many know but are reluctant to mention.
What separates physicians
“There’s a set of personality characteristics that differentiate physicians, residents and medical students,” Dr. Brigham said. “One is, in a non-psychiatric way, you tend to be more obsessive-compulsive. It’s about order, control and focus, which helps most people get through those first two years. If you don’t have those qualities, you develop those qualities.”
More to the point, physicians tend to get things done where other people give up, he explained.
“One of the major problems with us in terms of duty hours is not program directors’ saying, ‘You have to work more hours,’” he said. “It’s young training physicians who desperately want to take care of that patient, who desperately want to learn a little bit more, and they say, ‘I’m going to stay longer to do that.’”
Another personality trait of physicians, he said, is pleasure deferment.
“You like ice cream and don’t like broccoli? You eat the broccoli before the ice cream,” Dr. Brigham said. “What physicians have tended to do is take that to a pathological degree. You’re always deferring pleasure.”
Still, many physicians and physicians-in-training, he continued, are reluctant to give themselves credit for their abilities and accolades.
“In this room is representative of the top two percent of people in terms of accomplishment, intelligence and talents,” he said. “But the level of self-doubt that permeates any physician gathering exceeds that of most other people. In other words, there’s a good deal of people who are sitting in this room today who are just waiting to be discovered to be the fraud that they think they are.”
Accepting responsibility for environmental effects
The point of Dr. Brigham’s prelude was to demonstrate that the personality traits that make physicians and residents effective also make them particularly vulnerable to the often overly demanding environment of medical training and practice.
“Those environmental characteristics and personality characteristics can result in what Gary Small in 1981 described as the house officer stress syndrome,” he said,” which includes episodic cognitive impairment, [such as] not knowing how you got home, or being in the middle of a conversation and hearing, ‘Blah blah blah blah blah,’ even though a few seconds before you were interested.”
It can also involve chronic anger, cynicism and family discord. Those severely affected by it may also suffer from major depression, suicidal ideation and substance abuse.
“You can see this is not a new problem. This was described in 1981. So why are we focusing on this now?” he asked.
There’s a deepening awareness of what’s happening, Dr. Brigham explained. Citing research, he noted that medical students as a group are psychologically healthier at orientation than their peer comparison group.
“And then what happens? Depression goes up. Burnout goes up. Stress goes up. Empathy goes down. Compassion goes down,” he said. “We get them, and then we do something bad to them. The emphasis should be on what we’re doing.”
Along with that deepening awareness, however, the problem has become more acute.
“Fifty-four percent of practicing physicians evidence symptoms of burnout,” Dr. Brigham said. “If fifty-four percent of physicians were getting something like cardiovascular disease because of being physicians, we’d be on that like lint on a blue suit.”
Part of the challenge, he explained, is that interest in the issue of physician well-being has always been cyclical.
“What we’re committed to is to not have that happen again,” he said.
A new plan for promoting well-being
The ACGME last year convened a symposium to address issues related to physician well-being, including building resilience, fostering and nurturing well-being, recognition and intervention, reducing stigma and helping grieving communities heal.
The overall purpose of the symposium, Dr. Brigham explained, was to advise the ACGME Board of Directors on how it could effect change to improve well-being for residents, faculty and practicing physicians. Out of it grew an action plan and recommendations for six areas of impact on which the ACGME needs to focus:
- Building awareness among physicians, scholars and the press
- Working to maximize levers for change, including the Clinical Learning Environment Review and Common Program Requirements
- Ongoing dissemination to support awareness building
- Continuum collaboration involving the Coalition for Physician Accountability, the National Academy of Medicine and annual symposia
- Research from continuing ACGME’s own research to stimulating research within the field
- Large-scale culture change that includes CEOs and payers
As part of its physician well-being initiative, the ACGME will be convening a follow-up symposium this fall.
“There’s a story in the Talmud,” Dr. Brigham said in conclusion, “where in the temple they had a series of courtyards, and as you got closer to the center, it got more sacred. In the very center of the temple was the house of God. And nobody was allowed in there, except once a year. The high priest at Yom Kippur went in with one task: He had to say the name of God.
“Nobody knows what he said, and they surmised that either he just breathed or he wept. But they wondered what would happen if something happened to the high priest in the center of the temple. Nobody could go in and get him. So they tied a rope onto his ankle so if something happened, they could pull him out.
“We put our physicians into temples of awe, where people are either taking their first breath or taking their last breath. What we need to indicate is that we’re connected to them in ways that say, ‘We’re there for you, and if something happens, we’ll pull you out. We’ll be with you. We’ll nurture you. We won’t leave you on your own.’”
