Abstract
Humanities Training as a Prophylactic for Medical Student Burnout
Interim Director and Director of Research
Osher Center for Integrative Medicine
Harvard Medical School and Brigham and Women's Hospital
Burnout among physicians has far-reaching implications to society. In addition to contributing to high rates of physician suicide and depression, it erodes physician empathy, which deeply impacts the quality of care patients receive and the trust patients have in their care. With burnout rates among physicians now exceeding 50%, there is a great interest in interventions to protect against burnout. One promising approach is to use short-term integrative mind–body and behavioral interventions to help manage the stresses that lead to burnout. A growing body of clinical studies suggests that interventions, including mindfulness, yoga, and mind–body skills training, may be helpful in building the self-awareness and resilience needed for medical students, residents, and established physicians to mitigate burnout risk. This preliminary research likely played an essential role in Harvard Medical School's 2018 decision to now require all first years to participate in a mind–body resiliency training program.
Yet, other longer-term and more upstream preventive approaches might also be helpful in addressing burnout. One widely discussed, but surprisingly under-researched, strategy regards how early education, specifically participation in humanities curricula before medical school, might influence medical school students' susceptibility to burnout.
To test the hypothesis that medical students with higher exposure to the humanities would experience lower levels of burnout, along with associated negative and positive physician qualities known to underlie burnout, Mangione et al. 2 conducted an online survey of students enrolled at five U.S. medical schools during the 2014–2015 academic year. Enrolled participants reported their exposure to the humanities during college before medical school (e.g., music, literature, theater, and visual arts) and completed multiple validated rating scales measuring selected personal qualities, including empathy, tolerance for ambiguity, emotional intelligence, wisdom, and self-efficacy. Burnout was assessed with the Shirom-Melamed Burnout Measure.
A multivariate regression analysis based on 739 respondents showed that humanities exposure was a significant negative predictor of various component subscales of burnout. Specifically, as levels of humanities exposure before medical school increased, physical fatigue (p = 0.001, d = 0.29), emotional exhaustion p < 0.001, d = 0.29), and cognitive weariness (p = 0.01, d = 0.20) all decreased. Additional analyses showed that humanities exposure significantly predicted multiple personal qualities associated with the risk of burnout. Specifically, exposure to the humanities predicted, in order of effect size, tolerance for ambiguity (p < 0.001, d = 0.63), wisdom (p < 0.001, d = 0.59), empathy (p < 0.001, d = 0.46), appraisal of others' emotions (p < 0.001, d = 0.29), self-emotional appraisal (p = 0.01, d = 0.20), and self-efficacy (p = 0.02, d = 0.20).
Acknowledging typical survey-based study limitations, including recall and reporting bias, a relatively low return rate (24%), and the study's observational nature, the authors cautiously concluded that exposure to the humanities may be linked to important personal qualities and prevention of physician burnout.
The debate about educating medical students to be well rounded in both the arts and sciences is one that goes back to the beginning of medicine. William Osler himself described medicine as the profession of a “cultivated” person, and wrote: “[Science and humanities are] twin berries on one stem, grievous damage has been done to both in regarding [them]… in any other light than complemental.” 3 Although some enlightened medical schools have developed admissions criteria to attract pluralistically trained students, the majority still rely heavily on “premedical” technical knowledge, grades in science courses, and standardized examinations such as the Medical College Admissions Test.
This approach may seem to be valuable for selecting physicians well matched to today's medical predilections, which are reductionistic, and precision and technology driven. Yet they do not prepare incoming students for its culture, which is increasingly marked by systemic, complex, and ambiguous characteristics. According to this timely study by Mangione et al., this selection bias is less likely to produce wiser, more tolerant, empathetic, and resilient physicians. More research on this topic is clearly warranted. But preliminary findings suggest that Lewis Thomas, in a somewhat mocking commentary in the New England Journal of Medicine, may have not been too far off base in suggesting that “…any [medical school] applicant self-labeled as ‘pre-med’, or [proclaiming] membership in a ‘pre-medical society’..[should] be excluded from recognition by medical schools.” 4
Citations:
1. Kreitzer MJ, Carter K, Coffey DS, et al. Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care. Online document at:
2. Mangione S, Chakraborti C, Staltari G, et al. Medical students' exposure to the humanities correlates with positive personal qualities and reduced burnout: A multi-institutional U.S. survey. J Gen Intern Med 2018;33:628–634.
3. Osler W. The old humanities and the new science: The presidential address delivered before the classical association at Oxford, May, 1919. Br Med J 1919;2:1–7.
4. Thomas L. Notes of a biology watcher. How to fix the premedical curriculum. N Engl J Med 1978;298:1180–1181.
Corporate Burnout: Not Just Bad for Business
Director, Research Fellowship in Integrative Medicine
Director of Mind–Body Research
Division of General Medicine and Primary Care
Beth Israel Deaconess Medical Center
Harvard Medical Center
Although absent days (“absenteeism”) has historically been a common metric for lost productivity due to burnout, the related concept of “presenteeism”—people coming to work when they are actually physically or mentally unwell—may more aptly illustrate the growing problem of workplace burnout. Not just work-related stress, workplace burnout is an explicit state of physical or emotional exhaustion that involves a sense of reduced accomplishment and loss of personal identity. A large proportion of our workplace may be suffering from this type of emotional and physical distress as a result of an increasing imbalance between job demands and employee resources. Factors such as lack of perceived control, extremes of activity, unclear expectations, dysfunctional workplace dynamics, and lack of social support may all play a role in workplace burnout.
Statistics related to workplace stress and burnout are staggering. An external Deloitte U.S. marketplace survey of 1,000 corporate employees from 2015 reported that 77% have experienced employee burnout at their current job, 91% have an unmanageable amount of stress or frustration negatively impacting the quality of their work, and nearly 70% feel their employers are not doing enough to prevent or alleviate burnout within their organization. This phenomenon may be universal across all corporate sectors—from technology to finance to health care.
With a promising robust literature on mind–body interventions to reduce stress, improve resiliency, positive affect, and overall well-being, extending these strategies to the workplace is a logical extension. The vast majority of this mind–body research, however, has focused on the public sector, such as hospitals and schools. Most studies have looked at medical professionals and trainees. Although the private sector has received less attention, it is ironic in that the burnout problem is actually thought to be accentuated in the stereotypical cut-throat high-stress corporate environment. Corporate burnout is greatly understudied, but fortunately a few investigations have recently emerged.
In one feasibility study by Kersemaeker et al., 1 investigators developed and tested a mind–body training program, including mindfulness techniques and psychoeducation, tailored toward corporate workplace needs in four large organizations. Participating employees were from a European skin care products company, a global automotive supplier, a European space research and technology organization, and a global pharmaceutical company. The program consisted of 2-day-long trainings plus eight 2.5 h sessions, in groups of 12–25 participants. Employees were provided eight app-based audio recordings and encouraged to practice on their own at least 10 min per day. In addition to traditional teachings, including mindfulness, walking meditation, body scan, and compassion meditation, the curriculum included informal workplace exercises such as mindful communication (e.g., focusing on listening to colleagues and team members), mindful team meetings (e.g., a minute of silence at the start), mindful e-mailing, and daily mindful journaling.
Of the total sample (N = 425), a subset of participants (N = 226) provided survey data immediately pre- and postintervention. Considering this comparison, investigators reported significantly decreased burnout (mean difference [md] = 0.3 Burnout Measure, p < 0.001), perceived stress (md = −0.2 Perceived Stress Questionnaire, p < 0.001), and an increase in mindfulness (md = 1.0 on Freiburg Mindfulness Inventory and 0.8 on Mindfulness Attention Awareness Scale, both p < 0.001). Several indices of team climate, organization climate, and personal performance (measured by the Landau Organization and Team Climate Inventory subscales) showed significant improvements, with the largest changes in team cooperation, productivity, and stress (Cohen's d = 0.7, 0.8, −0.6, respectively; all p < 0.05). The average number of hours worked per week preintervention was about 46 h, and this did not change over time.
As a pre–post noncontrolled investigation, this study has obvious limitations. However, the data provide important feasibility information regarding implementation of a mind–body program in the corporate environment. The tailored approach was innovative in that the mindful exercises were designed to specifically target known stressors in the corporate workplace (e.g., employee competition, office interpersonal dynamics, high-stress atmosphere, and pressured deadlines).
Clearly, workplace burnout is a major problem that warrants attention. The individual health consequences are significant, and the human capital and global economics argument is equally compelling. In Europe, where the Kersemaeker study was conducted, total indirect costs due to lost work and productivity have been cited at 179 billion euros per year. 1 In the United States, gross estimations are $150–300 billion per year, including absenteeism, medical, legal, and insurance costs. One might say that the costs to the individual (with respect to human health and quality of life) are priceless, but the numbers also speak to broader implications. Burnout is bad for society, for companies, for business, and for the overall economy. Future studies will need to incorporate important cost analyses. On a basic level, per employee cost savings with corporate mind–body programs may be substantial and the downstream cost benefits exponential. Perhaps that is the bottom line that will motivate and move a corporate world workplace to a much needed healthier well-being.
Citation:
1. Kersemaeker W, Rupprecht S, Wittmann M, et al. A workplace mindfulness intervention may be associated with improved psychological well-being and productivity. A preliminary field study in a company setting. Front Psychol 2018;9:1–11.
Mitigating Burnout: Is It More About How We Build Community?
Medical Director, Benson-Henry Institute for Mind Body Medicine
Massachusetts General Hospital
Associate Director of Education
Osher Center for Integrative Medicine
Harvard Medical School and Brigham and Women's Hospital
It has now become well known that clinician burnout is a public health issue. More than 50% of U.S. physicians report significant symptoms. This syndrome of exhaustion and depersonalization can have serious consequences, from reduced job performance and high turnover rates to—in the most extreme cases—medical error and clinician suicide. In the United States, this has resulted in a staggering statistic of 400 physicians (>1 physician/day) committing suicide annually. And although physicians have been the most studied population, this is not unique to just physicians; nurses and other health care professionals have also documented this phenomenon of burnout. In response, the National Academy of Medicine has created an action collaborative on clinician well-being.
Although gender is not consistently an independent predictor of burnout, some studies have found female physicians to have 30%–60% increased odds of burnout. Suicide rates in women are 130% greater than the general population. Although there have been multiple reasons speculated, women have multiple caregiving responsibilities, and tend to be more likely to take time off when their caregiving responsibilities are disrupted, resulting in challenges in career advancement. Furthermore, the economic disparities in compensation between men and women are also well documented.
In this study by Luthar et al., 1 40 mothers on staff at the Mayo Clinic, Arizona, were randomized to either an Authentic Connections group (ACG; 12 weekly 1-h sessions of a structured relational supportive intervention) with protected time or to 12 weekly hours of protected time. The ACG curriculum was originally studied in women with low socioeconomic status and found to have clinically meaningful benefit.
The participants consisted of physicians, PhDs in clinical practice, nurse practitioners and physician assistants. The intervention was a manualized approach and delivered by a psychiatrist in private practice. The published article provided an outline of the topic covered in each week. Study researchers did evaluate the facilitator to ensure fidelity to the intervention. Psychosocial outcomes included the Brief Symptom Index, the Beck Depression Inventory, the Self-Compassion Scale, the Parenting Stress Inventory, and the Maslach Burnout Inventory. In addition, blood was collected to assess changes in serum cortisol levels.
The 21 participants assigned to the ACG attended 10 of 12 sessions. There were significant reductions in individual cortisol levels from baseline to after treatment. In addition, there were significant reductions in measures of depression and global symptoms. Differences became more pronounced and significant on all psychological outcomes at the 3-month follow-up, except for Maslach Burnout Inventory.
What is most interesting about this study is that this appears to be the first study among health care providers that examines both behavioral and biological outcomes. In addition, it focuses solely on women (mean age 40). Finally, it utilizes a group-based manualized approach that fostered a sense of community, solidarity, and “sisterhood,” as described in the article.
The authors are quite honest and cautious in their assessment of their results—small study design, one provider delivering the intervention, and short follow-up periods. However, when one thinks about the cost of the intervention—12 h of a psychiatrist's time (at a conservative estimate of $500/h) and the possible impact—one cannot help but wonder how low-cost group-based interventions can lead to such significant impact. That is, what is the return on investment of $6000 for a group of 20 individuals? The loss of one physician is estimated to be $500,000–$1,000,000 in the United States. But when we reflect upon absenteeism, presenteeism, medical error, and patient satisfaction (all of which have been found to be effects of burnout), this is a no-brainer. But this study demonstrates more than that. It addresses the unique and well-recognized needs of health care professionals who are mothers. And ultimately, what they need most is to be able to connect and share with one another, address challenges in a safe environment, and be supported to do so by having their time protected.
Citation:
1. Luthar SS, Curlee A, Tye SJ, et al. Fostering resilience among mothers under stress: “Authentic Connections Groups” for medical professionals. Womens Health Issues 2017;27:382–390.