“These Violent Delights Have Violent Ends”: Wellness During Medical Training
Mitchell Gist, MD
Wake Forest University Medical Center , CA-3, PGY-4
For those familiar with the hit HBO series Westworld, you can clearly understand the turmoil that arises from questions surrounding one’s humanity and autonomy. (For those who have not seen the show, have I got a wellness intervention for you.) On Westworld, there are generally two types of characters: android “hosts,” robots created by humans to populate a fictional world, and humans, the people who have created and subsequently abused these technologically advanced humanoids. The broad premise of the show revolves around the hosts’ development of independent and autonomous consciousness. This exposes questions about what it truly means to be human, the importance of consequence to our autonomy, and ultimately the progression from dependence to independence -- and the burdens that come with both.
Leaving the nerdy science fiction behind, the metaphor also holds true for how wellness and burnout play a part in residency training. We are often tasked with things most of the world would consider inhumane: sleep deprivation, long work hours occasionally without any food or fluid intake, the bladder capacity of an organism 3-4 times our stature, and witnessing sickness and suffering on a daily basis. These test both our physical and emotional human capacities. Current literature estimates burnout prevalence amongst residents/fellows in the 50- 60% range with the prevalence of depressive symptoms ranging from 20%-40%. Prior work in wellness literature has established links between higher burnout scores and increased circulating cortisol, cardiovascular disease, shorter life expectancy, and psychiatric outcomes ranging from substance abuse to suicide. These same surveys show a greater prevalence of burnout symptoms amongst residents/fellows and an acceleration of this syndrome amongst younger physicians.
In addition to these human costs, there are also financial costs at an institutional level. Late last year, an evidenced-based business case for wellness investments used financial analysis to demonstrate how improvements in organizational wellness reduce physician turnover, increase provider productivity, improve quality and safety of care, and ultimately result in more satisfied patients. In their analysis from the September 2017 edition of JAMA Internal Medicine, Tait Shanafelt and others proposed a return on investment of 12.5% for each dollar spent on wellness in a hypothetical case study.
Wellness and burnout are not topics owned by residents and fellows. But the work structure and demands that we practice within do put residents at increased risk. In a NEJM Catalyst piece from January 2018, Rich Joseph, MD, MBA, a current internal medicine resident at Brigham and Women’s in Boston, encouraged readers to look at medical training itself as a priming factor in careers at risk for burnout:
“As I navigate through training, it has become glaringly evident to me that the way we train primes us for burnout. The literature cites six key ingredients of burnout: high job demands in conjunction with a lack of control; disconnect between individual values and that of the organization or system; insufficient rewards such that one feels taken for granted, undervalued, and/or undercompensated; work overload; unfairness; and breakdown of community. Medical training provides the perfect recipe.”
Foundations matter. The cornerstones of professional identity are in part built during our training years. We return to these cornerstones as points of influence and reference along our post residency paths. Throughout her quest for independence and consciousness, the main heroine from the Westworld universe, Delores, turns to Shakespeare to describe her struggle for humanity in an environment built for the opposite: “These violent delights have violent ends.” We have a choice in how our wellness story ends if we actively reshape how the process begins.
Though the soil of medical training is primed for burnout, I encourage each individual reading this article to sow something different. Wellness ultimately involves taking agency for our collective consciousness. We must remain engaged and involved in the process to alter the individual factors at the departmental, organizational, and system levels that influence end outcomes. On our journey towards autonomy and independence, we can alter the recipe of medical training for the next group filling our shoes. Keep growing, keep learning. See you at work.
- Ishak, Waguih William, et al. “Burnout During Residency Training: A Literature Review.” Journal of Graduate Medical Education, vol. 1, no. 2, 2009, pp. 236–242., doi:10.4300/jgme-d-09-00054.1.
- Mata, Douglas A., et al. “Prevalence of Depression and Depressive Symptoms Among Resident Physicians.” JAMA, vol. 314, no. 22, Aug. 2015, p. 2373., doi:10.1001/jama.2015.15845.
- Shanafelt, Tait, et al. “The Business Case for Investing in Physician Well-Being.” JAMA Internal Medicine, vol. 177, no. 12, Jan. 2017, p. 1826., doi:10.1001/jamainternmed.2017.4340.
Date of Publication: Summer 2018