Physician Heal Thyself: A Call to Action for Prioritizing Trainee Health

“If you can’t come to work, there are only two numbers I want to know—your hospital room number and your vent settings.” Before the COVID-19 pandemic, this phrase or others like it had been heard by many. Echoing a pervasive culture throughout all of medicine, such phrases capture the mindset that is ingrained into us during training—patient care comes first at all costs, even at the expense of one's own health. The pandemic, however, has interrupted this ethos and invited a new outlook placing value on trainee health. For perhaps the first time, trainees are discouraged from working while ill as it has become unacceptable and a direct danger to health care colleagues and patients for trainees to do so. In turn, this has prompted systematic restructuring and flexibility.1 We must seize this opportunity as a catalyst for creating sustained structural and cultural changes to ensure trainee health remains a priority after the pandemic subsides. Within the context of barriers that trainees encounter, we discuss structural and cultural strategies that are needed to dissolve such barriers. We also emphasize that such strategies, while presented with a lens on trainees, should be applied broadly to all health care professionals. TRAINEES ARE NOT IMMUNE: PROVIDERS ARE PATIENTS During your training, if you ever missed an appointment, were unable to seek care, received circumvented care outside of the standard patient route, showed up for work while ill, or prioritized the health of your patients over your own, you are not alone. Trainees of any specialty, however, are not immune to disease. For example, 1 study detailed that 22% of trainees in 1 specialty self-reported having a chronic disease.2 In a separate study, 75% of trainees had either prehypertensive or hypertensive disease and 68% had clinically significant stress.3 Finally, a 14-year study highlighted suicide and neoplastic disease as the leading causes of death among trainees.4 Barriers that prevent trainees from addressing their health when necessary has and will continue to have important implications. Identifying the structural and cultural gaps that prevent self-care are essential to an ability to be proactive and to mirror the care and thought we provide to our patients into the attention that we give our own health. STRUCTURAL BARRIERS TO PRIORITIZING ONE'S HEALTH There are several structural barriers encountered by trainees. The design of residency programming, including long work hours, demanding workload, and the associated difficulty with finding time away from work are cited barriers preventing trainees from prioritizing their health.2,5 When it comes to “wellness,” many efforts have primarily focused on reducing burnout through educational interventions, often doing little to alleviate practical barriers preventing one from prioritizing health when necessary.6 Perhaps this is why trainees, who arguably should have some of the best access to care, have differential utilization of primary care physicians.2,5 It may also explain why coming into work while ill is commonplace among physicians.7 Perhaps this also contributes to the well-known stories of former trainees self-administering intravenous fluid while on call because they have a case of active gastroenteritis but cannot easily find available coverage. Often, trainees may retell these experiences with a sense of pride, being encouraged and admired by colleagues for rising to the challenge. In contrast to these perhaps infrequent explicit cases, the more frequent but subtle consequences of being unable to prioritize one's health are likely to go unnoticed. Perhaps such cases might involve the lack of routine check-ups, untreated mental health conditions, or possible complications during pregnancy.8,9 Interventions that specifically target some of the structural limitations of residency life can have powerful effects, especially on perceived barriers. At Duke University, they found a reduction in perceived barriers after implementing a concierge service that facilitated flexible scheduling of primary care video visits.10 Such an intervention highlights the practicality and importance of targeted strategies and provides evidence for broader dissemination. Most notably, these efforts emphasize the importance of reaching beyond our silos. EXAMPLES OF STRUCTURAL STRATEGIES IN A SINGLE PROGRAM Based on discussions in our surgical program on prioritizing trainee health during the pandemic, we are considering the following strategies to dissolve structural barriers. Supplemental Table 1, https://links.lww.com/SLA/D124 provides a summary of each recommendation and illustrative examples of how these might be operationalized. - Cross-specialty collaboration: Individuals from diverse specialties collaborate with each other to identify and to share creative solutions. As a surgical community, this means we actively participate in measures to reduce barriers for nonsurgical trainees too. Again, the experience at Duke University highlights the value of this strategy.10 - Predictable schedule and control: Trainees are offered predictable schedules and increased control and allowance for scheduling guaranteed time away from clinical duties. - Automate redundancy: Redundancy is built into the program such that use of coverage for anticipated or unanticipated absences is automated and normalized. - Scheduling assistance: Scheduling assistance for appointments is offered due to the context of a busy clinical training.10 - Workload assistance: To reduce compounding burden that results from the absence of team members, workload assistance is provided in some form (e.g. scribe assistance with documentation, dispersion of work across multiple team members, etc). - Formalized policy: These strategies are solidified in formalized policy to improve adherence. - Oversight and monitoring committee: An oversight and monitoring committee is created to assess effectiveness, evaluate adherence, and implement appropriate responses or policy changes. CULTURE AND ASSOCIATED STRATEGIES FOR PRIORITIZING HEALTH Even if structural strategies are implemented, cultural factors must also be addressed. Consider the trainee who suffers from severe anxiety or depression but is worried about being stigmatized or judged, having to provide explanation, or burdening others with more work and chooses to suffer silently rather than seek necessary medical care. This example is not an isolated situation, and it highlights an important lesson—the culture in which we promote solutions is just as critical as any implemented solution. Therefore, the effectiveness of such solutions is directly tied to the culture we foster. In this sense, simply instituting a policy that is not backed by a supportive culture is doomed for failure. Therefore, several cultural strategies should also be considered. Supplemental Table 1, https://links.lww.com/SLA/D124 provides a summary of strategies that are being considered in our group. Implementation of the following strategies may look different across institutions: - Foster sense of community: A sense of community is fostered to encourage members to be invested in each other's health. - Eliminate guilt: Strategies are implemented with the direct intention that trainees will not feel guilty for taking care of their own health when necessary. - Normalize self-care prioritization: The need for self-care is normalized and communicated at all levels with a deemphasis on hierarchy. - Discourage neglect of one's health: Neglecting one's health is explicitly discouraged rather than celebrated. - Dissolve stigma and judgment: Stigma and judgment associated with the need to tend to one's physical or mental health are eliminated.11 It may be of benefit to partner with the Human Resources department to create clear boundaries regarding what may or may not be asked or said when health issues arise. - Multidimensional definition of health: A broad multidimensional definition of health is adopted. This definition incorporates all aspects of one's health including but not necessarily limited to physical, mental, emotional, and spiritual health. Therefore, equivalent allowances that are made for physical ailments are also provided to non-physical ones. IMPLEMENTING CHANGE Although we would like to provide a one-size-fits-all approach, it is likely that each program will need to implement changes that consider the unique training environment and specific needs of its trainee population. Again, operationalization of these strategies will likely be different at each institution due to available resources and unique challenges. To facilitate operationalization of these strategies at each institution, we recommend the creation of a taskforce or group that can evaluate the existing environment, identify available resources, and target the modifiable factors. In doing so, we anticipate that solutions will not necessarily require additional financial resources for implementation but could entail restructuring of the existing and already utilized resources. Of note, there are a variety of frameworks for creating sustainable changes which may be adopted by these taskforces. For any group considering such frameworks, 1 common framework which is referenced by the Agency for Healthcare Research and Quality is Kotter's 8 steps for change.12,13 Importantly, it must be recognized that any implemented strategy will likely involve both successes and failures; however, the implementation process alone can help to solidify an organization's commitment to change. A CULTURAL REVOLUTION FOR EVERYONE More than ever before, providers are being challenged to prioritize their own health. One medical school class has even written their own oath, explicitly incorporating this challenge as a key tenet14:“I will honor my physical, mental and emotional health so as to not lessen the quality of care I provide.” We applaud this medical school class for promoting this among their core values. We also advocate for taking this 1 step further. Our commitment to care for our own health should also extend to each other, such that we collectively work to also honor the health of each other. In this sense, we invoke the term “each other” in its most inclusive sense and consider all members of our health care community—surgeons, non-surgical physicians, trainees, students, nurses, advanced practice providers, administration staff, and other health care allies. Together, by adopting an expanded shared identity that values the health of each member of our community, we will be better equipped to address acute challenges and to be more flexible in our approaches when personal health issues do arise. CONCLUDING THOUGHTS The physical and emotional cost of the COVID-19 pandemic has been dire. In this acute period, the health care community has had to confront its own shortcoming with prioritizing the health of its members. Prioritizing trainee health is more important than ever before. For the medical community, this is an opportunity to champion long-term structural and cultural changes and to fully commit ourselves to the health of trainees and all providers.