Evidence indicates that health professionals suffer from increasing rates of anxiety, depression, substance abuse, and burnout.1-3 The factors that contribute to these negative outcomes include demanding workloads, stressful environments and relationships, suboptimal work-life balance, and contact with the ill and dying. Burnout negatively impacts attitudes and behaviors, with lasting implications for patient care. The training environment for physicians lacks structural and educational support to address the human and emotional needs of trainees. The implications on the health workforce as well as on patients demand attention to this issue. I share my personal experiences from the time when I was in medical school and postgraduate training and offer recommendations for reform to bring about systems level changes and address the age-old need for healing the healers.
“So you are the girl who had the baby?” The professor asked.
“Yes Ma’am” I replied.
“Couldn’t you have planned better?” Her scathing query followed.
The lack of empathy I experienced during my final OB/GYN examination, a day after the birth of my son Hassan, was the culmination of a series of extremely stressful experiences throughout my medical school training. Three decades later, I feel compelled to share my experiences and how they impacted my well-being and motivation to practice as a physician.
My experience is not unique. Medical school and residency training are not designed to be kind or compassionate to the very people who are training to take care of the health and well-being of other human beings. As new medical students, none of our teachers or peers were aware of the deep sorrow and grief that surrounded my sister Rubeena (Guddi) and me. We were classmates and had lost our father in an air plane crash prior to joining medical school. No one ever asked, how are you doing, what are you feeling, are you well? We were fortunate to have developed an armor of resilience by being together and by having the support of a strong mother.
In the final year of medical school, I married my husband Ehsan who was an army officer posted in Abbottabad, a city at the other side of the country. Ehsan was very supportive and encouraged me to finish my final year of school. In life, things don’t always go as we plan and before we knew it, we were expecting to be parents. I returned to Karachi to complete the final year of school. During the ensuing year, I faced the stress of being away from husband and was fearful and anxious that I may not be able to take my final exams because of my pregnancy. One by one, the written examinations [the first part] were done – leaving viva voce examinations, the second part. If a student failed the viva exam for any subject, they failed the entire exam and would need to retake both parts. Medicine and Surgery viva voce exams came and went uneventfully. So far so good! The baby was expected in early December, so technically all five exams would have been over had he arrived on time. Nature decided to bring our son Hassan to us two weeks early. Amidst the joy and blessing of Hassan’s birth, I was swamped with feelings of “failing” and “disappointing” everyone, thinking that I would not be able to take the three remaining viva voce exams. With encouragement and support from my husband, my sister Guddi and my family, and my classmate and friend Huma Agha, I managed to take and pass the remaining exams.
After finishing the final exams, I took six months to stay home with my baby and then started my OB/GYN internship. The next few years comprised the saga of a second pregnancy, being blessed with my second son, Farooq, balancing being a new mother and a physician, and constantly fearing the risk of “failing” or “being left behind professionally”. Finally, in 1995, I decided that the two nights per week clinical duties was putting me on the fast track to failed motherhood. After much soul searching, I opted for an alternate professional route and joined the Department of Medical Education at the College of Physicians and Surgeons, Karachi as a medical educator. Over the course of the next years, with significant encouragement from my supportive life partner and my children, I was able to carve out a professional path in academia that was congruent with my interests and passion for transforming health professions education and health care delivery for improving patient outcomes.
Based on my early stressful experiences as a medical trainee and medical doctor, I never found the courage or motivation to return to clinical work. A primary focus of my professional energies remains focused on developing attitudes, values and competencies in future physicians that enable them to retain their humanism, compassion and empathy. I have often wondered if the training environment for young doctors in training could be restructured in such a way to be more humane and considerate to the needs of trainees. After all, they are human beings too!
A Way Forward to Heal the Healers
“Wellness must be a prerequisite to all else. Students cannot be intellectually proficient if they are physically or psychologically unwell.” Earnest Boyer
Health professionals suffer from increasing rates of anxiety, depression, substance abuse, and burnout.1-3 In the United States, studies have demonstrated burnout rates as high as 50% among medical students, with 25% of students experiencing depression and 10% reporting suicidal ideation during medical school. Health professions trainees who experience burnout suffer academically and personally.4-6 The factors that contribute to these negative outcomes include demanding workloads, stressful environments and relationships, lack of work-life balance, and contact with the ill and dying. Burnout negatively impacts attitudes and behaviors, with lasting implications for patient care.7-8 Physician burnout costs the United States health care system $4.6 billion a year, a number that brings heightened attention to an age-old problem.9 In addition to the common set of stressors experienced by all physicians, parenthood brings another set of challenges, particularly for women.10-11
Research indicates that high levels of empathy and humanism have a protective effect on preventing burnout among health professionals.12-14 Addressing the professional and personal challenges associated with mental health issues and burnout can and should start early.15 Recognizing this need, institutions across USA are developing wellness programs. Learning environments, policies and programs that promote wellness in medical students are primary prevention measures. Increased awareness and acceptance of mental health concerns may encourage students to identify early warning signs of stress and burnout and seek help. Improved access to counseling and support is imperative. To be successful, these strategies need culture change and restructuring of medical education. Finally, wellness efforts need to be coupled with rigorous evaluation methods and sharing findings of successes and obstacles, so we can learn from each other.
An example of a successful medical student wellness initiative includes Vanderbilt University’s Wellness Program that is well-supported by staff and infrastructure organized to provide students with supportive mentors and advisors. The keys to Vanderbilt’s success include institutional support as well as faculty and student engagement. Other examples include resilience training (OHSU), stress rounds (UCSF), Dr. Rachel Remen’s Healer’s Art curriculum (implemented at multiple institutions), lunchtime seminars on mental health and stress management (Louisville), health and wellness day (Wayne State), pass-fail curriculum (Mayo, Johns Hopkins, University of Virginia), stress-relief sessions prior to exams (Nevada, MSU), and the medical student wellness curriculum at University of Illinois at Chicago (UIC) College of Medicine (COM). Many of these programs are part of larger institutional efforts at addressing a long standing need for addressing wellness.
UIC College of Medicine’s Medical Student Wellness initiative was initiated by concerned students and is supported by the COM Office of Students Affairs. Activities include wellness programing, peer-to-peer support, curriculum development, research, and social gatherings (wellness chai chats) at faculty advisor’s home. Most recently, a new project, Tom C. Reeves “Wellness First” is developing meaningful, evidence-based and sustainable opportunities for students from all UIC campuses to develop skills, empowering them to flourish and thrive in medical school and develop resilience for life-long well-being throughout their professional careers. An important component of Wellness First is training of faculty and staff in CBCT® (Cognitively-Based Compassion Training), an extensive year-long teacher certification training program developed at the Emory University Center for Contemplative Science and Compassion-Based Ethics. As part of the team of UICOM teachers currently in CBCT Teacher Training, I hope to facilitate students’ access to wellness activities and resources, as well as provide skills training to enhance and sustain their well-being through their professional trajectory.
Congruent with the importance of the need to pay attention to social determinants of health for our patients and communities, we also need to be mindful of the social and emotional determinants of the health and well-being of our trainees. This is all the more important at this time; the COVID-19 pandemic, with its unique demands, has placed additional burdens on health professionals and trainees.16-18 The entering medical school class in many institutions is training virtually and is faced with isolation as an added factor that may negatively impact students’ well-being. Careful design and evaluation of wellness programs will have much to contribute to our shared understanding for developing best practices. At UIC, prior work with family medicine residents has demonstrated that even brief interventions have the potential for positive effect on trainee wellness.19 My personal experience also highlights the value of family and peer support.
There is an urgent need to restructure medical education to utilize evidence-based and systems-based approaches for fostering nurturing training environments that support developing physician healers, who in addition to being competent and compassionate in taking care of others, also are able to take better care of themselves. Environments in which when a medical student or resident is blessed by the birth of a baby, her face lights up with smiles; if there are any tears, they are of joy, not of fear and anxiety.
Acknowledgement: This writing is dedicated to my father Brigadier Syed Hazur Hasnain, SJ & Bar, who taught us the value of kindness and compassion, education, excellence, integrity, perseverance, and self-empowerment, and to my mother Shireen Hasnain, who as a single parent was our rock – she was not allowed to go to school as a child but made sure that each of her children, five daughters and a son, received the gift of formal education.
-Memoona Hasnain, MD, MHPE, PhD, Co-Lead NCEAS Community of Practice
Dr. Hasnain is a tenured Professor and Interim Department Head in the Department of Family and Community Medicine, College of Medicine, University of Illinois at Chicago (UIC). She is the founding Faculty Advisor for the UIC COM Medical Student Wellness Committee; Co-Chair, Gold Humanism Honor Society (GHHS), UIC Chapter, Director, Patient-centered Medicine Scholars Program; and Co-Director, Engage-IL. The primary focus of Dr. Hasnain’s work is at the intersection of medicine and public health, with an emphasis on humanism, empathy, social justice, health equity, interprofessional education, service and scholarship. She is a nationally recognized expert on health disparities. Dr. Hasnain has received numerous accolades for her research and teaching and is a recipient of the prestigious Macy Faculty Scholars Award by the Josiah Macy Jr Foundation. This award is given to select educators nationally to accelerate needed reforms in health professions education to accommodate the dramatic changes occurring in medical practice and health care delivery.
- Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-1385. doi:10.1001/archinternmed.2012.3199.
- Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2009 Jul-Aug;39(7-8 Suppl):S45-51. doi: 10.1097/NNA.0b013e3181aeb4cf. PMID: 19641438.
- Kulkarni S, Dagli N, Duraiswamy P, Desai H, Vyas H, Baroudi K. Stress and professional burnout among newly graduated dentists. J Int Soc Prev Community Dent. 2016 Nov-Dec;6(6):535-541. doi: 10.4103/2231-0762.195509.
- Brazeau CMLR, Schroeder R, Rovi S, Boyd L. Relationships between medical student burnout, empathy, and professionalism climate. Acad Med. 2010;85(10 Suppl.):S33-S36.
- Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354-73.
- Haglund MEM, Aan Het Rot M, Cooper NS, Nestadt PS, Muller D, Southwick SM, et al. Resilience in the third year of medical school: A prospective study of the associations between stressful events occurring during clinical rotations and student well-being. Acad Med. 2009;84(2):258-268.
- Humphries N, Morgan K, Conry MC, McGowan Y, Montgomery A, McGee H. Quality of care and health professional burnout: Narrative literature review. Int J Health Care Qual Assur. 2014;27(4):293-307.
- Spickard, Jr A, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. 2002;288(12):1447-1450. http://doi.org/10.1001/jama.288.12.1447.
- Han S, Shanafelt TD, Sinsky CA, Awad KM, Dyrbye LN, Fiscus LC, Trockel M, Goh J. Estimating the Attributable Cost of Physician Burnout in the United States. Ann Intern Med. 2019 Jun 4;170(11):784-790. doi: 10.7326/M18-1422. Epub 2019 May 28.
- Potee RA, Gerber AJ, Ickovics JR. Medicine and motherhood: shifting trends among female physicians from 1922 to 1999. Acad Med. 1999 Aug;74(8):911-9.
- Cassidy-Vu L, Beck K, Moore JB. Burnout in Female Faculty Members: A Statistic or an Opportunity? J Prim Care Community Health. 2016 Sep 20. pii: 2150131916669191. 74(8), 911-919.
- Lamothe M, Boujut E, Zenasni F, Sultan S. To be or not to be empathic: The combined role of empathic concern and perspective taking in understanding burnout in general practice. BMC Fam Pract. 2014;15:15. doi: 10.1186/1471-2296-15-15.
- West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533. doi:10.1001/jamainternmed.2013.14387.
- Shapiro SL, Astin JA, Bishop SR, Cordova M. Mindfulness-based stress reduction for health care professionals: Results from a randomized trial. Int J Stress Manag. 2005;12(2):164-176. doi: http://dx.doi.org/10.1037/1072-5245.12.2.164.
- Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576. doi:10.1370/afm.1713.
- Hartzband P, Groopman J. Physician Burnout, Interrupted. N Engl J Med. 2020 Jun 25;382(26):2485-2487. doi: 10.1056/NEJMp2003149. Epub 2020 May 1.
- Jones Y, Durand V, Morton K, Ottolini M, Shaughnessy E, Spector ND, O’Toole J; ADVANCE PHM Steering Committee. Collateral Damage: How COVID-19 Is Adversely Impacting Women Physicians. J Hosp Med. 2020 Aug;15(8):507-509. doi: 10.12788/jhm.3470.
- Sani I, Hamza Y, Chedid Y, Amalendran J, Hamza N. Understanding the consequence of COVID-19 on undergraduate medical education: Medical students’ perspective. Ann Med Surg (Lond). 2020 Sep 5;58:117-119. doi: 10.1016/j.amsu.2020.08.045.
- Devens M, Hasnain M, Dudkiewicz B, Connell KJ. Facilitating resident well-being: a pilot intervention to address stress and teamwork issues on an inpatient service. Fam Med. 2012 Apr;44(4):265-8. PubMed PMID: 22481156.