Resilience, Empathy, and Wellbeing in the Health Professions: An Educational Imperative.

Hillel says, “If I am not for myself who is for me? And being for my own self, what am ‘I'? And if not now, when?” —Ethics of the Fathers, 1:14

BACKGROUND

Hillel the Elder, who was born in Babylon and lived in Jerusalem in the first century of the Common Era, is a Jewish sage credited with many aphorisms, including the famous one listed above. A closer examination of his wise words suggests that they can apply to many of us: students, faculty, and practitioners in the health professions, especially with regard to the important issue of self-care.

Serving others is the core mission of all healthcare professions. But many times these dedicated professionals neglect their own care to the detriment of themselves and their patients. Flight attendants, perhaps following Hillel's advice, remind us to put our oxygen masks on first, before assisting others. The reason is rather straightforward: If we are not in optimum health, our ability to help others is greatly compromised.

And yet data from the United States as well as other countries indicates that individuals working in health professions are at risk for high rates of chronic stress and burnout.[1] This applies to nurses, social workers, dentists, and other healthcare workers no less than to physicians. For medical doctors, however, the situation is particularly concerning. In a national study of more than 7000 physicians conducted by Tait Shanafelt and colleagues at Mayo Clinic, approximately 1 out of 2 physicians in practice experienced at least 1 symptom of burnout, and the rate rises even higher for some specialties.[2]

CAUSES OF JOB BURNOUT AND WHERE AND HOW TO INTERVENE

Christina Maslach, PhD, who developed the widely-used Maslach Burnout Inventory to assess job burn-out, defines burnout as a consequence of the relationship of an individual with his/her work setting. For those occupations that involve interactions with other people (patients, clients, students), burnout is characterized by 3 dimensions: emotional exhaustion, depersonalization, and reduced personal accomplishment.[3] Why are professionals in health fields at high risk for burn-out? It seems that several factors contribute to job burnout in healthcare workers, including high patient volume and overwhelming time pressures and demands, as well as limited or inadequate resources.

This phenomenon may begin earlier with the observed decline in empathy during medical student and residency training that leads to alarming rates of burnout in medical and other students in the health professions.[4-6] As educators, administrators, and academic health leaders grapple with developing interventions to address these issues, evidence is emerging that programs aimed at fostering resilience and stress reduction through the use of approaches such as mindfulness, reflective capacity, and appreciative inquiry also lead to increased empathy, reduced burnout, and improved wellbeing.[7]

While interventions at the individual level can help a person learn better coping skills, the fact that all professions experience these effects provides an opportunity to design and implement interprofessional approaches that can enhance the capacity for resilience among teams of coworkers. Epstein and Krasner define resilience as “the capacity to respond to stress in a healthy way” and assert that “resilience is the key to enhancing the quality of care, quality of caring and sustainability of the health care workforce.”[8] This necessitates an institutional culture that puts a priority on training and cultivating specific skills and attitudes for promoting resilience to students, clinicians, and all members of the healthcare team.

Furthermore, efforts must also be devoted to improving the environment in which healthcare providers live and work. One such shining example is the case report by Bauer-Wu and Fontaine in this issue of Global Advances in Health and Medicine describing the Compassionate Care Initiative at the University of Virginia led by the School of Nursing at that institution.

Another exemplar is occurring as we write these words. One of us is in Louisville, Kentucky, not only to speak to medical faculty and students about approaches to reduce stress and burnout, but also to participate in a community town hall meeting in which the University of Louisville School of Medicine is joining a civic initiative called “Compassionate Louisville.” The goal of “Compassionate Louisville” is to use intention and social innovation to create and celebrate a community and world becoming more and more compassionate. Indeed, it was inspiring to witness the dean of the medical school, Toni Ganzel, MD, MBA, sign the resolution document and emphatically state her commitment to nurturing and championing the growth of compassion in educational, research, clinical, and community-based programs at her institution. We look forward to seeing how this remarkable initiative evolves and impacts the local and national scene. Certainly, efforts at such partnerships between academic health centers and local governments are to be encouraged and lauded.

THE IMPERATIVE FOR THE CENTER FOR INNOVATION AND LEADERSHIP IN EDUCATION CONFERENCE

The level of work-related stress and burnout have created a sense of urgency for training programs and academic centers to identify appropriate solutions. To that end, the Center for Innovation and Leadership in Education (CENTILE) that we direct at Georgetown University Medical Center teamed with MedStar Health, Georgetown's clinical partner, to convene a national conference in Washington, DC, October 18-21, 2015 (www.centileconference.org), for the purpose of addressing the factors that underlie the rates of stress and burnout in the health professions and to highlight best practices that can be employed as educational interventions to foster resilience, empathy, and wellbeing for both individuals and on a system level. Six academic institutions (Maryland University of Integrative Health, Mayo Clinic, University of California-San Francisco, University of Cincinnati, University of Minnesota, and Vanderbilt University) have joined to co-sponsor this forum.

This timely conference will for the first time bring together educators, researchers, practitioners, faculty development leaders, and academic policy makers to present and discuss the strategies to promote resilience, empathy, wellbeing, self-awareness, and reflection and to manage stress, reduce burnout, and foster professional identity formation in students, residents, fellows, faculty, and practitioners across the health professions.

While most of the conference program has been developed with proposals for symposia, panel discussions, and workshops submitted by individuals and groups from around the world, 6 plenary speakers have been invited to address the specific themes of the conference. Christina Maslach, PhD, from the University of California at Berkeley will open the conference with an overview of what has been learned from current research on burnout and the implications from what has emerged that point toward successful interventions, especially with regard to health-care. Her research colleague, Michael Leitner, PhD, from Acadia University, Nova Scotia, Canada, will share outcomes from a team-level intervention designed to enhance workplace civility that had benefits on reducing burnout and promoting trust, satisfaction, and work engagement in nurses.

On the theme of empathy, Clifford Saron, PhD, who is at the UC Davis Center for Mind and Brain, California, will review psychophysiological, emotional expression, and qualitative data that suggest a trainable capacity to increase one's engagement with suffering and diminish one's aversive responses to it. Eve Ekman, PhD, will follow in the second day to shed light on the phenomenon of the empathic connection from the fields of psychology (humanistic, social, health, and contemplative), neuroscience, and medical education in order to consider how, where, and when interventions should be optimally given to healthcare providers.

On the final day, Steven Southwick, MD, from Yale University, New Haven, Connecticut, who has written on the science of resilience, will share how his work with former Vietnam prisoners of war and instructors in Special Forces, as well as studying individuals who went through trauma during childhood, convinced him that resilience can be learned. Mary Jo Kreitzer, PhD, RN, of the University of Minnesota's Center for Spirituality & Healing, Minneapolis, will round out the plenary presentations by discussing strategies to improve health and wellbeing in students enrolled in health professional education programs, as well as organizational strategies to advance wellbeing and engagement at a university-wide level.

We hope that outcomes from the meeting will provide valuable insights into understanding the causes of chronic stress and burnout in healthcare workers and how to best train the next generation of healthcare practitioners so they are optimally prepared for the rigors of the profession. But it is essential that faculty and academic leaders develop interventions not only for individuals but also for institutions and systems. Even the most resilient individual will not thrive in a toxic or unhealthful environment. Thus, we hope that this conference will help drive the momentum for a vigorous national effort to improve the wellbeing of health professionals and also to reduce the numbers of those who opt to leave the field. As Hillel said back in the first century, “If not now, when?”