Towards Healthier Doctors

On June 17, 1963, Canadian Health Minister Judy LaMarch announced that cigarettes were linked to lung cancer. It was an important announcement for human health and one for which Canada displayed leadership. Unfortunately, after the news conference she promptly lit a cigarette. Sneering at the seeming hypocrisy of such an act would be easy, but we shouldn’t throw stones. Do we not recommend lifestyle and behavioral changes targeting patient wellness while ignoring them in our own lives? This gap between physician recommendations and actions needs to be closed. Not only for the good of physicians, but that of our patients and the healthcare system.

On June 17, 1963, Canadian Health Minister Judy LaMarch announced that cigarettes were linked to lung cancer.It was an important announcement for human health and one for which Canada displayed leadership.Unfortunately, after the news conference she promptly lit a cigarette.Sneering at the seeming hypocrisy of such an act would be easy, but we shouldn't throw stones.Do we not recommend lifestyle and behavioral changes targeting patient wellness while ignoring them in our own lives?This gap between physician recommendations and actions needs to be closed.Not only for the good of physicians, but that of our patients and the healthcare system.

wellness concerns
Wellness is multidimensional.It involves more than a lack of illness as traditionally thought.The definition of health according to the World Health Organization is, "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."This definition encompasses a broader sense than mere biological function.Wellness includes the dimensions of spiritual, occupational, environmental, emotional and intellectual wellbeing along with personal awareness and proactivity in one's health.
The training and practice of medicine are difficult.Maintaining the dimensions of wellness is not easy in these environments.One's personal wellbeing and ability to care for patients can suffer.A physician's wellness is important and an unmatched healthcare commodity.
Trainees are faced with many stresses, from their changing roles and increased workload to life events.Trainees are embedded in a high-stress environment and have high rates of depression. 1,2pproximately a quarter of medial students experience depression, but are less likely to seek help -significant barriers such as stigma and confidentiality exist. 3,4Studies suggest that mental health worsens through medical school and this distress can continue through postgraduate training. 5,6According to a multi-institutional study in the United States, 11% of medical students seriously considered dropping out in the preceding year, with burnout, depression and quality of life being predictive factors. 7Although the above studies focused on mental health, other aspects of wellness deserve similar concern.
Physician wellness also impacts the quality of care delivered.Burnout has been linked to reduced professionalism and empathy, 8 whereas wellbeing is associated with compassion for patients. 9hysicians proactive about their health more often discuss health promotion with their patients, 10 and yet a third of physicians do not seek regular healthcare. 11Interaction with other healthcare team members is likely negatively impacted when personal wellness is neglected, expanding the effect of this neglect.These concerns have led to a number of undertakings targeting physician and trainee wellness.

wellness efforts
There is reason to be optimistic.Efforts are underway to promote wellness throughout the medical profession.These include national, provincial and institutional initiatives: large-scale efforts to provide resources and revise training requirements, and smaller projects addressing student wellness.The essential nature of physician wellness is gaining traction.
Large-scale efforts target both trainees and physicians (links below).These provide resources specific to issues of the medical profession including crisis lines.At the national level the Canadian Medical Association (CMA) has established the Center for Physician Wellbeing and recently launched the Canadian Physician Health Institute (CPHI) in partnership with the Canadian Medical Foundation to support physicians and trainees.At the resident level the Canadian Association of Interns and Residents (CAIR) provides resident specific resources on their website and supports the recently launched ePhysicianHealth website.The latter resource provides online modules addressing specific wellness topics.Changes are also afoot in residency and clerkship call hours, limiting demands on trainee time.The Canadian Federation of Medical Students (CFMS) recently launched a medical student wellness website and is distributing wellness packages to all Canadian medical students.In Ontario the Ontario Medical Association's (OMA) Physician Health Program (PHP) and the recent inaugural Ontario Medical Student's Association Wellness retreat highlight further encouraging efforts.Thankfully, this is a time of increasing activity in this area with many complimentary efforts being launched.
Small-scale efforts involve multiple approaches.Curriculum changes have been introduced to reduce competition between students with broad pass-fail grading along with optimizing exam schedules as occurred at the University of Ottawa.In order to make personal connections with students both peer and faculty mentorship programs have not only become commonplace but standards for accreditation.Some schools have created separate support services for medical students and integrated wellness into their curriculum such as Queen's University.A number of student led initiatives have also been funded, giving the student perspective a larger role and allowing targeted activities addressing student needs.
Thus, wellness is being approached at both the large-and small-scale, within and across medical training and practice.While coordination of efforts is important, the wisdom of this approach whether intentional or otherwise is that wellness is clearly not 'one-size-fits-all'.Although the breadth of efforts demonstrates that the issue of wellness has earned wider attention, there is much work to be done.At the professional and resident level positive changes are underway, however, a key time to engage learners is during their undergraduate medical education.In the words of Dr. Chris Simpson, CMA President-elect 2013-2014, "Given that health and wellness habits are learned early, it is this population of medical colleagues who, arguably, would benefit the most from a more activist wellness program." 12

forging healthier doctors
Focusing on the student level is an important way forward for wellness in the medical profession.By nurturing wellness at the early stages of training students can learn skills and be imparted values that can lead to changes in the larger healthcare culture as their careers progress.Coordination of the current efforts is needed to best address student wellness.A number of improvements are possible to current programs.
Firstly, initiatives should be carefully planned and monitored.Thus far evidence of effectiveness has been lacking.This concern must be addressed in the planning of new projects and implemented in existing ones; ensuring efforts are not futile or counterproductive.Though driven by positive intentions, one must have evidence to support the interventions proposed. 5,9Programs for mentoring in the majority lack short and long-term evaluation criteria, making assessment of the effectiveness difficult. 13Thus, existing programs need to clarify their goals and put in place clear outcome measures.
Secondly, implementation must be based on the best available evidence.Using stigma as an example, the importance of evidence-based interventions is apparent.Stigma is a major concern, especially towards mental health.This leads students to feel unable to seek help and ostracized due to their illness.Addressing stigma is a significant component of moving forward with wellness, but how does one approach this?5][16] However, the delivery of these workshops is key to their effect as they can also consolidate negative views. 17Learning how to deliver programs in accordance with best evidence is a key aspect of moving forward.
Lastly, some efforts must be targeted to specific issues and utilize models of behavioral change.As noted above, large awareness campaigns are not globally effective.Specific issues need to be targeted and skills taught, whether these be life skills, personal coping skills or healthy behaviors.Furthermore, the delivery should be planned using a validated model of change.By example, the I-Change model involves 3 stages, those of awareness, motivation and action; all must be considered in bringing about positive change. 18,19rying to introduce such changes will not happen without stressing the importance of wellness in the curriculum and the profession.It must be seen as part of professional responsibility; first to yourself, second to your peers and profession and finally to your patients.Making wellness central to medical education will not be without issue.A proportion of the student population is resistant to the idea of needing help or having future difficulties.The topic of wellness is thus difficult to broach with them.Furthermore, there still exists significant stigma especially towards mental health in our society.These need to be overcome for the good of all.Change is needed and must be evidence based, thoroughly planned and carefully implemented.

conclusion
Wellness is a goal of medicine and needs to be applied to the training and practice of those involved as well.It is a part of aligning our practice with our principles.It is about the validity of our advice for our patients, but also the care we provide ourselves.While systemic and student barriers exist, there are efforts underway to address the shortcomings.Addressing wellness needs at the trainee level is an approach that will seed long term change within the culture of physicians, wellness becoming central to the curriculum and penetrating the healthcare system.If successful, these students become more resilient doctors, better teammates and better caregivers.The move towards physician wellness is needed to form a connected, caring network of peers working together for their own and their patients' wellbeing.