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Chapter 4: Wellness and Its Impact on Professionalism

Chapter Authors: Ann E. Burke, MD & Patricia J. Hicks, MD

The specific goals of this chapter are to highlight the importance of managing one’s own wellness and reducing unhealthy stress responses to situations that may arise during training.  Another aim is to raise awareness and promote understanding about the impact of stress on professional behavior in individuals and teams. Pediatric training can be a time of great growth and a time of increased stress due to a number of factors. Studies report that the prevalence of burnout among pediatric residents ranges from 55-76%.1,2 Professional behavior is particularly vulnerable during times of extreme stress, anxiety and burnout. Stress may be caused by a combination of factors including sleep deprivation, the pressures of the work environment, the vulnerabilities (relative lack of experience and knowledge) of residents inherent in the training process and the acuity and complexity of patients. Learning how to utilize healthy coping mechanisms to respond to stress is of utmost importance.3

When wellness has been compromised and stress prevails, individuals may manifest unprofessional behaviors they would be unlikely to exhibit under normal circumstances. Maladaptive coping of stress, or lack of wellness, can influence professionalism In a number of ways. These include a state of detachment in providing clinical care that is prominent during burnout, a lack of insight or inability to recognize when one is practicing in an impaired state, an imposed lack of commitment or depletion of prior commitment to one's professional responsibilities. Additionally, poor coping with stress can result in a state of tension in attempting to balance one’s personal and professional life. Many of these behavioral characteristics overlap with characteristics of burnout.4   In addition to the impact stress and/or lack of wellness has on the individual; stress within a patient care team can have a substantial impact on team members and function. Strategies to combat lapses in professionalism in this area are available to trainees and programs. Fostering healthy, adaptive, and mindful responses to the inevitable stress of training should be of great priority in programs. Consistently responding to stressors with healthy responses is the goal of mindful, competent physicians. This is especially important to trainees as they are in the midst of formation of their own professional identity and development of life-long strategies.  Explicit discussions about ways to cope and respond to stress need to occur.3,5     

The two responsibilities outlined in the Physician Charter that are most relevant to this area of professionalism are:

  • Principle of primacy of patient welfare
    • One of the fundamental principles of the charter is that physicians are expected to be dedicated to serving the interests of the patient, not allowing market forces, societal  pressures, or administrative exigencies to compromise this principle. Implied is the importance of striving to not allow one’s personal life to adversely impact the primacy of patient welfare, but if that is not feasible, then identifying an alternative colleague who can serve this role.
  • Commitment to professional responsibilities
    • This responsibility includes the obligation to participate in the process of self-regulation, including remediation and discipline of physicians who have failed to meet professional standards. Maintaining high standards for professional behavior even under times of stress is a responsibility that we share for ourselves and our colleagues. Recognizing and reporting lapses in professional conduct through appropriate channels is an element of this commitment.

The Pediatric Milestones that are most relevant to this area of professionalism are:

  • Personal and Professional Development
    • Develop the ability to use self-awareness of one’s own knowledge, skills, and emotional limitations that leads to appropriate help-seeking behaviors 
    • Use healthy coping mechanisms to respond to stress 
    • Manage conflict between personal and professional responsibilities 
    • Practice flexibility and maturity in adjusting to change with the capacity to alter behavior 
  • Professionalism
    • Professional Conduct 

Behavioral Statements

The components of professionalism and the importance of wellness and management of stress listed above provide general goals. It may be helpful to identify specific behaviors or practices that would exemplify the spectrum of behaviors in these domains and would predict stages from least desirable to most desirable way of being.

Examples of Exemplary Professional Conduct:

  • Demonstrates a commitment to professional responsibilities, even during periods of stress, by making a personal commitment to a respectful workplace
  • Chooses altruism
  • Works collaboratively with other members of the team, engaging in reflective self-assessment and accepting external scrutiny to improve professional standards
  • Recognizes limitations and demonstrates appropriate help-seeking behaviors and models this behavior to others
  • Shows advanced coping mechanisms and healthy responses to stress
  • Proactively plans how to personally respond to anticipated stressor and helps other to anticipate stressors as well
  • Adapts easily to almost any situation and embraces change and challenging situations as a positive experience
  • Demonstrates flexibility and resilience
  • Acknowledges stress responses in colleagues and provides them with support and strategies to seek assistance

Examples of Lapses in Professional Conduct:

  • Expresses concern that limitations may be seen as a weakness and doesn’t seek help
  • Easily frustrated with stress and rigid about accepting change
  • Demonstrates potentially disruptive behavior in the workplace: abrupt and dismissive comments, angriness and/or gestures or body language that convey significant frustration and anger
  • Practices though impaired
  • Responds to stress by complaining about the “system,” engendering discontent in colleagues
  • Disregards and/or ignores a colleague’s obvious distress or impairment

Teaching Professionalism

Learning Objectives for the Trainees

  • Identify and appreciate the impact of wellness and stress on professionalism as it relates to one’s professional responsibilities and the ability to function effectively.
  • Identify signs of impairment (in one’s self and/or other professionals) and utilize effective help-seeking behaviors.
  • Recognize and respond to personal stress with healthy coping mechanisms that assist in maintaining excellent professional and humanistic attitudes and behaviors. 
  • Recognize the importance of wellness in balancing one’s personal and professional time/life.

Reflective Exercises

  • These reflective exercises can be used for individual reflection on professionalism issues or can be modified and discussed as a part of a larger group meeting.  Where applicable, related competencies/milestones are indicated. (Additional reflective exercises6)
  • After holding a discussion about professional responsibilities of physicians, ask trainees to describe, in one page or less, an incident in which they were challenged with a decision that involved professionalism in stressful situations. 
  • Ask trainees to reflect and describe (either in group or individually journaling) strategies that they use to cope with stress and maintain wellness.  
  • Discuss as a group, what wellness means to the trainees. Consider using the AAP Resilience curriculum materials7 and develop an Individualized wellness plan. 
  • Using any of the vignettes below, ask residents to describe a similar real-life situation. Ask them to identify the conflicting values and what they learned from the situation.

Vignettes

The vignettes that follow were developed for use in a small group or noon conference setting to help stimulate discussion about issues of professionalism.  Program Directors are encourage to expand upon these to reflect local issues and experiences. 

Chapter 4 - Wellness and Its Impact On Professionalism

Vignette 1 - Moody senior resident

A senior resident becomes irritated with a nurse who has paged her that the new admission –a child with a rash and high fever- has arrived to the ward. The resident complains to her medical student that she should not even be on call today because she has one more call this month than the other senior resident. Later she feels badly that she was abrupt with the nurse and sad she complained, but she just feels so out of control sometimes. The nurse pages again about 10 minutes later to let the senior know that the family speaks only Spanish and will need an interpreter. This news sends the resident into a “tailspin” of moodiness, frustration and worry. She again feels disturbed with her inability to cope but does not think to apologize to the medical student or nurse.

Points to consider during discussion:

  • What concerning behaviors is the senior resident displaying?
  • Have you ever had times where you feel this overwhelmed and/or stressed? What strategies do you use to cope with these situations in the moment?
  • What strategies could be used to prevent this kind of behavior? What has happened to this resident?

Vignette 2 - Drunk med student

A fourth-year medical student is completing a rotation as a sub-intern in the PICU. Her performance has been outstanding, and the senior resident on the service has already submitted an excellent evaluation about her. It is the last day of the rotation, and the student arrives at work obviously intoxicated and unable to care for her patients appropriately. The senior resident, without knowledge of the attending, sends her home to “sleep it off” with no further feedback. She receives honors for the course. Approximately five months later, at the resident selection committee meeting, two resident members describe the incident and recommend that she be excluded from the list of potential candidates for the residency program.

Points to consider during discussion:

  • What other courses of action could the senior resident in the PICU have taken five months previously?
  • What should the program director do?
  • Should this incident affect her ranking in the program?
  • What actions would be appropriate for the medical student to take after the incident?

Vignette 3 - Remark from senior resident

Dr. Z is the senior resident on the ward team. Although his first preference had been to complete a nephrology fellowship at his current hospital, he recently matched to an outside program and is preparing to move out of the area. During resident work rounds, he makes a glib remark about the nephrology service attending: “He is such a compulsive idiot. It is not necessary to follow the electrolytes so frequently. It is obvious the patient is improving.” The medical student and intern on the team appear uncomfortable with his remark.

Points to consider during discussion:

  • If you were the intern on the service and wanted to convey your discomfort to the senior resident, how would you approach that conversation?
  • What do you think contributed to the senior resident’s behavior and how could these underlying factors be prevented or curtailed?
  • What does respectful workplace mean to you? Does your institution have expectations about these concepts?

Vignette 4 - Is everything okay?

One of your senior resident colleagues arrives late each morning for morning report and does not check in with the night team as she is supposed to do in her role as ward supervisor. In addition, you notice that she seems withdrawn and anxious. She shares with you the fact that she is really questioning her choice of being a doctor. She is not making personal connections with her patients like she used to either. She admits that she is not sleeping well and feels tired all the time.

Points to consider during discussion:

  • What are the behaviors that make one worry about burn-out, anxiety and/or depression?
  • How would you approach the senior resident? How could you help her?
  • Are there any programs that exist or could be started to assist residents who are having difficulty?
  • Are there ways to help decrease the risk of this situation in the first place from a program standpoint?

Vignette 5 - Not home for the holidays

The holiday schedule was just posted in the residency program office and you have been scheduled to work during the Christmas holiday for a second year in a row. Your significant other was upset last year because you were on-call Christmas eve, and it was a particularly busy night. You are not looking forward to informing him/her about this year’s schedule.

Points to consider during discussion:

  • Assume that you are the resident and are conflicted about what to do. What would you do?
  • Would you approach the Chief resident about the schedule?Why or why not?
  • Would you just accept the schedule and not make a big deal out of it?

Vignette 6 - Worrysome nurse

You have been called by a nurse about a patient care issue. This nurse has a history of calling you quite a bit for what you deem are non-emergent issues. You are concerned about this as it disrupts your other duties.

Points to consider during discussion:

  • What actions would you consider as your next steps?
  • Who should you involve in your discussion(s)?
  • What action(s) will satisfy your professional responsibilities in this circumstance?

Assessment Tools

Burn-out inventory (Maslach)8
Individualized Learning plan for wellness7, scoring rubric from Lockspeiser et al.9

References

  1. Landrigan CP, Fahrenkopf AM, Lewin D et al. Effects of the ACGME duty hour limits on sleep, work, hours and safety. Pediatrics 2008; 122;250-258.
  2. Antiel RM, Reed DA, Van Arendonk KJ, et al.Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA Surgery. 2013; 148(5):448-455.
  3. Forsythe GB. Identity development in professional education. Academic Medicine. 2005; 80:S112-117.
  4. Eckleberry-Hunt J et al.An exploratory study of resident burnout and wellness. Academic Medicine 2009, Vol. 84:2
  5. Epstein R. Mindful Practice. JAMA 1999; 282:833-839.
  6. Kesselheim J , Garvey K, Sectish T, Vinci R. Fostering humanism and professionalism in pediatric residency training. MedEdPORTAL; 2010. Available from: http://services.aamc.org/30/mededportal/servlet/s/segment/mededportal/?subid=7906
  7. Introduction to Personal Wellness (Part D of Resilience in the Face of Grief and Loss).  Available from: http://www2.aap.org/sections/palliative/ResilienceCurriculum.html
  8. Maslach Cm, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual: 3rd ed. Consulting Psychologists Press Inc. 1996.
  9. Lockspeiser TM, Schmitter PA, Lane L, et al. Assessing residents’ written learning goals and goal writing skill: Validity evidence for learning goal scoring rubric. Academic Medicine 2013. 88:1-6

Index of Pediatric Competencies addressed by learning activities:

  • Professionalism
    • Professional Conduct
      • Reflection 1
      • Reflection 2
      • Reflection 3
      • Vignette 3
  • Personal and Professional Development
    • Develop the ability to use self-awareness of knowledge, skills, and emotional limitations to engage in appropriate help-seeking behaviors.
    • Use healthy coping mechanisms to respond to stress
    • Manage conflict between personal and professional responsibilities. 
    • Practice flexibility and maturity in adjusting to change with the capacity to alter behavior

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