A Doctor For The Doctor

   As I interview in the virtual “Zoom” era for residency, I am frequently reminded of the advice seasoned residents have offered. One particularly meaningful piece of advice that comes up time and again is to “look for residents with bags under their eyes” as a marker of a program’s emphasis on wellness or lack thereof. Given how difficult it is to get a “feel” for a residency program virtually, much less to see the bags under someone’s eyes in the confines of a laptop screen, what wellness initiatives should prospective residents be looking for? And how can programs expand on current wellness initiatives to fit the needs of their residents?
 
   While reading a recent article about the lack of routine healthcare among resident physicians, I was surprised to learn that one-third of residents reported not having a primary care physician (PCP) for preventive health visits or medication renewals. Residents without a PCP are less likely to undergo annual blood glucose, blood pressure, and skin cancer screenings. Furthermore, residents who have not met with a mental health provider in the past year are more likely to endorse signs of burnout and depression1.  Knowing that over a quarter of residents experience depression during training even before the COVID pandemic increased stressors and isolation makes this last point particularly important2.
 

   Given the unpredictable time constraints that accompany a resident schedule, difficulties navigating private insurance, and the culture of independence within medicine, one way to promote wellness for resident physicians is by providing “a doctor for the doctor.” Scheduling resident physicians with op-out PCP and mental health provider appointments the moment they enter residency can make this easy.  Doing so also reflects a culture of caring about health and can be an extremely popular intervention, with one program having 93% of interns participating in opt-out mental health care3. Additionally, ensuring periodic protected half-days from clinical duties to attend follow up appointments would allow residents to prioritize their own health while taking care of some of the nation’s most sick and vulnerable populations; this is done at many training programs, including the University of New Mexico, University of Utah, and University of Nebraska. The University of New Mexico instituted protected half-days for residents over the past several years, which have been very well received by both trainees and the institution. It is in the beginning stages of expanding efforts to offer PCP and mental health appointments in order to further streamline the accessibility of these services.

    If coordinating medical appointments and giving residents additional time off for their health sounds like a heavy lift, consider that physician well-being impacts patient care, as well. Data has shown that physicians with higher ratings of personal well-being provide better health counseling for their patients4, have a lower probability of making medical errors4, and exhibit more compassionate care5. Conversely, physicians having unaddressed depressive symptoms may provide inferior quality of care 6.  Even in healthcare institutions with primary care access challenges, other possible benefits of scheduling residents within their own system should be recognized, including engendering loyalty that may be helpful for retaining residents as future faculty.  Of note, however, care should be taken so that residents are not scheduled to be treated by supervising faculty or fellow learners, and these visits should not result in a financial penalty.

   To ensure revitalized resident physicians who derive pleasure from their work, many systemic changes at the residency program level should be instituted. To truly embrace wellness, programs must encourage residents to prioritize their own healthcare before fulfilling their duties as providers. Tending to one’s own health should be normalized, encouraged, and even rewarded. 

   Nobody comes to work not wanting to do their best. Rather, burnt out, disillusioned physicians result from years of placing their own well-being and professional fulfillment on the proverbial back burner, with the unrealized hope that the next year of practice will allow for greater health and happiness. My hope is that with incremental progress, dark circles under the eyes will no longer be a normalized badge of honor inherent to residency training. Instead, residency programs will shift the paradigm of wellness to model building a culture of health and well-being starting from day one, and this shift can be initiated with something as simple as normalizing routine PCP and mental health appointments for residents.

References:

1. Rangel EL, Castillo-Angeles M, Kisat M, Kamine TH, Askari R. Lack of Routine Healthcare among Resident Physicians in New England. J Am Coll Surg. 2020 Jun;230(6):885-892. doi: 10.1016/j.jamcollsurg.2019.11.005. Epub 2019 Nov 23. PMID: 31765695.
2. Mata DA, Ramos MA, Bansal N, et al. Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis. JAMA. 2015;314(22):2373-2383. doi:10.1001/jama.2015.15845
3. Sofka S, Grey C, Lerfald N, Davisson L, Howsare J; Implementing a Universal Well-Being Assessment to Mitigate Barriers to Resident Utilization of Mental Health Resources. J Grad Med Educ 1 February 2018; 10 (1): 63–66. doi: https://doi.org/10.4300/JGME-D-17-00405.1
4. Gross CP, Mead LA, Ford DE, Klag MJ. Physician, heal thyself? Regular source of care and use of preventative health service among physicians. Arch Intern Med 2000;160:3209-3214.
5. Shanafelt TD, Trockel M, Ripp J, et al. Building a program on well-being: key design considerations to meet the unique needs of each organization. Acad Med 2019;94:156-161.
6. Pereira-Lima K, Mata DA, Loureiro SR, Crippa JA, Bolsoni LM, Sen S. Association Between Physician Depressive Symptoms and Medical Errors: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(11):e1916097. doi:10.1001/jamanetworkopen.2019.16097