Promoting Wellness During Transition from Fellowship to First Job

Ashish K. Khanna, MD, FCCP; Sheela Pai Cole, MD, FASE

The transition from fellowship to staff physician can be challenging, both in academia and private practice. Fellowship is a period of training, learning, and skill acquisition in a protected environment. This protection comes in several shapes and sizes, such as the limiting of work hours by the Accreditation Council for Graduate Medical Education (ACGME) and having an attending physician present to oversee difficult family discussions, end-of-life decisions, procedural challenges, key clinical decisions, and the diplomatic management of expectations of multiple clinicians in the critical care unit.

At the end of June every year, critical care fellows in the United States make a key transition. They go from being trainees to trainers of new trainees. This transition involves several changes, such as transitioning from mostly reading evidence-based data to actually practicing medicine on patients who may not always meet criteria for precise evidence-based protocols. Adaptation, assessment of risk versus benefit, and managing expectations are suddenly the purview of these newly minted intensivists. Furthermore, the impressions they make on ancillary staff, patients and families, and trainees will follow them for the rest of their careers. Finally, the pressures of academic productivity may add to the tense milieu that these physicians constantly face.

The Society of Critical Care Medicine’s (SCCM) In-Training Section has offered help, guidance, and mentorship to trainees at this critical juncture. In several series of published literature surveyed from this fragile population, the In-Training Section has asked the question, “What were your biggest concerns during transition to your first job?” The results point to a recurrent theme— burnout.1,2,3 Burnout has many facets, which manifest as challenges with work-life balance, uncertainty dealing with patient and family dynamics, pressures of board certifications, and dealing with clinical decision-making scenarios not described in publications. While the concept of burnout has risen to mainstream consciousness, many questions remain regarding its definition and application.4

Physician wellness, an obvious surrogate for prevention of burnout, is gaining recognition for its role in patient care practices, in the integrity of the healthcare system, and to the continued growth of the physician workforce. Currently, both nationally and internationally, 20%-50% of physicians report burnout characterized by emotional exhaustion and depersonalization. Furthermore, poor physician wellness increases the risk of negative mental health outcomes, including suicide, while compromising the quality, safety, and efficiency of patients’ medical care. Unwell physicians are more likely to order unnecessary care, commit medical errors, and leave the medical profession early, generating shortages in the ever-dwindling medical workforce. At the same time, patients of burnedout physicians may have an increased risk of mortality and longer post-discharge recovery times. Indicators of positive physician wellness such as job satisfaction, self-reported good health, and positive personal health practices are associated with increased patient satisfaction, improved physician-patient communication, and improved patient adherence to medication and health behaviors.

The three main components of reduction in physician burnout are personal resilience, organizational obligations to promote a culture of wellness, and efficiency of practice. The Stanford University School of Medicine tackles these components and adopts a multipronged approach to creating a well-adjusted community. Programs such as BeWell offer health and diet advice along with year-round sessions that bolster self-worth, increase self-awareness, and provide stress management strategies. Leadershipsupported groups such as WellMD have conducted wellness surveys and shared the results with administrative and clinical leadership to increase retention and recruitment among physicians. On a trainee level, fellows and residents are introduced to extracurricular opportunities such as creative writing, art appreciation, and medical humanities, which help channel clinical angst.5

Another tool in the trainee armamentarium is improved communication, both verbal and nonverbal. Communication sessions led by palliative care medicine physicians aid in neutralizing conflict both among healthcare providers themselves and between patients and their families.6

It appears that increased clinical demands and time constraints lead to pressured family discussions. This further leads to worsening feelings of failure for the burned-out trainee and feelings of dissatisfaction for the family. At the Cleveland Clinic, implementation of innovations such as a robust eICU (electronic intensive care unit) program for nocturnal coverage of the regional ICU programs has resulted in a significant decrease in paging volumes to the primary intensivists, who have anecdotally reported increased wellness while on service.7 This is a prime example of an efficient work flow model that is now preventing burnout.​

Burnout is often under- or unrecognized. Raising awareness is therefore the first step in prevention for the motivated and ambitious group of physicians who are transitioning to their first ICU staff physician jobs and are riding the wave of training success. At Stanford, fellows are asked to complete burnout surveys, not necessarily to identify its existence but more as a thought-provoking exercise. In addition, a specific wellness program is in place that includes eight one-hour sessions (approximately one every six weeks). Here guest Stanford faculty interact with their fellows. Two of the more popular workshops are creative writing workshops, in which fellows are encouraged to share their experiences via writing, and art appreciation workshops, in which fellows’ paintings are open to observation and interpretation.8 These workshops are meant to whet the appetite for incorporating creativity into busy daily schedules. Another element of healing is pet therapy. Pet Assisted Wellness at Stanford (PAWS) is now in its 20th year. On many occasions time is reserved to provide pet therapy to caregivers. Everyday simulation of what being an independent practitioner looks like is another important intervention. This can include asking the fellows to lead multidisciplinary rounds and engaging them in family discussions, especially those that involve difficult situations.

Burnout in early career critical care professionals is not a new phenomenon. However, opportunities exist for prevention, early recognition, and remedy. As faculty, our obligation to this impressionable group is to be role models. Sharing challenges that we overcame at early points in our careers helps to allay fears of insecurity and bolsters self-confidence. At our institutions, we must set up processes, programs, and work cultures that promote wellness and increase the joy of coming to work despite the nature of critical care practice and its associated stresses. Finally, the role of SCCM is vital through its specialty sections and groups, such at the In-Training Section, that focus attention on the important transition phase from fellowship to independent practice. 

References
1. Patel MB, Laudanski K, Pandharipande PP. An international career development survey of critical care practitioners. Crit Care Med. 2014 Apr;42(4):e300-303.
2. Sreedharan R, Bhalala U, Khanna A, et al. “My biggest concern . . .”: transitioning from fellow to faculty [Abstract 658]. Crit Care Med. 2015 Dec;43(12 Suppl 1):166.
3. Kitagawa M, Beesley S, Sreedharan R, Peters N, Bhalala U, Khanna A. Concern over clinical competency during transition from critical care training to the first job [Abstract 925]. Crit Care Med. 2016 Dec;44(12 Suppl 1):307.
4. Brady KJS, Trockel MT, Khan CT, et al. What do we mean by physician wellness? A systematic review of its definition and measurement. Acad Psychiatry. 2017 Sep;90(12):1-15.
5. Greene JA, Jones DS. The shared goals and distinct strengths of the medical humanities: Can the sum of the parts be greater than the whole? Acad Med. 2017 Dec;92(12):1661-1664.
6. Chang BP, Carter E, Ng N, Flynn C, Tan T. Association of clinician burnout and perceived clinician-patient communication. Am J Emerg Med. 2018 Jan;36(1):156-158.
7. Udeh C, Canfield C, Khanna A, Duggal A, Tote J. Impact of nocturnal ICU telemedicine on interhospital transfer volume. [Abstract 107]. Crit Care Med. 2018 Jan;46(1):36.
8. Koppe H. Transforming challenging patients into interesting people—creative writing as burnout prevention for health professionals. Int J Whole Person Care. 2014;1(1).