Originally published by our sister publication Anesthesiology News
Having completed her residency in 1999 at The University of Texas Medical School, in Houston, Alicia Kowalski, MD, was soon hired as an instructor in the Department of Anesthesiology and Perioperative Medicine at The University of Texas MD Anderson Cancer Center, in Houston. From there, her career advanced remarkably quickly, just as planned.
But it didn’t take long for her to realize something was wrong: She had never been taught how to take care of anything other than her patients.
“I began to get anxious,” recalled Kowalski, currently a professor of anesthesiology and perioperative medicine at MD Anderson. “All of a sudden, the institution wanted us to perform a lot more academic work, and I didn’t have the necessary skills. I barely knew how to use email and didn’t even know what PowerPoint was or how to submit an abstract.”
To further complicate matters, Kowalski was the mother of two young boys, and in addition to her myriad professional responsibilities, she now had a young family to raise at home. That was when she realized she was in over her head.
“I had spent 12 years training for my career, but that training had only prepared me for the clinical aspect of it,” she recalled. “As for the rest—research, time and stress management, professional development, health and well-being—I felt like I was adrift at sea. I knew I had to do something to get my head above water or else I was going to drown.”
Kowalski found a way to stay afloat. She continued to fight her way through the ever-increasing demands on her time and energy, somehow managing to delicately balance clinical, academic, professional and personal responsibilities. Meanwhile, she continued her advancement at MD Anderson: assistant professor in 2002, associate professor in 2008, and full professor in 2015.
Yet through it all, one thing remained constant in Kowalski’s life: No matter what she did, she always carried a profound baseline level of stress with her, the prospect of burning out a constant bedfellow. Finally, when professional development sessions at her institution proved insufficient to address her stress, Kowalski knew she needed to take matters into her own hands.
“I partnered with Imelda Tjia, MD [an associate professor of anesthesiology at Baylor College of Medicine, in Houston], a colleague from medical school and residency, and we discussed the possibility of hosting a workshop where we could offer physicians a series of experiences to fortify their resilience and confidence,” she explained.
That was how the Burnout to Brilliance Physician Wellness Symposium was born, starting Kowalski down a path she had never anticipated as a wide-eyed medical student two decades before. She was well on her way to becoming a champion of physician wellness.
Burnout Finally Front and Center
Launched in the spring of 2017, Burnout to Brilliance is a physician wellness symposium with the aim of arming physicians with a series of tools they can translate into their lives, with a focus on successful work–life integration. The three-day conference offers a series of didactic lectures on professional development, and opportunities for personal resiliency skills training. As the website states, “[W]e translate the knowledge we have on preventing, avoiding and managing burnout into actions and practical experiences, bridging the gap and removing the disconnect.”
For Kowalski, the connections made at the conference are tangible. “For example,” she said, “some of our participants are afraid of heights. But once they overcome those fears and fly down a zipline, they are able to internalize that confidence and carry it into other aspects of their lives, such as public speaking.”
Kowalski is certainly not alone in recognizing the scourge of physician burnout, as the topic has been the subject of myriad research. As far back as 1981, R.E. Hales penned an article in American Medical News titled “Physician burnout: the seeds are planted early—in the critical years of residency” (1981;24[29]:suppl 3,12). More recently, a 2022 survey by Medscape (www.medscape.com/slideshow/ 2022-lifestyle-burnout-6014664) found that 47% of more than 13,000 physician respondents in a variety of medical disciplines and locations said they were burned out. Clearly, the problem is not limited to Kowalski—or anesthesiologists.
Given the spate of publicity the issue has received in recent years, physician wellness has finally come to the forefront of the practice’s consciousness. In a 2017 article (JAMA Intern Med 2017;177[12]:1826-1832), authors Tait Shanafelt, MD, Joel Goh, PhD, and Christine Sinsky, MD, made a business case for investing in physician well-being. In their article, the authors argued that in addition to the moral and ethical reasons to address physician burnout, the phenomenon has direct financial effects on institutions, namely the costs associated with turnover ($500,000-$1 million per physician, according to one report), the costs associated with decreased productivity, and effects on quality, safety and patient satisfaction.
“At its core, we now have robust evidence that burnout and professional fulfillment in physicians impact quality, patient experience, clinical productivity and turnover,” said Shanafelt, the Jeanie and Stew Ritchie Professor of Medicine and Chief Wellness Officer at Stanford University, in California. “When you think about the implications, it means that all the components of healthcare’s triple aim—trying to provide access and high-quality care at lower cost—are undermined by clinician distress. For that reason, many organizations have expanded to a quadruple aim that incorporates clinician well-being.”
In addition to that business case, Shanafelt argues that there’s also an ethical case for healthcare employers to provide a safe and healthy work environment.
“I often draw the analogy that in construction work, we give people hardhats and ear protection because we don’t want them to be injured doing the work,” he said. “Meanwhile, occupational burnout is the work-related injury of a career as a physician. So, what’s the protective gear we’re providing and what efforts are we pursuing to improve the safety of the work environment to minimize that work injury?”
Introducing the Chief Wellness Officer
For Kowalski, institutional commitment is a critical component in physician wellness. The majority of an individual’s professional fulfillment comes from the organization’s efforts and initiatives.
“Culture can vary widely between institutions, and that can have a direct and profound effect on physician well-being,” she explained. “For example, an academic institution might be completely focused on being No. 1 in national rankings, while an institution like the VA [Veterans Administration] wants to be a competitive employer and have low turnover rates, high retention and high physician satisfaction.”
In a 2017 publication (Mayo Clin Proc 2017;92[1]:129-146), authors Shanafelt and John H. Noseworthy, MD, laid out nine organizational strategies to promote engagement and minimize burnout among physicians. Operationalized at Mayo Clinic, these strategies include the following:
- Acknowledge and assess the problem.
- Harness the power of leadership.
- Develop and implement targeted interventions.
- Cultivate community at work.
- Use rewards and incentives wisely.
- Align values and strengthen culture.
- Promote flexibility and work–life integration.
- Provide resources to promote resilience and self-care.
- Facilitate and fund organizational science.
The authors recognized that despite the success of their institution’s efforts, it is only the tip of what may be a very large iceberg. “It’s a complex problem,” Shanafelt said, “and if we really want to be effective in our efforts to address physician wellness, we need to first authentically make it a priority for the organization. If it’s a true priority, we then need to put into place the leadership, structure, strategy, resources and performance metrics for the organization to improve.
“We can’t just say that well-being is important,” he added. “If we really want to improve clinician well-being, we’ve really got to take a systems view and not just promulgate slogans.”
Another way institutions can take a step toward ensuring physician wellness is by employing a Chief Wellness Officer (CWO), a distinction Kowalski herself earned in 2018, when she completed the Chief Wellness Officer Course offered by Stanford University. That immersive, one-week program is designed for healthcare leaders who have been given broad responsibilities by their organizations to initiate or expand programs on physician health and well-being. Stanford is one of only two organizations in the United States that currently certify chief wellness officers. The other is The Institute for Physician Wellness (IPW), where Kowalski serves as the primary educator in the six-week CWO certification course. Earning that distinction is no easy task, she noted.
“It’s a formidable achievement,” Kowalski said. Certification from the IPW culminates with a capstone project that has new CWOs develop a wellness program for their own organizations.
The importance and potential impact of CWOs were detailed in an article by Kishore et al, posted to the Health Affairs website in 2018 (www.healthaffairs.org/do/ 10.1377/ forefront.20181025.308059), titled “Making the Case for the Chief Wellness Officer in America’s Health Systems: A Call to Action.” The authors contended that now that healthcare has embraced the idea of chief safety and quality officers to improve patient care, and chief information and technology officers to manage data requirements, it needs to recognize the importance of a senior leader who is empowered with developing and heading robust physician wellness programs.
“It’s important that CWOs also remain engaged in clinical activity, both to maintain credibility and stay in touch with the clinical and front-line challenges faced by their colleagues,” Kowalski added. “Either way, this needs to be a thread in the fiber of the organization’s culture.”
The CWO movement has garnered national attention. In a 2019 report, “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being,” the National Academy of Medicine (NAM) recognized the importance of the CWO as a core element in the implementation of professional well-being systems. This year on Oct. 3, the NAM released its “National Plan For Health Workforce Well-Being” (https://nam.edu/initiatives/ clinician-resilience-and-well-being/ national-plan-for-health-workforce-well-being/ ). One of the plan’s goals is to have institutional leadership recognize the “negative impacts of health worker burnout” and foster a “culture of well-being.” Among the action items is investment in well-being leadership roles, including CWOs.
Physician Wellness Begins in Medical School
If all of these efforts have one thing in common, it’s this: They all come after physicians have finished their education. Yet as Kowalski explained, there’s much that medical schools can do to help future physicians learn the skills they will need to prevent future burnout.
“Historically, medical school and residency were almost all clinical,” she said. “However, there’s an awareness now to provide wellness education in medical school. In fact, a number of medical schools have incorporated humanities into their curricula, to help expand the right brain, because studies show that physicians with better observation skills have greater empathy with their patients.”
Kowalski believes that humanities education will not only teach young physicians greater empathy for their patients, but also for themselves, an important first step on the road to a life of wellness. As Batistatou et al stated in a 2010 article (Hippokratia 2010;14[4]:241-243), “medical humanities provide insight into human conditions, illness and suffering, perception of oneself, as well as into professionalism and responsibilities to self and others. ... All sciences included in Medical Humanities are important for the high quality education of future doctors.”
The Association of American Medical Colleges (AAMC) appears to agree, saying arts and humanities are ‘essential’ to the human experience, with myriad benefits in medical education. In a monograph titled “The Fundamental Role of the Arts and Humanities in Medical Education,” the AAMC offers a comprehensive look at this topic in educating physicians. Promoting clinician well-being is included.
For her part, Kowalski partnered with Tija and Ellen Friedman, MD, the director of Baylor College of Medicine’s Center for Professionalism, to design an eight-week professionalism curriculum for medical students. After approval by the college’s educational committee, the course helps participants form their professional physician identity and is offered as an elective to medical school students.
“There’s nothing earth-shattering about the curriculum,” Kowalski said. “We talk about communication, self-regulation, appreciation, empathy.”
Straightforward or not, efforts to address concepts like burnout and wellness in medical school and during residency are on the rise, Kowalski said. “They are less fortified than the clinical rotation, but there is a movement to begin to incorporate these things into curricula in a formal manner.”
Work Your Passion
Although the philosophical backing by multiple national organizations is promising, there are still thousands of physicians walking the fine line of burnout, seemingly unsupported by their institutions and just trying to make it through the day. It’s these individuals, the clinicians on the front lines of medicine, whom Kowalski desperately wants to help. The answer, she said, is certainly not digging deeper for more reserves.
“It’s not about resiliency,” she pointed out. “Physicians are some of the most resilient people on the planet. Instead, I think it’s a physician’s responsibility to be personally optimized. Regardless of where you are on your own life’s journey, personal optimization is critical to wellness.”
One way physicians can achieve this balance, Kowalski said, is by spending 20% of work time on something they love. This idea is the product of evidence published by Shanafelt et al in 2009 (Arch Intern Med 2009;169[10]:990-995), showing that every 1% of professional effort spent on one’s most meaningful activity reduces the risk for burnout, with a threshold phenomenon at 20%.
“For me, that passion is working with physicians to ensure their wellness,” she said. “For some physicians, it may be focusing on a certain disease process or patient population. For others, it may be research, administrative [activities] or education. Whatever fortifies you, you should be free to pursue it.”
For his part, Shanafelt is encouraged by the fact that physician wellness is no longer relegated to the sidelines of healthcare. “When I would give a presentation or grand rounds on this topic 15 to 20 years ago, it was always the physicians and faculty who invited me and participated,” he commented. “But over the last decade, it’s increasingly becoming the leaders of the organization who are engaged. So that’s a critical inflection.
“I think we’re transitioning from a time of awareness to systems-based interventions and making clinician well-being a core value of healthcare organizations,” he added. “I am still an optimist on this front. The follow-through will be key, but I think there is a lot of momentum, and vanguard organizations are taking action. Hopefully, we can maintain the momentum and translate it into meaningful change.”
The Fires of Burnout Rage On
Meanwhile, the fight continues. Burnout is still a very real occurrence in medicine—a phenomenon Kowalski said takes on even more importance given the nature of the job.
“On the meta scale, physicians are healers,” she noted, “and how can you be a healer if you’re not engaged in it and not fulfilled by it? How can you be a healer if your empathy is shot and your compassion is fried? We need to remember throughout our careers that in healing humanity, we are called to do something more noble than ourselves.”
Still, this nobility comes at a price. “When I was a resident, I passed out in the ICU from food poisoning,” Kowalski recalled. “The nurse from the OR came and put an IV in me so I could finish my shift.” Instead, an injection promoting work–life balance would have been preferable.
—Michael Vlessides