Caring for the Caregivers

Maintaining wellness can be a challenge for medical students and physicians, whose work demands constant empathetic engagement with patients.

The good news: Medicine is a rewarding career in many ways.

The bad news: there are occupational hazards.

According to Mayo Professor Liselotte Dyrbye, MD, MHPE, and others, students entering medical school typically have better mental health than their peers. Along the line, however, this changes. Despite comparable rigor to other graduate level education, medical students (and physicians) develop risks for higher levels of burnout and behavioral health concerns, including anxiety, depression, suicidality, and substance abuse.

There are varying aspects of psychological distress within medical school and beyond. One of the skills needed to be a physician is empathic engagement. However, such necessary “caring” comes with its own potential burden. Some studies have pointed to a decline in medical student empathy beginning in clinical training years. Recent studies utilizing more sophisticated tools have found empathy among medical students actually increases.

Christina Maslach has described three dimensions of burnout: emotional exhaustion, depersonalization/cynicism, and inefficacy/lack of personal achievement. Earlier this decade, Tait Shanafelt and others determined that more than half of U.S. physicians experience professional burnout.

Resilience has typically been thought of as the ability to adapt well in the face of challenges. Some individuals appear to naturally be more resilient than others, but resilience can be taught. And, attitudinally, it can be utilized in a proactive, rather than reactive, way.

Numerous medical schools have been focusing on specific strategies to enhance health, such as wellness committees, changes in curricula, and so on. Our current UND School of Medicine and Health Sciences building was planned in such a way as to enhance social/interdisciplinary interaction. We also developed a dedicated position (Wellness Advocate), formed a Wellness Committee, and are reviewing changes in curricula that will do a better job of taking student wellness into consideration.

What are individual protective factors that can reduce burnout and other problems?

There are several simple things you can be mindful of that could help you remain engaged and empathetic, but not excessively stressed:

Remember your three Rs: Relationships, Routines, and Rest—

  • Social connectedness and stable personal relationships are paramount. And, remember that your “supports” need support. There are groups available for students’ spouses/significant others.
  • Setting a schedule, whether for study, exercise, or meal time, is also key. If you found an exercise regimen that has worked, try to maintain some semblance of that. Many students take advantage of the UND Wellness Center (already covered in your student fees!). Others do yoga—$5 fees at local studios are popular with many students. Also, there are intramural sports teams year-round.
  • Mindfulness exercises have been found to reduce stress and increase overall well-being. The elective course “Mind-Body Medicine” introduces students to such concepts.
  • Take advantage of the opportunities afforded by the School during particularly stressful times (exam weeks!) such as morning meditations, therapy dog visits, and other activities as you find them helpful.
  • Sleep hygiene, sleep hygiene, sleep hygiene.

Attitudinally/cognitively, the following are important to both students and physicians–

  • Acknowledge the potential for stress and burnout. Knowledge is power.
  • Being heard: feel that you have a voice.
  • Understanding locus of control: what is within your control and what is unlikely to change in the near future?
  • One of the more important aspects of facing challenges is perspective. It is important to remember the acknowledgement of choice. “I continue to choose to study/work here.” “Meeting this challenge is part of my goal.” The concept of “work-life balance” might be helpful for some. For others, it is not either-or. Work/ school is a fluid part of life, part of “the mix.” What is the current recipe and how/when do I change it?

Resilience does not preclude people from experiencing more significant behavioral health issues. When an individual requires professional treatment, there needs to be an environment that allows for such acknowledgement, as well as access to care. This means reduction in stigma.

The sooner students/physicians (or those around them) can recognize their difficulties and address them, the better the outcome. One unique step our University Counseling Center has taken is to develop a mobile app for medical students who may not have in-person access to counseling, such as those on rural rotations. We have also worked with the North Dakota Professional Health Program to expand its scope, accepting medical and physician assistant students.

In closing, personal responsibility for lifestyle management is important. We are responsible for our own self-care. But how institutions of higher learning, our own included, are designed is just as important. Such places must continue their commitment to maximize healthy learning environments.

By Michelle Montgomery, MSW, and Andrew McLean, MD 

Montgomery is Wellness Advocate for the
School, and McLean is chair of the SMHS
Department of Psychiatry and Behavioral Science.