Wellbeing

Part IIntroduction

© Springer Nature Switzerland AG 2020

E. Kim, B. Lindeman (eds.)WellbeingSuccess in Academic Surgeryhttps://doi.org/10.1007/978-3-030-29470-0_1

1. What Is Wellbeing?

Denny Scaria¹  , Mary L. Brandt²  , Eugene Kim³   and Brenessa Lindeman⁴  

(1)

Department of Surgery, Baylor College of Medicine, Houston, TX, USA

(2)

Division of Pediatric Surgery, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA

(3)

Division of Pediatric Surgery, USC Keck School of Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA

(4)

Department of Surgery, University of Alabama School of Medicine, Birmingham, AL, USA

Denny Scaria

Email: Denny.Scaria@bcm.edu

Mary L. Brandt

Email: mlbrandt@texaschildrens.org

Eugene Kim

Email: eugeneskim@chla.usc.edu

Brenessa Lindeman (Corresponding author)

Email: blindeman@uabmc.edu

What is wellbeing? The Oxford English Dictionary informs us that wellness first appeared in written English in 1654 and, like adding ness to ill to make illness it was a way to designate the state of being well (i.e. absence of disease)" [1] Despite its’ early origins, the concept of wellness fell out of favor and the word is hardly found in any publication from the 1800s until the 1960s. If and when it was used, it was used only in the context of the absence of disease.

The modern understanding of the term wellness originated with Halbert L. Dunn in 1961. Dr. Dunn, chief of the National Office of Vital Statistics, was looking for new terminology to convey the positive aspects of health that people could achieve, beyond simply avoiding sickness [1]. His ideas led to the slow growth of a movement concerned with optimizing health rather than just preventing disease. The wellness movement gained momentum over the next two decades, reflected by the first publications in the medical literature concerning wellness in the early 1980s. Wellness, intoned Dan Rather in November 1979, introducing a 60 Minutes segment on a new health movement known by that name. There’s a word you don’t hear every day [1]. A PubMed search bears this out. The first article on physician wellness, published in 1980, was entitled Physician Survival: Should the Doctor Come First?, and explored difficult doctor-patient relationships and the effect they had on the physician (and, as a result, on the patient) [2]. The first articles in PubMed on physician burnout were published in 1981: Burnout: A current problem in Pediatrics [3] and Physician burnout: When the healer is wounded [4].

The concept of burnout first appeared in 1974 in a publication by Herbert Freudenberger who developed the term to describe the consequences of severe or prolonged stress and anxiety experienced by people working in the healing professions" [5]. Burnout is defined by Merriam-Webster as exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration [6]. In the medical literature, burnout is defined by the presence of one or more of three cardinal symptoms of burnout: losing enthusiasm for work (emotional exhaustion), viewing and/or treating patients and colleagues as objects (depersonalization) and feeling others could do your job better than you (low personal achievement) [7]. And too often, the surgical literature which addresses physician wellbeing is in fact addressing burnout. This may be because of the assumption that reduction in burnout leads to greater wellbeing. And as such, it is important to be reminded that although burnout is often used as a surrogate for lack of physician wellbeing, it is not the opposite of wellbeing. The opposite of wellbeing is the distress that results when one is not able to appropriately respond to the stresses that result from caring for others.

1.1 Origin of Wellbeing Concepts

Wellbeing is not just a modern concept, but it was addressed thousands of years ago, starting with Plato, Socrates, Epicurus and Aristotle. Two distinct schools of thought about wellbeing have been described in the literature: hedonistic and eudaimonistic [8]. The hedonistic view argues that the good life consists of a life with more positive than negative pleasures. On the other hand, eudaimonism argues that the good life consists of the life that is worth seeking or living.

For a surgeon, wellbeing through a hedonistic lens may consist of greater positive pleasures, such as going through a great surgical case, getting manuscripts published, being praised by colleagues, going on vacation to a favorite destination, being loved by significant others, and enjoying favorite foods and drinks. Negative experiences may include the arduous nature of the work, being called to see inappropriate consults, a nurse or resident reporting mistreatment, and the coding department constantly filling an inbox with inquiries. However, if the positive pleasures outweigh the negative pleasures, then the hedonistic approach to wellbeing is sustainable.

In contrast, the good life may look quite different to those ascribing to the eudaimonistic view. The writings of Ryff et al. offer a framework of components of the good life referred to collectively as psychological wellbeing [9, 10]. These include self-acceptance, personal growth, relatedness, autonomy, relationships, environmental mastery and purpose in life. Let us look at the wellbeing of the above surgeon from a eudaimonistic perspective. Surgeons are living the good life if they are happy with who they are and the choices they made in the past. They are glad to be assistant program director and that they spent time traveling during research years in residency. They have a strong group of friends at work that they trust and can confide in. They are satisfied with relationships they have with family. They have set reasonable standards for themselves, and they are content with where they are in their careers. Even though their colleagues may be publishing more and may be more academic, they believe that they are putting their efforts into what they truly believe in and are happy with that. They may work at a county hospital where they and the staff have a high degree of mutual respect. They can get the most out of a team to care for patients. With regards to long-term goals, they find meaning in their work as they help those less fortunate through the county hospital and are grateful for being able to be physicians. Moreover, they continuously feel challenged as trauma surgeons and look back at how much they have grown over the years as human beings and as surgeons. If you ascribed to the eudaimonistic view of a good life, you would argue that this surgeon, regardless of the negative pleasures he may be experiencing day to day, is living the good life and has wellbeing. He has eudaimon or he would be described as flourishing.

1.2 Concept of Wellbeing

Despite consideration of a definition of wellbeing and descriptions of the good life from the hedonistic and eudaimonistic perspectives, we must also consider how it has been used in the literature. While some have argued that wellbeing is a construct, something that is dependent on the existence of a mind, Dodge et al. posit that it is not a construct and suggest that it can be measured [11, 12]. However, this level of granularity is seldom seen in the literature on wellbeing in surgeons and surgery residents.

One of the landmark studies about surgeon burnout was published in 2009 and surveyed approximately 25,000 surgeons through the American College of Surgeons [13]. Around 8000 recipients responded, making it one of the largest studies done at the time and perhaps to this day, on evaluating the perceptions of surgeons on burnout and career satisfaction. In this study, 40 percent of respondents met criteria for burnout, 30% screened positive for depression, and significant percentages had a mental or physical quality of life more than one half of the standard deviation lower compared to the general population. Moreover, only 74% would choose a career in surgery again. In their discussion of the findings, the authors call for increased efforts to improve the physical and emotional health of surgeons, but they do not define these terms or wellbeing specifically.

Similar patterns emerge upon examination of the literature on residents. A survey of US general surgery residents in 2014 collected surveys from 753 general surgery residents, and 69 percent of these residents met criteria for burnout, with 44 percent having considered dropping out and 44 percent indicating that they would not pursue general surgery again if given the option [14]. Among the respondents, female residents and those working more hours were more likely to be burned out. Following this, a systematic review of wellbeing in residents from all specialties suggests sleep, exercise, family interactions, religious activity and missing significant life events as wellbeing markers, all of which were reduced in training, but goes further to describe that there is no consensus yet on how wellbeing should be measured [15]. The author goes on to note that the included studies touch upon aspects of wellbeing that have been put forth in the psychology literature such as autonomy, competence and relatedness.

While the studies above measured burnout, others have attempted to measure psychological wellbeing. A 2004 study of residents in North Carolina assessed their psychological wellbeing, which they only defined as the absence of psychological distress, using the Symptom Checklist-90 and Perceived Stress Scale, finding that more than a third of the residents met criteria for clinical psychologic distress [16]. Moreover, a study by Salles et al. used the short grit scale to determine the association between grit and psychological wellbeing, finding the two were positively correlated. However, as we have pointed out above, this may only approach one aspect of the different components of a person’s wellbeing [17]. Multiple groups have also studied the association between emotional intelligence and psychological wellbeing, finding that those with higher emotional intelligence were less likely to be burned out [18–20]. Therefore, although studies conducted in surgery to date may be attempting to assess wellbeing, what is measured most often is the absence of negative experiences such as burnout rather than true wellbeing.

Therefore, what is wellbeing and how do we measure it? Merriam Webster defines wellbeing as the state of being happy, healthy, or prosperous [21] which they differentiate from wellness: the quality or state of being in good health especially as an actively sought goal [22]. However, Dodge et al. studied this question at length, stating As interest in the measurement of wellbeing grows, there is a greater necessity to be clear about what is being measured, and how the resulting data should be interpreted, in order to undertake a fair and valid assessment [11]. They argued that defining wellbeing is fundamental to measuring it, and went further to propose a new conceptual framework for wellbeing, shown in Fig. 1.1:

Fig. 1.1

Wellbeing can be viewed as a see-saw balance between psychological, social and physical resources versus psychological, social and physical challenges [11]

The balance point between an individual’s resource pool and the challenges faced.

In a follow up paper the authors propose a multidimensional framework (Fig. 1.2) to measure wellbeing that incorporates both the challenges and resources from the model above [12].

Fig. 1.2

Wellbeing can be further analyzed as a multidimensional balance between challenges and resources. Factors that contribute to wellbeing, such as physical health, happiness, work-life balance, work environment, social support, education, and security, each are faced with balancing reousrces and challenges. Some areas have greater resources than challenges, while other areas are the opposite. It is important to consider wellbeing as a multidimensional concept [12]

This framework is similar to the Job Demands-Resources (JD-R) theory initially proposed by Bakker et al. [23]. This posits that all jobs are characterized by a set of job demands, those aspects of the job that that require physical and/or cognitive engagement, and resources, both personal and work-related facets that can stimulate personal growth and help employees to achieve work-related goals. According to JD-R theory, work engagement is fostered and individuals perform well when the work environment poses high job demands in combination with sufficient job and personal resources to meet those demands [24]. One study identified that more positive perceptions of job resources were related to lower levels of burnout in surgical trainees [25]. Thus interventions that strive to optimize individuals’ job demands and increase both their personal and professional resources should be targeted [26].

1.3 Definition of Wellbeing

Clear definitions lead to clear thinking and, in that spirit, we would like to propose an alternate definition of physician wellbeing, as physician wellbeing is more than the above definition applied to physicians. We are in need of a definition to guide our discussions, strategies and research. We propose to define physician wellbeing as:

The ability to appropriately respond to expected and unexpected stresses in order to be healthy, happy and prosperous in work and in life.

Since prosperity is often misinterpreted as being only about money, it is important to understand the meaning of that word as well: Prosperity is the condition of being successful or thriving [27]. If we were to rephrase the definition with this in mind, it might look like this: Physician wellbeing is the ability to appropriately respond to expected and unexpected stresses in order to thrive in a healthy, happy and successful manner in work and in life. This definition also has the advantage of including the concept of resilience within the definition of wellbeing instead of considering it separately. Resilience, which has taken on a deserved and important role in discussions of physician wellbeing is defined as 1. the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress and 2. an ability to recover from or adjust easily to misfortune or change [28]. Resilience is innate to human beings, and is especially innate in physicians. Resilience by definition has two variables that cannot be separated – the force on the system and the system’s response, or put a different way, the stresses of our work and our ability to respond.

Therefore, while most studies which describe interventions to improve wellbeing focus on reducing burnout, this may not be the best or only way to improve wellbeing. Wellbeing for a surgeon, thereby, may assume a state of balance between opposing forces. On one end there are the psychological, social and physical challenges. Psychological challenges may include burnout, social challenges may refer to the work environment, and physical challenges to the physical health of the surgeon. On the other end, resources could include psychological parameters such as grit, social resources may include support systems such as family, colleagues and friends, and lastly physical resources may again be state of good health. Therefore, rather than adopting a eudaimonisitc or a hedonistic view, wellbeing must be assessed in a customized manner for the individuals who are being assessed. Wellbeing for an attending surgeon and a surgical resident may not necessarily be able to be measured with the same tool. Although wellbeing in and of itself refers to a state of balance between resources and challenging demands, according to Wassell and Dodge, tools to measure wellbeing and the interventions to improve wellbeing should be customized to the group to which it is applicable [12]. We suggest that there may be a need for a tool developed in a multidisciplinary fashion to evaluate wellbeing designed for physicians and perhaps for surgeons specifically. Truly, the imperative underlying discussions of physician burnout is the common desire to ensure the safest and best care for our patients, a goal not entirely possible without a workforce whose wellbeing remains a critical component.

References

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© Springer Nature Switzerland AG 2020

E. Kim, B. Lindeman (eds.)WellbeingSuccess in Academic Surgeryhttps://doi.org/10.1007/978-3-030-29470-0_2

2. Why Focus on Wellbeing?

Mary L. Brandt¹  

(1)

Division of Pediatric Surgery, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA

Mary L. Brandt

Email: mary.brandt@bcm.edu

Keywords

Physician wellbeingBurnoutSuicideDepressionErgonomicsExerciseNutritionLeadershipSleep restrictionSleep deprivation

The primary reason to focus on our own wellbeing and that of our colleagues is to prevent losses associated with living in a state of chronic and/or severe distress. These losses are known to all who practice medicine and include declining personal health, loss of relationships, loss of employment and even loss of life. In addition to these personal losses, physician distress also leads to profound losses for institutions. These institutional losses can be measured in dollars, patient satisfaction and institutional prestige, losses that are therefore persuasive to organizational leadership. And finally, and perhaps most importantly, chronic distress, particularly if it is the result of misalignment of core values, results in loss of meaning and purpose, or, put a different way, loss of a life well-lived.

2.1 Personal Losses

The personal losses experienced by physicians, PAs/NPs, nurses and other medical providers who are suffering from work-related distress include impaired physical health, impaired mental health, loss of relationships, loss of employment and loss of life.

2.1.1 Loss of Physical Health

It is not surprising that physicians experience impaired physical health; we are terrible at practicing what we preach when it comes to routine health care. According to a large survey performed by the American College of Surgeons, 25% of surgeons did not undergo recommended screening for colon cancer, heart disease or prostate cancer" [1]. This pattern starts during residency; in a recent study of surgical residents, 56% did not have a primary care provider, 37% had not seen a dentist in 2 years and 29% did not have a current prescription for glasses or contacts [1]. Research will determine whether age appropriate screening and routine dental and eye exams will be a metric that might serve as a surrogate for the ability of individuals and institutions to focus on self-care. This is not trivial; burnout correlates with an increased incidence of cardiovascular disease and short life expectancy [2]. Another area for institutional focus in terms of physical health is ergonomic injury. Although this is more acute, and often severe, for surgeons, ergonomic issues are found in all hospitals and clinics, and for everyone who works there. In institutional terms, significant ergonomic injury results in personnel unable to work. For this physician, this means loss of employment but also a loss of things that might bring one joy such as golf, tennis, hiking and other physical activities [3–5].

2.1.2 Loss of a Healthy Lifestyle

Most of us who work in health care would choose a healthy lifestyle with attention to diet, hydration, exercise, and sleep when possible. Often our working conditions and schedules interfere with choices we might otherwise make, a loss which also contributes to loss of personal health.

Hippocrates recognized the importance of a good diet 2400 years ago when he said, Let food be thy medicine and medicine be thy food. For physicians who understand the importance of a healthy diet of real food, there are barriers at work that make it almost impossible to achieve a healthy diet without bringing all food from home [6]. It is a sad reality that our hospitals provide food that, in general, meets the sub-standard expectations of the American public, often without other, healthier choices. This is a financial necessity according to the hospitals, but it must be recognized and discussed as a decision that is financially based, but that is in opposition to what is requested by physicians and supported by data. The deleterious effects of a diet high in fat, high in sugar and consisting mostly of processed foods are well known, and physicians routinely counsel patients to avoid these food, while partaking of the morning donut at Grand Rounds, on-call pizza and free junk food that is available in many hospitals [7, 8]. Although all of us occasionally indulge in foods like this (and there is nothing wrong with that!) , most of us would also choose healthy, well-prepared food if it were available. In a nutshell, eating healthy is a choice that requires additional energy. If we are to prevent a default to poor eating habits, we (both individuals and institutions) have to create environments and habits that make it easy to choose healthy food over poor food. Appropriate nutrition is an important part of good patient care; The acute effects of caloric intake on cognition are well understood, but unfortunately, many physicians routinely skip meals, consume food too rapidly, or consume food with poor nutritional value [9]. Good food not only provided optimal nutrition, as Lemaire points out, good food also improves a sense of wellbeing [1, 10]. A part of good nutrition that deserves more focus is hydration. Along with not eating properly, physicians are notorious for not staying hydrated during the working day and/or when on call [8]. One study of clinicians completing 150 shifts in the UK revealed that significant portions started (36%) and ended (45%) their shifts clinically dehydrated [9]. From the individuals point of view, you are likely to be dehydrated (not just hypo-hydrated) if your urine is darker than normal and you are thirsty [11].

Like diet, many physicians and other healthcare providers would choose to maintain physical fitness with regular exercise but feel that they are not able to do so because of the time constraints and demands of their jobs. In time-constrained settings, choices have to be made… do I spend time with my family, prepare my healthy meal for tonight or go for a run? Often the return on investment for tired, stressed physicians is less for exercise than for other aspects of self-care. This is reflected in the data; …in several surveys of US surgeons, only 50% met the CDC guidelines for aerobic exercise and only 33% met the requirements for resistance (weight) training [1]. When one considers that, apart from the small percentage of compulsive (or almost compulsive) exercisers, exercise is often sacrificed for other aspects of self-care, it becomes apparent that this may be a particularly important marker of institutional success in promoting healthy behaviors.

Physicians and other health care providers must be present and providing care 24/7 in the hospital setting. For that reason, sleep restriction (chronic, low-grade sleep deprivation) and sleep deprivation (a sleepless night on call) are the norm, not the exception for many practitioners. The negative effects of sleep deprivation and chronic sleep restriction on health is well known [12]. With the exception of a very small percentage of people who need 7 or 9 h of sleep, adults need 8 h of sleep per night, 60% of surgeons reported an average of less than 6 hours of sleep per night, resulting in chronic sleep restriction [1]. As more information becomes available about sleep, call schedules may have to be adjusted. For example, there is evidence that combining sleep deprivation with being awake from midnight to dawn is additive in its deleterious effect [1].

Thinking about physical health as the number of women in medicine grows extends beyond our own physical health. New mothers who are practicing physicians are ironically disadvantaged compared to other women in the workforce when it comes to breastfeeding their newborns. This is truly a walk the walk issue for health care institutions since the data is clear that breast milk, when it is possible to provide it, is key in promoting optimal health in the newborn. Although it may not directly affect the health of the provider in question, it is truly shameful that many medical institutions have relegated breast pumping to bathrooms and other public spaces.

2.1.3 Loss of Mental Health

The incidence of mental health issues in medical students is no different at baseline than the general population. However, with time in training and time practicing, the incidence of depression and its horrific endpoint, suicide, increases to well above that of the general population. In terms of a summary of the issues that create psychological stress for physicians (and everyone else in medicine), I can’t do better than this summary, published in 2005 by BA Harms: Once entering medical practice, additional stressors include shift work, long workdays, high case loads, time pressures, poor sleep habits and high performance expectations, challenging patients, personal fears regarding competency, and changing roles in the workplace. In addition, physicians and trainees regularly face suffering, fear, failures, and death, as well as difficult interactions with patients, families and other medical personnel [13]. Added to the stressful nature of our work, there are two additional stressors that warrant mentioning here, the second victim syndrome and a sense of not being safe at work.

The second victim syndrome occurs in response to medical errors, adverse outcomes and malpractice lawsuits [14]. Due to the emotional trauma these events create, the physicians who find themselves experiencing them inevitably become a second victim [15]. This is not an uncommon situation since physicians will experience errors and adverse outcomes in their careers. 42% of all US physicians will be sued during their career, a number that increases to 90% for surgeons [14]. Because we are human, all of us will make mistakes and will experience adverse outcomes that had nothing to do with our actions - and these events will deeply hurt us. The culture of medicine is to hide our emotions after these events, to pretend that all is right. As a result, institutions need to recognize the need for support of any physician who finds themselves in the position of being a second victim and create the infrastructure necessary to provide that support.

Safety at work is increasingly a problem, both in the sense of personal safety and job security. Even a minor sense of not being safe can wholly dominate the world of a physician [9]. The issue of physical safety is relatively minor for most physicians, as institutions usually have a mature security system in place. However, job security has become a major concern for many physicians. As the finances and culture of medicine have shifted to a more corporate model, more and more physicians experience the feeling that their positions at work are somehow not as safe as they once perceived them to be. As Shapiro has pointed out, Job insecurity is a threat to wellness for physicians in downsizing or struggling systems…Managing patients while simultaneously feeling insecure about one’s employment is challenging [9]. This feeling of being unsafe is often exacerbated by a sense that they are not respected or supported by leadership. This perception is important; Shanafelt has demonstrated that in physicians who are burnt out, 11% of the variation in burnout and 47% of the variation in satisfaction with the organization was explained by the leadership rating of the division/department chairperson [2]. This is also supported by a large study of over 20,000 workers performed by Christine Porath. In her study, she found that those who feel respected by immediate supervisors, report 56% better health and wellbeing, 89% greater enjoyment and satisfaction with their jobs, and are significantly more likely to stay [9].

2.1.4 Loss of Relationships

It is well known that there is a high rate of divorce in medicine [16]. Although there are no published data, there is also much anecdotal evidence of friendships and other family relationships that have suffered as the result of work related stress. In addition to the loss of these important relationships, the current medical care environment has