January 2019

NEWS & OPINION

Insights
Part II: The weariness, the fever, and the fret


by J.C. Noreika, MD, MBA


J.C. Noreika, MD, MBA

In Part II of a series on burnout, we examine efforts of academicians to transform medical education and training by reengaging the humanities

There is widespread concern regarding physician burnout. Although the problem’s cause, scope, and scale remain unsettled, empirical evidence exists: Doctors increasingly relinquish autonomy for employment; abandon the clinic and opt for early retirement; medical centers initiate programs to confront its symptoms in healthcare professionals; and medical schools and residency programs provide education aimed at its prevention in students and trainees. The latter’s distress is the subject of two large studies, iCompare (Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education)1 and FIRST (Flexibility in Duty Hour Requirements for Surgical Trainees).2 More than two-thirds of participants in the iCompare study reported moderate or high levels of burnout.
Research affirms that administrative burdens that clinicians perceive as meaningless promote work-related dissatisfaction, leading to burnout and related consequences. Deemed a public health problem, it commends research into methods preventing burnout’s onset in medical school and post-graduate training and non-judgmental countermeasures for mid- and late-career professionals who had not been instructed in its management.
Medical education’s model was formalized in 1910, and little has changed over a century. The Carnegie and Rockefeller Foundations commissioned Abraham Flexner to evaluate the unregulated, haphazard training systems then operating in the United States and Canada. Flexner was an educator with distinguished connections at Johns Hopkins University. Studying best practices in Europe, especially in Germany, his 1910 report proposed curriculum standards grounded in the sciences.
This dogma has come under scrutiny. As technology progressed and regulatory oversight expanded, the cardinal role of the physician —“to witness others’ suffering and provide comfort and care”—has been devalued.3 In 1905, Dr. William Osler affirmed that doctors be deeply acquainted with “the leaven of the humanities” to guard against destruction of the physician-patient relationship through “overspecialization and narrowness.” Did he anticipate burnout?
Medical schools are realigning curricula to reflect the impact of technologic change and economic reality. Enhancement of productivity, efficiency, and cost-effectiveness will require future physicians to collaborate in broadly defined healthcare teams that empower patients to alter attitude and behavior. This holistic approach stands in contrast to today’s fee-for-service specialization mindset that rewards diagnosis and treatment of specific problems. Although patient-centric healthcare is a meme of reformers, evidence of its reality is slow to emerge. Yet providers who ignore the totality and complexity of patients’ biologic, environmental, socio-economic, and cultural milieus may soon test the boundaries of obsolescence.
Educators are turning to the arts and humanities to equip students, interns, and residents to better care for patients and themselves. Acknowledgment of burnout—emotional exhaustion, depersonalization, and low personal accomplishment—and its fallout on patient care are redefining medical schools’ application and selection processes, curricula, and clinical experiences.
The National Transformation Network (NTN) has adopted a “mission of improving medical education in terms of professional character formation, competence, and caring.” Seven medical schools from New Hampshire to California comprise its organization. “The goal is to create a student body diverse not only in race, ethnicity, and gender but in experience, socioeconomic status, and qualities that are embodied in the triple aim.”4
Sidney Kimmel Medical College of Thomas Jefferson University requires attendees to complete two humanities “selectives.” This initiative contends that students can learn attributes of the “good doctor” through competence in close observation, empathy, interpersonal communication, consideration of diverse perspectives, development of comfort with ambiguity, exploration of health’s social dimensions, and promotion of self-care. Partnering with the Pennsylvania Academy of the Fine Arts, the Lantern Theater Company, and the Koresh Dance Company, offerings include the history and ethics of medicine, creative writing, music, and training in mindfulness. Collaboration between artist and anatomist helps students visualize human anatomy beyond two dimensions. Some students elect to pursue their medical degrees with emphasis on the humanities and their clinical correlates. Mangione reported on “the association between exposure to the humanities and both a higher level of students’ positive qualities and a lower level of adverse traits.”5
Megan Voeller, director of humanities in Jefferson’s Office of Student Life and Engagement, has helped develop JeffMD Humanities Selectives. More young adults attend our nation’s medical schools today than ever before. According to the 2017–2018 Liaison Committee on Medical Education (LCME), the total number increased by 16,071 or 22.8% in the last 10 years.6 Observing that students self-select and commence medical study with idealistic expectations, she states most come pre-equipped with empathy and compassion. Her mission is to support and reinforce these pre-existing characteristics through years of scientific training that emphasizes disease and its treatment. If not tempered by the humanities, the experience can foster cynicism.
Fifteen Jefferson medical students have opted to pursue a humanities track. They will probe the convergence of science and art. Like Harvard’s 1938 Grant Study meticulously documented by psychiatrist George Valliant, I hope Jefferson will track the careers of these young women and men. Can exposure to writers and poets like Drs. William Carlos Williams and Anton Chekov and author-patients Joan Didion and William Styron help physicians retain and intensify satisfaction in a vocation that must witness human suffering and provides its solace?

References

1. Desai SV, et al. Education outcomes in a duty-hour flexibility trial in internal medicine. N Engl J Med. 2018;378:1494–1508.
2. Bilimoria KY, et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016;374:713–27.
3. Rosenthal DI, Verghese A. Meaning and the nature of physicians’ work. N Engl J Med. 2016;375:1813–1815.
4. Green S. Triple aim: a shared mission to improve medical education. Dartmouth Medicine. Fall 2018:6–7.
5. Mangione S, et al. Medical students’ exposure to the humanities correlates with positive personal qualities and reduced burnout: a multi-institutional U.S. survey. J Gen Intern Med. 2018;33:628–634.
6. Barzansky B, Etzel SI. Medical schools in the United States, 2017–2018. JAMA. 2018;320:1042–1050.

Editors’ note: Dr. Noreika thanks Dr. Mark Tykocinski, Thomas Jefferson University, for his assistance in the preparation of this article. Dr. Noreika has practiced ophthalmology since 1981 and has been a member of ASCRS for more than 35 years.

Contact information

Noreika: jcnmd@aol.com

Part II: The weariness, the fever, and the fret Part II: The weariness, the fever, and the fret
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