Big Ideas on Burnout: Trainees Propose System-Wide Solutions

The Special Symposium on Quality at the 2020 ASH Annual Meeting tackled an often-overlooked driver of quality of patient care: burnout. Physician burnout – characterized by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment – is a well-recognized and growing problem, and satisfaction at work has even been tied to safe patient care.

While recent efforts to address burnout have largely focused on physician-level interventions, invited speaker Shelly Dev, MD, from Sunnybrook Health Sciences Center in Toronto, pointed out that, in 2020, the physician burnout epidemic came head-to-head with the COVID-19 pandemic and highlighted the need for new, systems-level approaches to wellness.

“Historically, the responses to good evidence about the very real and mounting problem of burnout and mental illness was an exercise in Machiavellian manipulation,” Dr. Dev said. “Our institutions convinced us that we were the problem – that we needed to become more well. We weren’t working hard enough at keeping well, so of course we were burned out.”

The co-chairs of this year’s Special Symposium on Quality, Sarah H. O’Brien, MD, and Nathan T. Connell, MD, MPH, invited trainees to pitch their “big ideas” for battling burnout. Of 26 trainees who submitted their proposals for reducing burnout levels, four were selected to present five-minute presentations. Following the session, attendees ranked their favorite proposals. The first-place winner received a $1,000 cash prize and the three other finalists were each awarded $500. Dr. O’Brien said that the four finalists came from different levels of training, noting that it is never too early to emphasize the importance of physician wellbeing.

“If we are to have authentic conversations about how we can mitigate the harm done by burnout – or eradicate it altogether – we must be prepared to have difficult, uncomfortable, yet morally courageous conversations,” Dr. Dev added. “The ideas being presented today are predicated on one major condition: That our medical culture is unwell and in dire need of restructuring and reimagining.”

Here are the trainee competition winner and finalists.

Winner: Andrea Anampa-Guzmán, a medical student at the Universidad Nacional Mayor de San Marcos in Lima, Peru

Ms. Anampa-Guzmán’s proposal centered on targeted mentoring for female trainees through the “Blood Sisters” program for female hematology/oncology fellows, which addresses the fact that women are more likely to experience burnout than their male counterparts.

“Women physician fellows experience increased burnout compared to males for several reasons,” Ms. Anampa-Guzmán said. “Female physicians are more susceptible to face gender discrimination, deferred personal life decisions, barriers to professional advancement, and gender and maternal biases. These factors contribute to burnout and make it unique in women.”

Blood Sisters focuses on this issue through a proposed structured mentorship program. The project matches first-year female fellows with second- and third-year female fellows in training programs across the U.S. This type of “buddy system” has been proven an effective method to provide support, monitor stress, and improve wellbeing in medicine, she added.

After trainees sign up for the program, they complete a survey to be matched by clinical specialty and research interest. The survey also assesses professional quality of life (QOL). The program begins with an introductory interactive session to provide information on how to launch and maintain the “sibling” relationship and, after being matched, participants are encouraged to check in at least once per month for one year. “Sisters” would also have the opportunity to meet face to face at the ASH annual meeting.

The success of the Blood Sisters program is assessed via professional QOL surveys at six months and one year. Participants also provide open-ended feedback in these assessments.
Ms. Anampa-Guzmán noted that this program has the benefit of creating a sense of community and increasing opportunities for professional development among trainees. “Older sisters will develop mentoring skills – valuable for interacting with other mentees in the future – and younger sisters will receive one-on-one assistance from a single comfortable point of contact and gain a jumpstart on networking and learn about peer perspectives on work-life balance,” she said.

Finalist: Wilson Andres Vásconez, MD, pediatric resident at the University of Miami/Jackson Memorial Hospital in Miami, Florida

With his proposal, Dr. Vásconez addresses physician resilience with an institution-wide curriculum initiative that targets how doctors process grief and loss and cultivates an environment that fosters resilience among trainees and fellows. The curriculum is based on the American Academy of Pediatrics’ “Resilience in the Face of Grief and Loss” curriculum, which covers the intellectual and emotional characteristics that health care professionals need in order to provide high-quality, compassionate care, as well as methods for maintaining personal wellness and resilience.

The program is two-tiered, with opportunities for e-learning and in-person workshops. In the e-learning sessions, small groups meet with chief residents, program directors, psychiatry house staff, and other designated institutional officials to discuss how health-care providers respond to grief and loss, and how those responses affect others. At the in-person workshops, participants will develop individualized wellness plans with long-term strategies. Dr. Vásconez noted that the program allows doctors to identify and reflect on stressful clinical events or medical errors in a safe space.

The second tier of the program involves ensuring that institutions are adhering to the policies proposed in the curriculum, such as allowing reduction of physician duties, increasing trainees’ protected time, and allowing time for wellness days. Dr. Vásconez also proposed wellness check systems, such as sending a quick early morning email survey after heavy clinical rotations. All of this would happen during a two-week wellness and resilience elective, he added.

Finalist: Amar Kelkar, MD, Resident at the University of Florida College of Medicine in Gainesville, Florida

Dr. Kelkar’s proposal explored the intersection between art and medicine, in an approach he called “arts for medicine.”

His proposal uses technology to marry the three major ways of thinking about art and medicine; the art of medicine (natural conversations and shared thoughts on how doctors affect their patients and vice versa), medicine as art (artistic depictions of medicine), and art as medicine (such as music therapy to help patients cope with stress or express themselves). The goal, he explained, is to use technology to encourage open-minded, artistic expression.

Participants would receive a monthly prompt (e.g., “water,” “serenity,” or “sunlight”) and be asked to create something along that topic. The prompts should be broad, Dr. Kelkar noted, to account for a wide variety of artistic expression. The program’s success, he added, would depend on “buy-in” from large organizations and participation from several people to reduce individual stigma to share one’s creations.

Finalist: Jafar Al-Mondhiry, MD, a third-year hematology fellow at the University of California, Los Angeles

Dr. Al-Mondhiry’s idea to mitigate burnout tackled a root cause of the problem among hematologists: frequent exposure to fatal illness and struggles with end-of-life care. The end-of-life process is more complicated for patients with hematologic malignancies, he explained, because these diseases have less consistent trajectories and even critically ill patients can be treated with curative intent.

He proposed training in end-of-life care through “Death Rounds,” citing research demonstrating that fellows rate end-of-life and palliative services teaching as “below average” compared with other fellowship training. In each meeting, a trainee would provide a description of the patient, their hospital course, the events on the day of their passing, and the trainee’s own feelings afterwards. The sessions would be facilitated by palliative care staff and conducted in an informal fashion that uses a standard set of question prompts from established patient death debriefing exercises.

These one-hour monthly meetings offer trainees an opportunity to reflect on the event and their emotions surrounding it in a nonthreatening environment. It has the additional benefit of fostering greater socialization among trainees, palliative care clinicians, and other members of the care team. This type of training represents “the opposite of burnout,” Dr. Al-Mondhiry said, and could lead to a higher sense of personal accomplishment, and lower rates of emotional exhaustion and depersonalization.