Contribution of a positive psychology-based conceptual framework in reducing physician burnout and improving well-being: a systematic review.

BACKGROUND: The PERMA Model, as a positive psychology conceptual framework, has increased our understanding of the role of Positive emotion, Engagement, Relationships, Meaning, and Achievements in enhancing human potentials, performance and wellbeing. We aimed to assess the utility of PERMA as a multidimensional model of positive psychology in reducing physician burnout and improving their well-being. METHODS: Eligible studies include peer-reviewed English language studies of randomized control trials and non-randomized design. Attending physicians, residents, and fellows of any specialty in the primary, secondary, or intensive care setting comprised the study population. Eligible studies also involved positive psychology interventions designed to enhance physician well-being or reduce physician burnout. Using free text and the medical subject headings we searched CINAHL, Ovid PsychINFO, MEDLINE, and Google Scholar (GS) electronic bibliographic databases from 2000 until March 2020. We use keywords for a combination of three general or block of terms (Health Personnel OR Health Professionals OR Physician OR Internship and Residency OR Medical Staff Or Fellow) AND (Burnout) AND (Positive Psychology OR PERMA OR Wellbeing Intervention OR Well-being Model OR Wellbeing Theory). RESULTS: Our search retrieved 1886 results (1804 through CINAHL, Ovid PsychINFO, MEDLINE, and 82 through GS) before duplicates were removed and 1723 after duplicates were removed. The final review included 21 studies. Studies represented eight countries, with the majority conducted in Spain (n = 3), followed by the US (n = 8), and Australia (n = 3). Except for one study that used a bio-psychosocial approach to guide the intervention, none of the other interventions in this review were based on a conceptual model, including PERMA. However, retrospectively, ten studies used strategies that resonate with the PERMA components. CONCLUSION: Consideration of the utility of PERMA as a multidimensional model of positive psychology to guide interventions to reduce burnout and enhance well-being among physicians is missing in the literature. Nevertheless, the majority of the studies reported some level of positive outcome regarding reducing burnout or improving well-being by using a physician or a system-directed intervention. Albeit, we found more favorable outcomes in the system-directed intervention. Future studies are needed to evaluate if PERMA as a framework can be used to guide system-directed interventions in reducing physician burnout and improving their well-being.

Mental Health from Medical School to Medical Practice: Finding a Path Forward.

Medical students, residents, and practicing physicians experience high burnout, depression, and suicide rates, and the COVID-19 pandemic has exacerbated stress for many.1-6 While laudable, current well-being efforts appear insufficient to meet the challenges that so many are facing. This essay explores approaches that individuals and organizations can take to promote mental health and well-being from medical school to practice.

Maladaptive Perfectionism, Impostorism, and Cognitive Distortions: Threats to the Mental Health of Pre-clinical Medical Students.

OBJECTIVE: While medical student wellness has been a subject of recent study and discussion, current efforts may fail to address possible underlying, harmful cognitive distortions regarding academic performance. The authors sought to examine dysfunctional thoughts (maladaptive perfectionism, impostor phenomenon) and negative feelings (shame, embarrassment, inadequacy) that may contribute to poor mental health in pre-clinical medical students. METHODS: A survey was administered to first-year medical students at Saint Louis University that included assessments for maladaptive perfectionism, impostor phenomenon, depression, and anxiety, as well as questions about feelings of shame, embarrassment, inadequacy, comparison, and self-worth. RESULTS: A total of 169 students (93%) participated. Students who met criteria for maladaptive perfectionism were significantly more likely to report greater feelings of shame/embarrassment and inadequacy (P < 0.001) than their peers who did not; similar associations were observed in students who reported high/intense levels of impostor phenomenon (P < 0.001). Furthermore, students who reported feelings of shame/embarrassment or inadequacy were significantly more likely to report moderate/severe levels of depression symptoms (P < 0.001) and moderate/high levels of anxiety symptoms (P = 0.001) relative to students who did not report these negative feelings. CONCLUSIONS: These preliminary data support a model for how negative thoughts may lead to negative emotions, and depression and anxiety in medical students. The authors propose strategies for preventive interventions in medical school beginning in orientation. Further research is needed to develop targeted interventions to promote student mental health through reduction of cognitive distortions and negative feelings of shame, embarrassment, and inadequacy.

Cognitive Behavioral Therapy for Maladaptive Perfectionism in Medical Students: A Preliminary Investigation.

OBJECTIVES: Maladaptive perfectionism is associated with psychological distress and psychopathology. Medical students have been found to be particularly prone to maladaptive perfectionism. Recent research has indicated that Cognitive Behavioral Therapy (CBT) that targets unhealthy perfectionism leads to reductions in perfectionism and related distress. This preliminary investigation aimed to evaluate the efficacy of a CBT program directed at medical students who had significant levels of maladaptive perfectionism. The impact on associated psychological distress was also assessed. METHODS: The study used a case series methodology with an A-B design plus follow-up. First-year medical students who screened positive for maladaptive perfectionism and consented for the study (N = 4) were assessed at baseline to evaluate the levels of maladaptive perfectionism, anxiety, and depression. They participated in an eight-session CBT program for reducing maladaptive perfectionism after a waiting period. Assessments were repeated post CBT and at 3- and 6-month follow up periods. RESULTS: Results indicated positive and durable effects on maladaptive perfectionism among program participants. CONCLUSION: The current research provides promising results for the use of CBT in at risk medical students with maladaptive perfectionism.

Mistreatment of medical students in the third year may not be the problem.

Mistreatment and abuse of medical students has been recognized as a significant problem in medical schools. We believe, however, that the problem of mistreatment has been viewed incorrectly. This misperception of mistreatment exists in two primary ways. First, mistreatment has tended to be viewed as a "diagnosis" of unprofessionalism of the perpetrator when it may be more appropriately viewed as a symptom with a range of possible underlying causes. The second misconception that appears to be prevalent is the belief that the link between mistreatment and student well-being, distress, and falling empathy is clear. It is not. We present (1) evidence that other factors in the clinical learning environment may be having a greater negative impact on student mental health and well-being and (2) recommendations for changes that may produce enhancement to medical student mental health in the clerkship year.

Association of medical student burnout with residency specialty choice.

CONTEXT: Given the trend among medical students away from primary care medicine and toward specialties that allow for more controllable lifestyles, the identification of factors associated with specialty choice is important. Burnout is one such factor. The purpose of this study was to examine the associations between burnout and residency specialty choice in terms of provision for a less versus more controllable lifestyle (e.g. internal medicine versus dermatology) and a lower versus higher income (e.g. paediatrics versus anaesthesiology). METHODS: A survey was sent to 165 Year 4 medical students who had entered the residency matching system. Students answered questions about specialty choice, motivating factors (lifestyle, patient care and prestige) and perceptions of medicine as a profession. They completed the Maslach Burnout Inventory-Human Services (MBI), which defines burnout in relation to emotional exhaustion (EE), depersonalisation (DP) and personal accomplishment (PA). Burnout and other variables were tested for associations with specialty lifestyle controllability and income. RESULTS: A response rate of 88% (n = 145) was achieved. Experiences of MBI-EE, MBI-DP and MBI-PA burnout were reported by 42 (29%), 26 (18%) and 30 (21%) students, respectively. Specialties with less controllable lifestyles were chosen by 87 (60%) students and lower-income specialties by 81 (56%). Adjusted odds ratios (ORs) indicated that the choice of a specialty with a more controllable lifestyle was associated with higher MBI-EE burnout (OR = 1.77, 95% confidence interval [CI] 1.06-2.96), as well as stronger lifestyle- and prestige-related motivation, and weaker patient care-related motivation. The choice of a higher-income specialty was associated with lower MBI-PA burnout (OR = 0.56, 95% CI 0.32-0.98), weaker lifestyle- and patient care-related motivation, and stronger prestige-related motivation. CONCLUSIONS: Specialty choices regarding lifestyle controllability and income were associated with the amount and type of medical school burnout, as well as with lifestyle-, prestige- and patient care-related motivation. Given that burnout may influence specialty choice, particularly with regard to the primary care specialties, medical schools may consider the utility of burnout prevention strategies.

Is medical education systemically racist?

After the murder of George Floyd, many professions, organizations, and institutions have begun to confront the long and persistent legacy of racism in the United States. Within that context, it is critically important for the medical education community to address the question of whether medical education is systemically racist, and if so, what should be done to address this problem. In this commentary, this author seeks to answer these questions, primarily by focusing on the role of standardized multiple-choice examinations in determining who gains admission to medical school and which medical students are then determined to be the best and the brightest. Analysis leads the author to the conclusion that medical education clearly meets the definition of systemic racism and that recent attempts to increase the racial and ethnic diversity of medical students have largely failed. The author then outlines a three-pronged approach to address this problem with interventions at the admissions, medical school, and graduate medical education levels.

Reimagining Well-Being Initiatives in Medical Education: Shifting From Promoting Wellness to Increasing Satisfaction.

The well-being movement in medical education has been underway for over a decade. It seems appropriate to examine and evaluate these efforts to support the mental health needs of learners, faculty, and staff as medicine and medical education evolve in response to the COVID-19 pandemic and beyond. To date, most interventions intended to promote well-being have focused on individual strategies rather than environmental drivers of distress, and the primary offerings have comprised strategies such as mindfulness, meditation, yoga, nutrition, exercise, and sleep. Responses to this programming from medical learners have primarily ranged from ambivalence to resentment, with many feeling that the programming failed to adequately address their particular needs and the challenges they were experiencing. In this commentary, the author challenges the assumption that well-being per se should be the ideal target or goal. Learners and faculty may be better served by considering other goals-those that do not focus directly on well-being but that are instead foundational for well-being in that they directly address the challenges that students, residents, and faculty are facing. In other words, goals and associated interventions would focus on the experience of school and work rather than focusing primarily on encouraging healthy practices outside of school and work. The author proposes using the lens of satisfaction through which to view and assess progress toward well-being, increasing satisfaction within 3 interconnected domains: (1) school and/or work, (2) self, and (3) life in general. Attention to these domains may be more likely to produce improvements in well-being that have been sought for years but that remain elusive.

IgA Nephropathy as the Initial Presentation of Celiac Disease in an Adolescent.

Immunoglobulin A (IgA) nephropathy (Berger's disease) is the most common glomerulonephritis worldwide. The disease typically is chronic and lifelong and eventually progresses to impaired renal function in a substantial proportion of cases. It has been known for some time that there is a correlation between IgA nephropathy and celiac disease, but until now it has remained unclear whether treatment of the underlying celiac disease has any meaningful impact on the progression of the renal disease. Therefore, until now, screening for celiac disease in patients presenting with IgA nephropathy has not been universally recommended in the absence of suggestive gastrointestinal symptoms. This report describes a case of IgA nephropathy in an adolescent boy that turned out to be the initial presentation of celiac disease. More importantly, it documents the complete laboratory normalization of his renal anomalies at 5-year follow-up after treatment of his celiac disease with implementation of a gluten-free diet. This case highlights the importance of awareness that suspected IgA nephropathy, even in the absence of gastrointestinal symptoms, should prompt screening for underlying celiac disease as a potential, and possibly treatable, cause.

Preventing physician burnout: satisfaction or something more?

Physician burnout and depression have been recognized as serious international problems and the secondary costs of poor physician mental health are substantial. Interventions to address this problem can be split into two categories: those focusing on the individual, and those addressing the work environment. Individual-focused programs often include instruction in mindfulness, nutrition, and exercise, while those in the work environment have focused largely on stressors such as administrative burden, electronic health records, and productivity pressures.The recent IJHPR article entitled "Burnout and intentions to quit the practice among community pediatricians: Associations with specific professional activities", by Grosman et al., offers an additional path to address burnout and well-being in pediatricians through increasing of hours in more satisfying professional activities. While "satisfaction" was the metric in this study, what lay at the root of that satisfaction may be deeper and more profound. What the study does not measure is that the less-burned out physicians who felt greater satisfaction may have also felt a greater sense of meaning in their lives.Grossman et al. rightly urge health care managers to encourage diversification of the pediatrician's job by enabling greater engagement in the identified 'anti- burnout' professional activities, however more can and should be done. Physicians themselves should take an active role in both the seeking of, and connection to, meaning. Burnout and frustration, understandably, may have led some doctors to possess a sense of cynicism that has obscured meaning in their lives. If physicians cannot find a path to meaning on their own, they should seek colleague partners, coaches, or therapists to assist. Physicians can advocate for programs to reduce work-force stressors, but they can also advocate for formal programs such as Healers Arts programs, Schwartz rounds, and narrative medicine programs to help reconnect to meaning in their daily clinical work. Brief courses in cognitive behavioral techniques may also help in combating problematic mindsets endemic in medicine such as negativity bias, maladaptive perfectionism, and pessimistic explanatory style. With effort, a growth mindset, and when needed, guidance and some reinforcement, these negative and toxic mindsets can diminish; they can fade, and further open physicians to the healing power of meaning.

Reflections on a Decade Leading a Medical Student Well-Being Initiative.

One of the earliest longitudinal efforts to improve medical student well-being, and perhaps the only one that has tracked mental health outcomes continuously, is the decade-long medical student well-being initiative at Saint Louis University School of Medicine. In this Invited Commentary, the author describes his experience leading that effort as the associate dean for curriculum to help inform more nascent efforts taking shape across the medical education continuum and in practice.Starting in 2006, a simple model with three components was developed to guide the new well-being initiative: (1) Reduce unnecessary stressors and enhance the learning environment; (2) teach students skills to better manage their stress and provide and encourage them to use a range of psychological and emotional support resources; and (3) create more opportunities for students to find meaning in their work. Over the next 10 years, striking decreases in adverse mental health outcomes were seen with an 85% reduction in the depression rate and a 75% decrease in the anxiety rate in first-year medical students.The author argues that the following factors contributed to the initiative's effectiveness: addressing the problem largely as one stemming from the learning environment, developing a deep understanding of the lived experience of students and avoiding making assumptions about what they need, reducing students' cognitive load, addressing problematic student mind-sets through a modest resilience curriculum, treating students with respect and compassion, and creating greater opportunity for students to find meaning in their work.

Taking Students as They Should Be: Restoring Trust in Undergraduate Medical Education.

A recently published editorial focused on trust in the relationship between teacher and learner; in this Invited Commentary, the authors examine trust between administrators, course directors, curriculum committees, and medical students, exploring the ways that a lack of trust may be manifest, how this impacts students, and how trust can be built in undergraduate medical education (UME).The hierarchical and paternalistic culture in medical education can skew curricular and policy decisions in the direction of distrust of students, leading to overscheduling and overprogramming of students through much of UME and to inflexible policies and procedures. Students may feel unheard or disrespected by some administrators and course directors when asking for changes, particularly when advocating for reductions in workload or increased flexibility. The collective impact of this lack of trust appears substantial, leaving many students with feelings of frustration, resentment, and cynicism.Trust can be built, and efforts to do so have little associated cost. Administrators and course directors need to demonstrate respect, compassion, flexibility, and trust in students. Trust is built on relationships, and administrators should avoid isolation and engage meaningfully with students. Efforts should be made to reduce overscheduling of students so that they have more opportunity to pursue activities in which they can find meaning. Flexibility in scheduling of mandatory sessions and exams should be introduced wherever possible. If we take these collective steps, students will be more likely to find a path to becoming the doctors they are capable of becoming.