Wider Systems of Care By Jon Courand, MD

Beyond the Kale:

Wellness 2.0 and the Move Toward the Wider Systems of Care

By Jon Courand, MD

When I first became interested in physician wellbeing in the fall of 2014, there was very little conversation about burnout, stress management, work-life balance and resilience building. Two years earlier in 2012, Tait

Shanafelt and his group at the

Mayo Clinic had released their first published article about levels of burnout in the physician workforce as compared to the general population, finding levels of burnout at 45% and satisfaction with their work life at 48%. The conversation on levels of burnout and work life satisfaction increased considerably when just three years later, in 2014, the rates of burnout had climbed to 54% while satisfaction with work life had fallen to 41%. The realization that over one half of all physicians who completed the study were experiencing burnout reverberated nationally, this caught the attention of national healthcare organizations and leadership, including Dr. Tom Nasca at the Accreditation Council of Graduate Medical Education (ACGME), Dr. Victor

Dzau at the National Academy of Medicine (NAM) and Dr. Darrell

Kirsch at the Association of American Medical Colleges (AAMC). At this same time, it was noted that there were higher rates of suicide among physicians than in the general population.

Currently, approximately 400 physicians die by suicide per year, more than one physician death each day. In 2014, the deaths of two residents just weeks from each other in New York City raised the alarm even higher about physician mental health and well-being. A lot of progress has been made since this time. Both the ACGME and Liaison Committee on Medical Education (LCME) have included requirements for medical student and resident mental health screening and counseling, while also helping them discover the true meaning in their work in medicine. The Federation of State Medical Boards continues to work with state medical boards to limit or remove licensure questions related to physicians accessing past or current mental health care. Nationally, healthcare organizations are building infrastructure to support Wellbeing Champions in both focused and organizational roles to drive wellness initiatives within those healthcare systems.

Such a focused approach made progress when, in early 2020, we saw the rates of burnout fall to 40%, lower than in 2011. Of course, months later, the COVID pandemic would reverse all those gains and push rates of burnout, moral injury and compassion fatigue to their highest levels. Thankfully, the well-being infrastructure was already in place to intervene actively and to aggressively support our faculty physicians,

trainees, medical students and staff through the series of pandemic surges over two years.

At the end of 2020, the ACGME published their report on their Clinical Learning Environment Reviews (CLER) of Healthcare Systems and Hospitals across the country from 2017 until February of 2020.1 One primary focus of these CLER visits is provider well-being. This report entailed the visit of over 9,700 individual training programs, with interviews of over 100,000 clinical faculty, residents and fellows. Nationally, this report’s data showed that generally well-being programs were focusing only upon wellness initiatives aimed at the individual rather than the system.

Early on, wellness initiatives looked at burned out providers as intrinsically susceptible to the challenges of medicine, assuming that if they could just be made more resilient, they would do well and even flourish in medicine. In this view, it was the individual physician or trainee who was to blame for their stress, burnout and mental health concerns. Given this incomplete understanding, the last five years have focused upon building resilience for providers and providing support when they “broke down.” Along the way however, those who worked and published in this field began to see these physicians and trainees as products of their environment. A common phrase was “you don’t blame the fish for the polluted water.”

With this new understanding, providers on all levels were then told, “it’s not your fault, it’s the environment, but since health care is not going to change anytime soon, we need to continue to work to make you resilient.” This was the average level of progress published in the ACMGE report. Of the many recommendations that have come from this report, one has had great impact: “CLEs that address well-being primarily through activities aimed at building resilience may be missing the more urgent system-level issues such as inefficient workflows, inadequate staffing and sub-optimal designed EMRs.” This report and others have recognized that building resilience is no longer sufficient to address the burnout and wellness crisis affecting our physicians, trainees and staff. In fact, another recent study showed that even the most resilience physicians, those who scored the highest on a validated measure of resilience, still burned out at a rate of 30%!2 This updated approach to provider wellbeing has been called Wellness 2.0 by Tait Shanafelt and others.

As a way of moving this new paradigm forward, myself and a group of physicians in wellness leadership positions across the country published a report through the AAMC in November of 2021 entitled, “The Rise of Wellness Initiatives in Health Care: Using National Survey Data to Support Effective Well-Being Champions and Wellness Programs.”3 This report describes the current state of well-being programs and leadership of those programs nationally, and provides a roadmap for advancing provider well-being through 10 recommendations. The overarching theme includes the creation of an organizational wellness champion position, like a Director of Wellness or Chief Wellness Officer, to align existing hospital or institutional well-being efforts while considering the effect new policies and programs have on provider well-being during their inception. The second major focus is to address wellness interventions with a system-based, quality improvement approach. Within our Long School of Medicine Wellness Council and our Office of GME Wellness and Work Life Action Committee, we are devoting increasingly more time to system-based issues that affect workflow, efficiency of care and reduction in administrative burden.

Simple changes like replacing slow computers, allowing badges to serve as touch cards in accessing the EHR rapidly or letting physicians test out of required educational modules like Bloodborne Pathogen Training provide incremental but noticeable changes in their daily workload. It is clear now that while we must continue to address provider well-being on the individual level, the road to true provider well-being and opportunity to flourish in the practice of medicine lies along the path to better systems of care. Thankfully more and more leaders are joining us on the Wellness 2.0 path.

References 1. Koh NJ, Wagner R, Newton RC, Kuhn CM, Co JPT, Weiss

KB; on behalf of the CLER Evaluation Committee and the CLER

Program. CLER National Report of Findings 2021. Chicago, IL:

Accreditation Council for Graduate Medical Education; 2021. doi: 10.35425/ACGME.0008 2. Colin P. West, MD, PhD2; Liselotte N. Dyrbye, MD, Christine Sinsky, MD et al. Resilience and Burnout Among Physicians and the General US Working Population. JAMA Netw

Open. 2020;3(7):e209385. doi:10.1001/jamanetworkopen. 2020.938 3. Pipas CF, Courand J, Neuman SA, et al. The Rise of Wellness

Initiatives in Health Care: Using National Survey Data to Support

Effective Well-Being Champions and Wellness Programs. Washington, DC: AAMC; 2021

Jon Courand, MD is a Professor and Vice Chair in Pediatrics and the Assistant Dean for Well-being in Graduate Medical Education at UT Health in San Antonio. He is actively involved with Physician well-being on a local, state and national level, and chair-elect of the AAMC Council for Faculty and Academic Societies’ Committee on Physician Resilience. Dr. Courand is a member of the Bexar County Medical Society.

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