Not surprisingly, I received multiple responses to the recent PAAD (March 19, 2024) on the weaponization of wellness. I decided to post all of them anonymously unless otherwise instructed by the writer. Because many of these responses were lengthy I added an extra reader response today. Myron Yaster MD
From anonymous
I am almost 2 years into attending life as both a dual board certified pediatric and general anesthesiologist. It is crazy to think that I was a trainee just a couple years ago, and I am now practicing independently. I wanted to provide my own commentary on this topic.
Wellness in medicine is a topic that I have a love and hate relationship with. I, like many of my colleagues, are living and working through the consequences of the Covid pandemic during training. Today’s PAAD and review of wellness took me back to my own moral injury in training, but also gave me a different perspective as a new attending.
I was not exposed to this concept of wellness until the start of my residency during my intern year. At the time it sounded like there was a genuine push to make training more sustainable. I would hear stories from a more senior attending who was bewildered at how easy we have it compared to his experience in training where he easily clocked 120-160 hours a week in the hospital. Now as an attending, I catch myself sometimes having similar feelings about these “new generation” of trainees, and I am only two years removed from training. I do believe that the senior attending during my intern year was well intentioned. It is not easy to become a physician nor should it be. However, back then, training was different. There was no EMR, no cell phones, and not as much scrutiny and pressure to decrease patient length of stay in the hospital for example. As to why we still have beepers must boggle current Gen-Z trainees minds! I am a millennial and proud of to have lived through a time when beepers were on trend growing up.
Reflection is something I try to practice as it allows me to improve my understanding of the contexts I work in and provide perspective to my daily life. The first day of my residency was an eerie one. A pain fellow was found dead in the hospital parking lot leaving behind a wife and a small child. A year later, a resident committed suicide. Then months later, a medical student committed suicide after not matching in a residency position. These events are definitely very sensitive subjects and private but I think it should be ok to talk about it in the open. Never in my wildest imagination would I think that physician suicide would be something I would be exposed to multiple times at my own institution. These events are not published in news articles and media outlets but they definitely impacted me in ways I will never forget.
In Dr Rosenbaum’s article, there is one part that stood out to me. “As online discourse infiltrates training and practice environments, so do its implicit rules for behavior. Struggle is hardly new to training. But today, the one person posting about a toxic work environment may be more influential than the quiet marjority who are learning and thriving.” This couldn’t be more true for my own experience. During the beginning of the Covid pandemic, there were lots of unknowns and fear not only among patients and health care workers but moreso among anesthesiologists. We were now in the spotlight and tasked with intubating Covid patients. At my institution, the residents and a few attendings and some CRNAs were tasked with intubating Covid patients outside the OR in full astronaut looking garb. In the OR, it was mostly a junior and/or senior resident intubating while everyone in the room including my own attending more often than not would watch outside the OR door window. ASA came out with guidelines on intubating Covid patients and they recommended “the most experienced professional should perform intubations.” When I brought this up to our educational What’s App chat box, which includes only anesthesiology residents and attendings, I received no commentary from attendings. Frustratingly, I posted my concerns on an ASA forum and reached out aka “DM’ed” influential social media anesthesiologists and critical care physicians on Instagram. But all I received was the typical politically correct safe and vague responses. I had to reach out to the forum moderator to make my post anonymous because I heard of some chatter about my post at my institution. Some attendings found my post online which was associated with my public profile on the forum and thought it was unprofessional. Not a single attending at my institution brought this up to me in person, which further perplexed me when I got a 1 out of 5 in professionalism in my last ACGME milestones review when it had been 5 out of 5 all throughout residency. In addition my last residency clinical competency letter stated that “I need more insight into professionalism.” Again, no one addressed this with me before giving me these marks. Maybe this is all coming from just another one of those disgruntled residents. I know this is not an isolated event, and I am even more shocked when I hear the experiences that that my colleagues who trained in New York City during the height of the pandemic. What ever happened to collaboration and genuineness in our profession?
Furthermore, I’ve realized throughout training that no one is going to look out for you but yourself. You are your greatest advocate. After mandated quarantining in training, there needed clarification if residents would need to extend training for this missed time from clinical training. ABA released a statement on March 13, 2020 stating residents would be awarded clinical credit (https://www.theaba.org/2020/03/covid-19-statement-residency-fellowship-programs-trainees-2/). This was a surprising but very much welcomed response from the ABA. In addition, I tested the new ABA policy for the absence in training (https://www.theaba.org/about/policies/absence-from-training/) released in July 1st, 2019 at my institution. Historically residents who take an extended leave of absence outside of allotted vacation days such as parental leave had to extend residency at my institution despite good academic standing, completing case minimums, passing the written ABA board exam, and good ITE scores. Despite the flaw in the ABA policy as it is retroactive request where a trainee has to take leave first without the guarantee of ABA approval, and risk extending residency if not approved. Anyways, I did take parental leave for the birth of my firstborn child during the end of my CA-2 year during the COVID pandemic in 2020, and I was the first resident to be granted leave without extension of residency. It was a huge validation for myself but also a win for my coresidents who could now apply for parental leave and feel confident that our residency will support them as long as it follows ABA policy. Again, you are your greatest advocate, and no one will look out for you but yourself.
Now as an attending, I make decisions and choices that enhance my overall sense of fulfillment and satisfaction. I am one of “those anesthesiologists” who do not have a full time appointment because I left that position only after six months to try out an independent contractor lifestyle. I work extra when I want to, and I do not work when I do not have to. I am much happier because I am compensated a good salary for my work, and I still feel fulfilled taking good care of sick patients. I am well aware that my position may not be sustainable in the long run and compensation rates may go down. But as anesthesiologists, we always have a plan B, C, and D. For now, I will enjoy the time I do have living a well balanced work life job that I have nicely carved out for myself.
From Ethan Sanford MD
Regarding wellness in medicine, thanks to the PAAD team for carefully considering how we can help pediatric anesthesiologists achieve careers which bring joy and meaning. In the PAAD article, Dr. Rosenbaum describes training schedules, setting boundaries around “scut work”, and criticism/feedback during training as examples of possible conflict between expected discomfort and true harms to trainees.
I think it’s important to parse out what we should aim to accomplish with wellness efforts. I perceive wellness coaches I’ve worked with as providing tools and education which I am responsible for utilizing and practicing. This is quite different than refereeing the tension between training expectations and trainee expectations. This tension will (as it always has) dynamically transition over time with influence from cultural and social norms. The collective we should voice (our leaders most loudly) our experience and opinion in these arenas, but I think this is separate from my efforts to stay present, optimistic, and committed in my daily practice of work, family, and community. All of us change in time committed to these during phases of life. My work life shouldn’t be a drain on my happiness to be confined and limited. If it is, I should seek help to carefully consider my mindset, my activities and how I can make sustained effort ensure I am my actions are important and good. I think this is the core opportunity for wellness coaches and formal structures to help with rather than attempting to define what is right or wrong then pick sides in the complex social tensions of training. Instead, perhaps we should all take more responsibility in setting examples as caring, involved educators and clinicians who seek and find meaning in daily clinical work and in pushing for improvements in the care we provide.
From anonymous
I applaud the PAAD presented by Drs. Rebecca Margolis, Amy Vinson, and Concetta Lupa entitled, “The Weaponization of Wellness.” I would like to expand on that theme by highlighting another pressing issue in the same domain, namely “zero tolerance” policies.
In the name of “Wellness” medical schools and other institutions are increasingly enforcing “zero tolerance” policies. Wikipedia defines zero tolerance policies as those “… which impose a punishment for every infraction of a stated rule.Zero tolerance policies forbid people in positions of authority from exercising discretion or changing punishments to fit the circumstances subjectively; they are required to impose a pre-determined punishment regardless of individual culpability, extenuating circumstances, or history. This pre-determined punishment, whether mild or severe, is always meted out.”[1] While this may be appropriate in some cases, i.e. violent crimes, does “zero tolerance” always contribute to Wellness? Several questions arise regarding the definition and implementation of such policies.
Let’s consider rules regarding sexual harassment, which are certainly necessary and generally well-intended. Sexual harassment may be defined as ”...unwelcome conduct of a sexual nature that makes someone feel offended, humiliated and/or intimidated.” Does this include a gentle touch on the shoulder in the context of expressing support to a colleague or trainee, whether of the same or other sexual orientation? What about an attending anesthesiologist teaching a new resident the proper application of a jaw thrust by placing his/her hands over those of the trainee while the patient has an obstructed airway and is desaturating? What if a Professor is counselling an Assistant Professor in a well-intentioned way that is perceived by the latter as patronizing – and the two are of different sexual orientation? Perhaps an attempt at humor in the operating room or elsewhere is felt to be offensive by one individual but not by the others present. These examples may not universally evoke the descriptor, “sexual,” but they may well trigger zero tolerance policies considered by the institution to include sexual harassment.
Each of these examples may be perceived by the “receiving party” as unwelcome or even intimidating behavior. That individual may meet with their supervisor to complain or file a written report. The complaint must be taken seriously and may well lead directly to a formal investigation subsequent to which the so-called offender may be suspended. Faculty members so accused have been severely sanctioned and even terminated due to zero tolerance policies according to which those in positions of authority have no choice – they are prevented by the policies from “exercising discretion or changing punishments to fit the circumstances.” I am aware of accomplished clinicians, educators, and researchers losing their jobs or deciding to retire prematurely in the face of these and related perceived offenses.
Zero tolerance policies may undermine Wellness directives in the workplace. Friends that embrace outside the hospital refrain from doing so for fear that others may perceive this as inappropriate. Colleagues limit friendly banter and verbal humor for the same reason. Anonymity and “incident report” writing prevail when direct discussion would be more effective and less alienating. Esprit de corps in the hospital has taken a hit in many cases.
Compassion and nonjudgment are key components of Wellness. Perhaps we can all pause and find ways to apply them to everyone in and outside the workplace.