The Weaponization of Wellness
Rebecca Margolis DO FAOCA, Amy Vinson MD FAAP, Concetta Lupa MD, Stephanie Black MD EdM
Today’s PAAD by Lisa Rosenbaum in the New England J of Medicine is well worth the time for you to read it in its entirety. Indeed, it is not much longer than our review. Today’s reviewers, Drs. Rebecca Margolis, Amy Vinson, and Concetta Lupa are on the PAAD’s executive council and write frequently on issues of wellness, burnout and fellowship education. Myron Yaster MD
Original Article
Rosenbaum L. Being Well while Doing Well - Distinguishing Necessary from Unnecessary Discomfort in Training. N Engl J Med. 2024 Feb 8;390(6):568-572. doi: 10.1056/NEJMms2308228. Epub 2024 Jan 17. PMID: 38231543.
We extend our gratitude to Myron for accommodating today's unconventional format. Instead of the customary summary style, this editorial serves as a reflective commentary on the preceding NEJM article. The resonances evoked by the piece struck deep chords within us, as stewards of well-being within ASA, SPA & PAPDA. It articulates concerns many of us have grappled with: the tension between the dedication to our patients and profession, and the elusive concept of "wellness." Amid our efforts to foster a culture of sustainability, both personally and professionally, we confront the disquieting question: have our efforts inadvertently birthed a phenomenon susceptible to exploitation? Just as the discovery of atomic energy initially elicited celebration before its weaponization, we ponder whether the notion of wellness too is vulnerable to manipulation. We welcome your insights and contributions to this discourse.
As one highly regarded educator in pediatric anesthesiology mused, “I’m not here to make your fellowship easy. I don’t want to make your fellowship easy – it shouldn’t be. This is a hard job, and you have a lot to learn in a short period of time. I’m here to make sure you are supported through it and at the end, you felt it was worth it.” This pragmatic advice crosses the widening divides between professional duty, education, and personal well-being. At best, one can expect these three domains to coexist in some degree of tension, with balance being the goal. Like a three-legged stool, it works best when all three legs are equally strong and connected. It is a fool’s errand to view any of the three in isolation; a stressor to the system will impact all 3 and an emphasis on only one will lead to profound imbalance. Focus only on “education” and professional duty will suffer (we learn a lot through clinical service). Focus only on professional duty, and well-being will decay as we educate the next generation in unsustainable self-effacement. But critically, if we focus disproportionately on personal well-being, both education and professional duty will fall aside.
We are at a moment in the profession where anesthesiologists have a frighteningly high intention to leave their job.2 Clearly, expectations of the profession are not aligning with lived experience. It is undeniable that the corporatization of medicine is eating away at the well of professional fulfillment. But we in the wellness community also must own that the nebulous pursuit of improved clinician well-being may have the unintended consequence of unrealistic expectations by many and exploitationn of wellness initiatives by few. Not every day will be Instagram-worthy. In fact, most days won’t be. Some days we just need to show up for the job we are paid well to do – that our patients count on us to do. In fact, research tell us that you only need to spend 20% of your time doing something you are passionate about to feel fulfilled.3
The article mentions the growing trend of group chats. Group chats, as well-intended safe spaces, on occasion lend themselves to interpersonal connection through shared grievance. While entirely understandable, we’ve observed that this risks a feedback loop in which negativity may resonate and amplify in unchecked groupthink, in which dissenting opinion is not only uninvited but is viewed as “not us.” We are experiencing it in many facets of our society right now – even well-meaning folks seem poised to be outraged. Have our many stressors finally depleted our capacity for temperance and self-regulation? With so many people, often with big hearts, having these big feelings, how do we build supportive communities that invite diverse and respectful dialogue?
Educational efforts in our field are multifaceted and limited to a short period of formalized apprenticeship. As stewards of these efforts, we are challenged to impart the science and art of patient care and the advancement of our specialty through teaching principles of discovery, health care system knowledge, leadership, communication, and professionalism. In preparing the leaders of the future, we are tasked with the responsibility to give constructive feedback, coach through discomfort, and challenge our learners to garner strength and resilience in a very demanding setting where the stakes of a child’s well-being cannot be ignored.
This article reminds us that our best efforts to prepare trainees may be thwarted by efforts to augment well-being. When educators are concerned about giving honest feedback to trainees for fear of retaliation, they may refrain from sharing what would be the greatest actual service to the learner: insights on ways to improve. Idealistically, everyone knows that constructive criticism is for the long game of achieving excellence, but realistically, concerns for the reception of the feedback being taken personally sometimes may override the ability to provide meaningful feedback. Going one step further, when evaluations of instructors are tied to performance metrics, this can influence the type of feedback being delivered to trainees. We propose that while it is honorable to want to engender positive emotion from trainees, it is also possible to deliver constructive or corrective input in a way that demonstrates respect and genuine care for the learner, in part by showing how invested we are in them and their growth.
As educators, we must ask what the appropriate amount of challenge is that allows for growth and improvement. Professional athletes seek coaches that push them to extremes to optimize performance, yet, there are many times the messaging from medical trainees is incongruent with this notion that the challenge is preparatory. How can the vision be shown that some degree of discomfort prepares one for the real road ahead? The career after training is full of uneasiness, and not because of work hours or the lack of meal cards. We need to be able to embrace the discomfort and emerge from it stronger, understanding that not every day will feel “well” or “good.” The ultimate goal of this time invested in training should probably have an element of struggle, as the ultimate goal is to prepare for the responsibilities ahead in your long-term career, which will most certainly not be struggle-free.
Generational disparities in work ethic have long been observed, with older generations often characterizing younger ones as lazy—a recurring theme throughout human history. The definition of professionalism remains elusive, prompting questions like whether it's acceptable not to answer emails or if going above and beyond truly signifies professionalism. Moreover, expectations regarding post-call duties remain ambiguous. Interestingly, there's a convergence between the values of the millennial workforce and the ethos of pediatric anesthesia, suggesting that this specialty may naturally resonate with younger practitioners. Caring for children in acute settings demands peak performance, potentially serving as a unifying factor between the traditional and emerging approaches to values-aligned professionalism and well-being in medicine.
The unspoken question becomes this: Is professionalism, along with some of its necessary discomforts, actually at odds with well-being? We believe that the primary aim of physician well-being efforts is to build engagement and sustainability into our work—work that is inherently both hard and wondrous. The nexus of physician well-being in pediatric anesthesia is to be able to do this amazing work in a sustainable way, under humane conditions, that favor career sustainability and a greater proportion of positive over negative experiences. The focus of work in both the ASA and SPA Well-being Committees, congruent with PAPDA’s vision for fellows, is to advocate for work conditions that favor engagement, fulfillment, and longevity, that can be done with passion, expertise, and curiosity, with more satisfying elements than frustrating limitations, and that allow for the tending to the clinician in addition to the patient. The aim is not necessarily to create aspirational goals of work to make it feel less like work.
We know from the laws of thermodynamics that energy cannot be created or destroyed but can only change form. Similarly, we must be mindful that some of the changes we seek in the name of well-being may inadvertently unravel some of the features of the work that make it satisfying and purposeful. We also recognize that by calling this out in this way, we may evoke conflicting and strong feelings—we admit to our readership that we hesitated for a moment to put these thoughts forward for consideration for fear of backlash. However, knowing that we can work through hard things, we welcome that discourse because it is in the dialogue itself that we can find a deep well of professional fulfillment: greater understanding of and connection with one another.
Send your thoughts and comments to Myron who will post in a Friday Reader Response.
References
1. Rosenbaum L. Being Well while Doing Well - Distinguishing Necessary from Unnecessary Discomfort in Training. The New England journal of medicine 2024;390(6):568-572. (In eng). DOI: 10.1056/NEJMms2308228.
2. Ligibel JA, Goularte N, Berliner JI, et al. Well-Being Parameters and Intention to Leave Current Institution Among Academic Physicians. JAMA network open 2023;6(12):e2347894. (In eng). DOI: 10.1001/jamanetworkopen.2023.47894.
3. Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout among academic faculty. Archives of internal medicine 2009;169(10):990-5. (In eng). DOI: 10.1001/archinternmed.2009.70.