Shifting Focus from Burnout and Wellness toward Individual and Organizational Resilience.

Burnout is reported to be epidemic among physicians and medical trainees, and wellness has been the predominant target for intervention in academic medicine over the past several years. However, both burnout and wellness suffer from a lack of standardized definition, often making interventions difficult to generalize and extrapolate to different sites. Although well-meaning, current frameworks surrounding wellness and burnout have limitations in fully addressing the challenges of improving physician mental health. Wellness as a framework does not inherently acknowledge the adversity inevitably experienced in the practice of medicine and in the lives of medical trainees. During a crisis such as the current pandemic, wellness curricula often do not offer adequate frameworks to address the personal, organizational, or societal crises that may ensue. This leaves academic institutions and their leadership ill-equipped to appropriately address the factors that contribute to burnout. More recently, resilience has been explored as another framework to positively influence physician wellness and burnout. Resilience acknowledges the inevitable adversity individuals encounter in their life and work, allowing for a more open discussion on the tensions and flexibility between facets of life. However, emphasizing personal resiliency without addressing organizational resiliency may leave physicians feeling alienated or marginalized from critical support and resources that organizations can and should provide. Despite intense focus on wellness and burnout, there have not been significant positive changes in physicians' mental health. Many interventions have aimed at the individual level with mindfulness or other reflective exercises; unfortunately these have demonstrated only marginal benefit. Systems level approaches have demonstrated more benefit but the ability of organizations to carry out any specific intervention is likely to be limited by their own unique constraints and may limit the spread of innovation. We believe the current use of these conceptual lenses (wellness and burnout) has been clouded by lack of uniformity of definitions, an array of measurement tools with no agreed-upon standard, a lack of understanding of the complex interaction between the constructs involved, and an over-emphasis on personal rather than organizational interventions and solutions. If the frameworks of burnout and wellness are limited, and personal resilience by itself is inadequate, what framework would be helpful? We believe that focusing on organizational resilience and the connecting dimensions between organizations and their physicians could be an additional framework helpful in addressing physician mental health. An organization connects with its members along multiple dimensions, including communication, recognition of gifts, shared vision, and sense of belonging. By finding ways to positively affect these dimensions, organizations can create change in the culture and mental health of physicians and trainees. Educational institutions specifically would be well-served to consider organizational resilience and its relationship to individuals.

Keywords: Wellness; burnout; resilience

"We need to maintain our connection to our mission by strengthening and securing our support networks so that, when we come up against challenges, we do not face them in isolation, but rather feel part of a mutually supportive group of colleagues with a shared commitment to achieving our goals. The medical profession has always epitomized resilience, and we will continue to thrive if we affirm our shared mission, reach out empathically to one another, and rise together to meet the challenges ahead." - Darrell G. Kirch, 2014 Association of the American Medical Colleges (AAMC) keynote address

Over the past 5 years, physicians have seen a near exponential increase in publications on burnout and wellness (Figure 1). Medical educators, trainees, and physicians have encountered numerous workshops at national and regional meetings, blogs, webinars, tweets, and must-read papers devoted to these topics. The Accreditation Council for Graduate Medical Education (ACGME) made wellness a program focus, with new common core requirements to address resident burnout.[1] Medical schools and healthcare organizations offer myriad programs to improve the wellness of their students, residents, and faculty. In October 2019, the National Academy of Medicine (NAM) published Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.[2] Its objectives were to address clinician burnout/well-being and improve patient care, emphasizing that the key is an organizational approach. One goal was to create positive learning experiences by transforming medical education and training to optimize learning environments that prevent and reduce burnout and foster well-being.

PHOTO (COLOR): Figure 1. Number of articles with "burnout" and "wellness" in the title by year in PubMed.

Burnout in medicine is reported in many studies to be above 40-60%, which has been the primary driver of this intense focus.[[3], [5], [7]] There have been several articles suggesting methods for changing our educational settings to impact what some have called an "epidemic" of burnout.[8],[9] Interventions have included mindfulness training, guided reflection, wellness days, art therapy, and gratitude exercises.[[9], [11]] Unfortunately, the intense focus and widespread efforts have been largely unsuccessful, with one meta-analysis showing only a 10% reduction in burnout with intervention.[12] Organizational efforts such as changes in call schedules, team communication, teamwork, and workload have demonstrated modest efficacy but there are challenges in implementing these in different settings based on organization-specific resources, drivers, needs, and cultures.[13] We believe the focus needs to be shifted toward the lens of resiliency–both individual and organizational–to more fully address physician wellness and burnout.

The most pressing concern about burnout is that the relationship between burnout, depression, and suicide is often compared to an iceberg, with suicide at the surface, depression just below the surface, and burnout as the larger base supporting the whole.[14] There are challenges to this metaphor, including the fact that there are over 140 definitions of burnout with no clear consensus on the meaning or criteria.[2],[15],[16] While a single definition is not necessary to coherent discussion on burnout, consistency is critical to understanding burnout and its implications. Without clear nomenclature and validity, we are adrift in a conversation in which each participant has assigned burnout their own definition and significance. Additionally, consistency is needed to gauge intervention effectiveness and to understand burnout trends over time or across settings. Within the marked heterogeneity of assessment instruments, even the most commonly used Maslach Burnout Inventory (MBI) yields frequencies of burnout ranging from 0% to 85% depending on which of the three major subscales are used to define this multi-dimensional construct.[17] Such dramatic ranges of reported burnout—dependent on the measurement tool used—challenge understanding of what being "burned out" might mean as well as the benefit of any specific intervention.

Although we believe the MBI is the best instrument to measure burnout and gauge the effectiveness of intervention, the results are best reported not as a dichotomous variable (i.e. the presence or absence of burnout) but as a continuous variable (i.e. ranging from low to high risk of burnout). Moreover, all three MBI subscales need to be reported.[18] Failure to report all three subscales could result in an incomplete picture of the extent and impact of burnout. As illustrated in a recent meta-analysis of nearly 3000 citations, involving over 18,000 residents in 12 individual specialties, the combined subscales of emotional exhaustion and depersonalization were more important for surgical specialties, depersonalization and personal accomplishment were more important for non-surgical residencies, and low personal accomplishment—often omitted from studies using the MBI—was particularly important to the specialties of anesthesiology and psychiatry.[17] The inconsistency of reporting all three subscales creates difficulty for those who are trying to gauge differences across time, studies, and specialties. It also creates challenges to understanding the relationship between burnout and other mental health concerns such as depression, suicidality, and suicide.

Reported increases in mental health issues are not isolated to healthcare professionals, which should challenge assumptions that the environment of medicine is the cause of burnout.[[19], [21]] Because the narrative of burnout and mental health issues in medicine has been so pervasive, we have rapidly proceeded to interventions without fully understanding the problem(s).[22] In our view, this is at least partially due to unclear definitions of burnout, but also a failure to consider relevant conceptual or theoretical frameworks.[23] While burnout is one framework through which to view and care for physician mental health, it has obscured thoughts about, the approach toward, and interpretation of the limited data available in the literature. There are frameworks for understanding and addressing burnout, but there does not appear to be anything in the literature evaluating or validating existing conceptual frameworks for depression, suicidal ideation or suicide, and how these relate to physicians or burnout.[2],[5],[24]

The NAM has developed a very helpful framework in the job resources-demand model to articulate the systems contribution to physician burnout, based on principles of human factors and systems engineering, job organizational design, and occupational safety and health.[2] The three levels of systems identified were (1) frontline care delivery (e.g. individuals of the health care team and the physical environment); (2) health care organizations (e.g. departmental and institutional leadership and governance); and (3) the external environment (e.g. health care industry, laws, regulations and societal values). Together, these organizational factors are thought to contribute to 80% of all burnout cases.[25] Individual factors such as coping strategies, personal resilience, social support, personality and temperament mediate the effects of the work system factors on physician burnout.[2] While individual-focused strategies may be beneficial as an effective component of larger organizational efforts, on their own they are insufficient to address clinician burnout on a wider scale.

Burnout has been shown to transfer among physicians, nurses, and other health professionals, extending beyond the units in which they work and spreading through other social networks of an organization.[[26], [28]] The spread of burnout through the networks of trainees is not understood, nor the factors that may influence its "conductivity"–how rapidly it spreads through healthcare social networks. It is known that people differ in their emotional susceptibility, and it is likely that this would affect the spread of burnout from one individual to another.[29] Burnout spread among healthcare providers underlines the need for systems-based approaches to address burnout and avoid what some have titled "burnout contagion."[[26], [28]]

There has been a shift from focusing on burnout to focusing on wellness.[30] Similar to burnout, there are nearly a 100 different definitions and an array of suggested instruments to measure wellness.[31],[32] While there is no clear consensus on the definition of wellness, we favor using the World Health Organization definition "Wellness is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity." [33] Because wellness and burnout are used concurrently so frequently it is worth emphasizing that well-being and burnout are separate and distinct entities and that the absence of one does not imply the presence of the other.

In the wellness literature multiple different models emphasize similar dimensions, including physical, mental (including both intellectual and emotional), social, and spiritual.[16],[[34], [36]] These models can be helpful in providing wellness goals for both individuals and organizations. However, there are drawbacks to wellness models. First, while some will approach the dimensions of wellness as a framework, others may ruminate on the absence of wellness in a specific dimension such as physical activity or other leisure activity, stimulating further burnout.[37],[38] Overemphasis on a single dimension can be compounded by the fact that there is minimal acknowledgement within the models of wellness that the dimensions can be in tension with each other and vary based on individual and situational circumstances. Due to the rigorous nature of medical training, trainees are unlikely to have the time to devote to physical, spiritual, or intellectual dimensions of wellness that they had prior to medical school and will have to flex back and forth between these dimensions depending on their current situation. Once in training, learners often struggle to balance their professional, personal, and family lives, although trainees recognize that they are putting off some areas of their life for professional development.[39]

There have been a number of attempts to improve psychological wellness through educator conferences and in residency curricula.[10],[11],[40] These have generally focused on individual wellness and include mindfulness, journaling, self-reflection, stress management, and gratitude activities.[7] While these do provide potential skills for trainees to use throughout their careers, so far these individual approaches have only met with marginal success. Additionally exercises such as mindfulness are likely to frustrate those who recognize and are returned to dysfunctional environments that contribute to impaired wellness.[41],[42] Residency program leadership have been given frameworks and tools that are inadequate to address their residents' wellness, especially considering that threats to wellness, such as financial strain and unsatisfying social relationships, can come from outside of the residency setting.

One of the most significant drawbacks in using wellness frameworks is the failure to explicitly acknowledge adversity.[[34], [36]] In most definitions, wellness is tied to a sense of emotional well-being, happiness, or a positive sense of meaning in work, which can lead to the belief that wellness is the absence of adversity. However, adversity is inherent in life and along the continuum of medical education and practice. Medicine is a challenging field to negotiate and there are a number of negative emotional responses which inevitably arise due to tensions with patients, families, colleagues, and hospital or regulatory policies and procedures. These "micro-stresses" that accumulate during daily clinical care can be thought of as adversities.[43] Micro-stresses may be especially challenging for less-experienced trainees, who may feel more distress and negative emotion as a result.

The range of emotions physicians and trainees may experience include frustration, anger, shock, bewilderment, shame, embarrassment, fatigue, physical or mental exhaustion, feeling overwhelmed and sad, and these emotions can be particularly intense for medical students.[37],[38] When a provider has to deliver bad news, deal with an angry caregiver, or even handle minor events such as being unable to log into their computer, the cumulative effect of "micro-stresses" can be immense and lead to cynicism about the future. Emotions, both positive and negative, can spread throughout an educational setting through social contagion phenomena, and educators need to be aware of this possibility.[44],[45] While wellness models may provide some helpful ways of dealing with the stress such as exercise, spirituality, and psychological well-being, they do not provide an explicit way to reflect and build on one's ability to deal with adversity. The intensity of the emotions or distress about situations can be compounded by unrealistic expectations that the trainee or physician should not experience negative emotions.

The NAM has emphasized the important role organizations have in influencing positively or negatively individuals' sense of well-being at work. [2] Ratanawongsa et. al. stressed the importance and role residency programs themselves have in trainee well-being, making specific recommendations for organizations to deploy.[39] Stansfield et al., in the development of their Resident Wellness Scale, noted several items they categorized under "institutional support" as being critical for resident wellness—although this was primarily support needed due to a tragic event at work.[46] Organizations cannot simply rely on wellness curricula that emphasize individual coping strategies along different dimensions of wellness and expect to see significant improvements in their trainees and physicians.

A different approach that we believe is vitally important to improving physicians' mental health is to shift primary focus toward resilience.[47] Concerns over the decline in student resilience in combination with the current COVID crisis makes the necessity of this shift even more salient.[48],[49] All physicians encounter adversity in their career and personal life, whether it is divorce, death, litigation, or a pandemic; and they will need strategies to overcome these adversities. The COVID pandemic specifically has presented many threats to wellness and many providers are struggling with their mental health, exacerbated by economic uncertainty, threats to their physical health or those they love, and significant workload. These stressors are unlikely to resolve at any point in the foreseeable future. While wellness initiatives provide only a limited solution to addressing these stressors, learning to deal with uncertainty and building emotional, academic and psychological resiliency are potential ways to overcome the myriad adversities of the current pandemic.[[49], [51]] The best way to build resilient healthcare providers is to build a resilient organization and community to surround them.

While there are at least 17 definitions of resilience they all, unlike wellness, inherently acknowledge adversity.[49],[53] We define resilience as the act of coping, adapting, and thriving from an adverse event that arises from the complex interplay between individual, environmental, and socio-cultural factors.[54] Different from wellness models, resilience implicitly recognizes the inherent tension between the different dimensions of wellness and the flexibility required among these over time. This offers many avenues for physicians to reflect, considering times when they have demonstrated resilience, considering stories about other physicians and how they developed resilience over time, and considering activities to specifically build resilience. There is early evidence suggesting that strategies to increase resilience can be effective in addressing burnout.[6],[51],[55] Importantly, there also is emerging literature that provides specific interventions to increase resilience.[47],[50],[52],[54],[56],[57]

The model we propose emphasizes the importance of addressing individual and organizational resilience in relationship with each other (Figure 2). This emphasis parallels the NAM conceptual framework of a job resources-demand model that highlights the role and responsibility of organizational leadership. There is a valid concern that organizations may overemphasize personal resilience while avoiding critical systemic issues that could cause further marginalization of the individual.[58],[59] However there are approaches that incorporate both an individual's and an organization's resiliences.[38],[50],[53] Our proposal would require a significant shift in how resilience is currently viewed in the healthcare system: the "weakest link" would not be viewed as an individual in the organization, but the weakest bonds between the individual and the organization. In this case, it becomes the organization's primary responsibility to provide a community of support within the institution for an ailing healthcare provider.

PHOTO (COLOR): Figure 2. Conceptual model illustrating the dynamic interplay between individual and organizational resiliency.

Stressors affect both individuals and organizations and have the potential to overwhelm either. The factors influencing an individual's resilience fall into three major categories: internal, social capital, and societal factors.[60] Internal factors include aspects of personality including temperament (e.g. tolerance to ambiguity), outlook (e.g., optimism), talents, skills, and reflective capacity.[51],[55] Social capital is defined as the family or other social networks an individual has access to and could leverage if needed during adversity. Societal factors include the cultural background, community (including religious or educational), and institution to which they belong. It is important that personal resilience not be viewed as a static quality but a dynamic variable that may change based on situation and time.[47],[54]

Frameworks from the literature on community and organizational resilience include planned and adaptive resiliency.[[61], [63]] We propose adaptations of these frameworks for academic medicine that include the following dimensions: culture, social networks, learning, leadership, resources, adaptive capacity, systems, and capital. Communication is often included in this list, however we see this as one of the key factors bridging the connection between individual and organization resiliencies. Culture (including role modeling) and leadership can influence where resilience is experienced by an individual in their organization.[63],[64] The relationships between dimensions intertwine; capital (financial) and social networks/relational reserves both influence each other positively and can help organizations overcome the range of acute major or chronic everyday stressors.[65] Systems would include governance processes and infrastructure that would affect how the organization functions and responds to stressors. The organization's ability to learn, especially in crisis, is critical to adapting to societal changes and increasing challenges affecting the trainees' and physicians' mental health.[66] Organizational leadership must recognize the problem of individual mental health, use available resources, influence the organizational culture, and increase the adaptive capacity to respond to stressors, all of which will require capital. Organizations need to understand that the relationships between burnout, depression, suicidal ideation, and suicide are not entirely clear and a focus on burnout may not affect the other outcomes if the focus of their efforts are too narrow. It may be that one of the most effective ways to increase resiliency and mitigate burnout is to focus on building community within our healthcare teams and a sense of hope for the future.[67],[68]

Crises such as the COVID pandemic pose challenges for individuals and organizations, but they also create opportunities to build community. Powley describes how organization resilience arises in the face of a crisis.[69] He describes the process of resilience activation which occurs through three mechanisms: (1) "liminal suspension" (the reordering in relationships which the crisis creates with an opportunity to form and renew relationships); (2) compassionate witnessing (the emotional connections that facilitate responses to individual needs); and (3) relational redundancy (the social capital and interpersonal connections that further activate social networks beyond the usual reference groups to facilitate resilience). Leaders can facilitate this resilience activation intentionally and explicitly during a crisis. They should give special focus toward potentially marginalized individuals who might otherwise stay silent and ensure their psychological safety so they can effectively raise issues or challenge aspects of their adversity experiences.[70]

An individual's and organization's resiliency are intertwined and influence one another based on the affinity felt by the individual for the organization and vice versa. Block describes the value of focusing on a community of belonging, individuals' gifts, and a group's future possibilities (shared vision) in promoting this affinity.[71] For trainees it is especially important that they feel present in a community of belonging, which comes from explicitly and repeatedly communicating this message to them. At some point, many will question whether they belong in academic medicine, likely after some adversity such as a failed test, medical error, critical feedback, or untimely death of a patient. If they have peers and faculty who encourage their engagement in the medical community, it will mitigate these doubts and avoid the more severe mental health issues which can arise as a result. According to self-determination theory, increasing this sense of relatedness to group and community connections is one of the key drivers of human motivation.[72],[73] One way to reinforce this sense of belonging is to recognize each individual's gifts. This requires individuals within the organization to get to know each other personally and discover these gifts in each other which must be encouraged and facilitated by the leadership. Using these gifts and helping the individual to reach their full potential with them will demonstrate the organization's dependence on them as well as increase the individual's attachment to the organization.

Block states, "We are a community of possibilities, not a community of problems."[71] This bold claim means that if we focus on problems—especially tempting when it comes to burnout—it will be difficult to explore possibilities for the future and fully develop a shared vision for what the healthcare team can look like. Overlap between an individual's vision for their workplace and the organization's vision is critical to maintain their constructive engagement with each other. This is likely to free individuals to be much more creative in ways to build the community of belonging and identify ways to recognize gifts and use them. It will require dedicated organizational leadership to ensure all relevant factors and limitations are included as the shared vision begins to take practical form.

Bi-directional communication is the channel through which all of these take place and is a distinct facet on its own, taking place outside of the explicit creation of a sense of belonging, shared vision, and recognition of gifts. In Figure 2, the connections or "bonds" are represented by the interlocking arrows and the four key factors between the two spheres of individual and organizational resilience. Positively influencing at least one of these areas of connection will more tightly attach an individual to the organization and their leadership. Negatively affecting one of these will decrease the sense of attachment and could contribute to burnout, or even an outbreak of burnout. Some programs have recognized this and implemented initiatives to increase the sense of belonging.[74] Organizations would be well served by focusing on efforts to build tighter social bonds and an understanding of each trainee and faculty's giftedness than do most wellness activities.[47] We have provided in Table 1 examples of activities that individuals and organizations could pursue to enhance each bond of connection between the two.

Table 1. Individual and organizational activities to enhance connection.

An additional benefit noted by Block is that positively affecting these factors can also create space for "chosen accountability" by the individual.[71] There are many ways individuals could be asked to work to increase the resilience of their organization and consider small steps at the same time to increase their own resilience.[47],[50],[54] This will increase their accountability to develop and implement system-wide solutions that leadership may not have previously considered. This will also connect individuals more closely to the organization and its administrative leadership, while at the same time likely fostering their own personal resilience.

Hopefully we have illustrated some of the challenges and limitations with using burnout and wellness as the primary frameworks to refine our understanding and improve the mental health of medical trainees and physicians. The current generation of learners and early-career faculty face significant societal stressors beyond COVID that may affect their current and future outlook, including environmental degradation and catastrophe, educational debt, societal uncertainty, economic stagnation, housing costs, and the recent increase in perfectionism.[75] Mid-and late-career physicians have also had to deal with dramatic changes, including the implementation of electronic health records, changes to value-based purchasing, reduced physician autonomy, and the shift toward health system practices, and they are likely to continue experiencing stressors as a result of future change. Wellness initiatives alone are challenged to meet each of these different individual needs. A shift toward resilience, and specifically toward organizational resilience, may better address how physicians across the continuum of their career can overcome and thrive while facing the inevitable adversities inherent to medicine.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.