Resources on Clinician Wellness
- Resources for clinician wellness in COVID-19
- Meta-analytic reviews of clinician wellness interventions
- Some examples of individual wellness initiatives
- Commentary in journals and books
1. RESOURCES FOR CLINCIAN WELLNESS IN COVID-19
National Academy of Medicine, Resources to help the health and well-being of clinicians during the COVID-19 outbreak.
- Dozens upon dozens of resource collections from WHO, US government agencies (including several divisions of HHS), associations and organizations (e.g., Accreditation Council for Graduate Medical Education, American Association of Colleges of Nursing, AMA, American Hospital Association), healthcare providers and schools of health education (e.g., Johns Hopkins, Rush, UNC), and peer-reviewed journals, textbooks and trade press (e.g., JAMA, New York Times and TED talks).
Chaplaincy Innovation Lab Resources for Chaplains Encountering Coronavirus. https://chaplaincyinnovation.org/2020/05/chaplaincy-coronavirus
- Resources from CIL, other online resources, free webinars and other helpful reading (e.g., caring for patients from several different religious traditions, coping with moral struggles, and inspirational stories and lessons.
WHO, Doing what matters in times of stress, 2020; https://www.who.int/publications/i/item/9789240003927#.Xzq5d_TqcXg.email or just go to Google: “Doing what matters in times of stress WHO” (18 languages)
- An illustrated, low-literacy guide to core resilience processes; “grounding,” “unhooking,” and “acting on your values.” Available in 18 languages.
The Schwartz Center for Compassionate Healthcare. Resources for healthcare professionals coping with the COVID-19 pandemic.
- Remarkable organizations that has brought you the long-running Schwartz Center Rounds. This website provides good resources on Taking Care of Yourself, Taking Care of your Family, and resources and guidelines for healthcare leaders.
2. META-ANALYTIC REVIEWS OF CLINICIAN WELLNESS INTERVENTIONS
Melnyk BM, Kelly SA, Stephens J (2020). Interventions to improve mental health, well-being, physical health, and lifestyle behaviors in physicians and nurses: A systematic review. Am J Health Prom, 34/8, 929-41, https://doi.org/10.1177/0890117120920451
- 29 studies 2008-2018. Mindfulness and CBT-based interventions effective in reducing stress, anxiety and depression. Suggestion that interventions associated with deep breathing and gratitude may be beneficial.
Shanafelt T, Goh J, Sinsky C. (2017). The business case for investing in physician well-being. JAMA Intern Med, 177/12, 1826-1832. doi:10.1001/jamainternmed.2017.4340.
- Well-being interventions are beneficial for turnover, productivity, quality of care, patient satisfaction, and patient safety. Critical organizational factors include prioritization by leadership, physician involvement, organizational learning, structured interventions, open communication, and promoting cultural change.
Loams T, Medina JC, Ivtzan I et al (2019). A systematic review and meta-analysis of the impact of mindfulness-based interventions on the well-being of healthcare professionals. Mindfulness, 10, 1193-1216. https://doi.org/10.1007/s12671-018-1062-5
- 41 studies reflecting MBSR, MBCT and other mindfulness-based interventions. Beneficial effects in attenuating anxiety, burnout, depression, distress/anger, and stress, and in promoting compassion, positive well-being, and mindfulness (no surprise here, right?), with small to medium effect sizes.
Rudaz M, Twohig MP, Ong CW, Levin ME (2017). Mindfulness and acceptance-based trainings for fostering self-care and reducing stress in mental health professionals: A systematic review. J Context Beh Sci, 6/4, 380-90. https://doi.org/10.1016/j.jcbs.2017.10.001
- 24 studies, reflecting MBSR, Mindfulness-based Cognitive Therapy, Mindful Self-Compassion, and Acceptance and Commitment Therapy. Changes in mindfulness, self-compassion, and psychological flexibility, and benefits with stress and burnout. “Results were less supportive for psychological well-being.” Standard benediction that more research is needed.
Kunzler AM, Heimreich I, Chmitorz A, et al (2020). Psychological interventions to foster resilience in healthcare professionals. Coch Database Syst Rev, 05 Jul, https://doi.org/10.1002/14651858.CD012527.pub2
- 44 RCTs targeting resilience, hardiness or post-traumatic growth. Positive albeit “very low certainly” evidence that resilience training was associated with higher levels of resilience and lower levels of depression and stress.
3. SOME EXAMPLES OF INDIVIDUAL WELLNESS INITIATIVES
Beckman HB, Wendland M, Mooney C et al. (2012). The impact of a program in mindful communication on primary care physicians. Acad Med, 87(6):815-9.
- In-depth interviews with 20 physicians who had completed a 52-hour mindful communication program. Themes of beneficial effects of sharing personal experiences to reduce isolation, learning mindfulness skills for personal and clinical reasons, and developing greater self-awareness. Nice summary, that well-being interventions should “promote a sense of community, specific mindfulness skills, and permission and time devoted to personal growth.” See HERE.
Foureur M, Besley K, Burton G et al. (2013). Enhancing the resilience of nurses and midwives: pilot of a mindfulness-based program for increased health, sense of coherence and decreased depression, anxiety and stress. Contemp Nurse, 45(1):114-25.
- Pilot study of a one-day MBSR workshop (with a follow-up program of 8 weeks of meditative practices0 with twenty midwives and 20 nurses. Improvements in measures of general health, “sense of coherence,” and stress. See HERE.
Greeson JM, Toohey MJ, Pearce MJ (2015). An adapted, four-week mind-body skills group for medical students: reducing stress, increasing mindfulness, and enhancing self-care. Explore (NY). 11(3):186-92.
- Four-week stress management and self-care workshop for medical students, focusing on mind-body approaches. Beneficial student ratings of perceived stress and mindfulness. See HERE.
Ho RT, Sing CY, Wong VP (2016). Addressing holistic health and work empowerment through a body-mind-spirit intervention program among helping professionals in continuous education: A pilot study. Soc Work Health Care, 55(10):779-793.
- Three-day mind/body/spirit intervention resulted in emotional, spiritual and functional improvements among 44 helping professionals in training. See HERE
Isaksson Ro KE et al. (2008). Counselling for burnout in Norwegian doctors: one year cohort study. BMJ doi:10.1136/bmj.a2004.
- One day or week-long counseling interventions with 185 physicians in Norway, aimed at motivating reflection on and acknowledgement of the doctors’ situation and personal needs.” One-year improvement in emotional exhaustion, reduction in working hours and significant reduction in participants on full time sick leave (from 35% to 6%). See HERE.
Isaksson Ro KE et al. (2010). A three-year cohort study of the relationships between coping, job stress and burnout after a counselling intervention for help-seeking physicians. BMC Public Health, 10, 213.
- Three-year follow up of 2008 study of interventions focused on “coping strategies, often related to sources of identity, self-esteem and self-reliance.” Improvements in emotional exhaustion, job stress, and emotion-focused coping strategies. Sponsored by resource center that is available to all Norwegian physicians, funded by Norwegian Medical Association. See HERE.
Krasner MS, Epstein RM et al (2009). Association of an educational program in mindful communication with burnout, empathy and attitudes among primary care physicians. JAMA, 302(12), 1284-93.
- 8 week program with 70 primary care physicians, covering mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences etc. Benefits at 2, 12 and 15 months in mindfulness, burnout, empathy and other measures. See HERE
Rainbow THH, Sing CY, Wong VPY (2016) Addressing holistic health and work empowerment through a body-mind-spirit intervention program among helping professionals in continuous education: A pilot study. Social Work in Health Care, 55:10, 779-93.
- 3-day body-mind-spirit intervention with graduate students in behavioral health, incorporating a variety of approaches (such as expressive arts, mediation, qigong and group work) to foster self-awareness, self-care, developing strengths, and finding meaning. Benefits of significantly lower levels of negative affect and physical distress, less “spiritually disorientation,” and enhanced levels of daily functioning, positive affect, spiritual resilience, and tranquility. See HERE
Sood A, Prasad K et al. (2011). Stress management and resilience training among department of medicine faculty: A pilot randomized clinical trial. J Gen Intern Med 26(8), 858–61.
- 32 physicians, single 90-minute training in “attention” (“to delay judgment and pay greater attention to the novelty of the world”) and “interpretation” (“away from fixed prejudices toward a more flexible disposition while cultivating skills such as gratitude, compassion, acceptance, forgiveness, and higher meaning”). Significant improvement in resiliency, perceived stress, anxiety, and overall quality of life at 8 weeks. See HERE.
Sood A, Sharma V et al (2014). Stress Management and Resiliency Training (SMART) program among Department of Radiology faculty: a pilot randomized clinical trial. Explore (NY), Nov-Dec, 10(6), 358-63.
- Same methodology and program as 2011 study, with 26 radiologists. Improvement in perceived stress, anxiety, quality of life, and mindfulness at 12 weeks. See HERE.
Shanafelt TD, Kaups KL et al. (2014). An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons. Annals of Surgery, 259(1), 82-88.
- Over a thousand physicians took an assessment of well-being and separately estimated their well-being. Measured WB was poor compared with norms; estimated WB was above average. (All the children are above average, right?). When given this feedback, most expressed intention to make one or more changes on behalf of reduced burnout and fatigue and enhanced work-life balance and career satisfaction. See HERE.
Tarantino B, Earley M, Audia D et al (2013). Qualitative and quantitative evaluation of a pilot integrative coping and resiliency program for healthcare professionals. EXPLORE, 9(1), 44-7.
- Beneficial outcomes for 84 participants (largely nurses and NPs) of “Healing Pathways” course, including Reiki, guided imagery, yoga, toning, meditation, intuitive scanning, creative expression and mentorship. See HERE.
West CP, Dyrbye LN et al. (2014). Intervention to promote physician wellbeing, job satisfaction, and professionalism: A randomized clinical trial. JAMA Intern Med. 174, 527–33.
- 19 bi-weekly group meetings with 74 practicing physicians, “incorporating elements of mindfulness, reflection, shared experience, and small-group learning.” Improved meaning and engagement in work and reduced depersonalization at one-year follow up. Note that participation was facilitated by protected, paid time. See HERE.
4. COMMENTARY IN JOURNALS AND BOOKS
Brown, S, Gunderman, RB. (2006). Enhancing the professional fulfillment of physicians. Acad Med, 81/6, 577-82.
- Lessons from nonmedical industries, why physician fulfillment matters, enhancing physician fulfillment.
Gordon JS. (2014). Mind-body skills groups for medical students: Reducing stress, enhancing commitment, and promoting patient-centered care. BMC Medical Education, 14:198
- Review of experiences at medical schools of mind/body skills groups developed at the Center for Mind-Body Medicine in Washington. Groups have been 8-12 weekly 2 hour sessions exploring variety specific mind-body skills including relaxation techniques, deep-breathing, biofeedback and autogenic training, and guided imagery, along with self-expressive techniques. Review asserts benefit in “reducing stress in medical students; in enhancing the students’ experience of medical education; and in helping them look forward more confidently.” See HERE.
Henry LG, Henry JD. (2002). The soul of a physician: Doctors speaking about passion, resilience and hope. AMA Press.
- Essays based on interviews with dozens of physicians about areas of emphasis in their lives and work that evoke meaning and passion: “reformers/activists,” “innovators,” “teachers/managers,” “artistic-oriented caregivers,” and others.
Jensen PM, Trollope-Kumar K, Waters H, Everson J. (2008). Building physician resilience. Can Fam Physician, 54, 722-9
- In-depth interviews with family physician peers. Themes of attitudes and perspectives, balance and prioritization, practice management style and supportive relations. Also viewable as Améliorer la résistance des médecins; Oh, Canada! See HERE.
Kemper KJ, Mo X and Khyat R. (2015). Are mindfulness and self-compassion associated with sleep and resilience in health professionals? J Alt Com Med, 21/8, 496–503.
- Descriptive study with 213 clinicians and trainees from several disciplines. The answer is “yes.” See HERE.
Krall EJ (2014). Ten commandments of physician wellness. Clinical Med Res, 12(1-2): 6-9.
- Krall is a psychiatrist at the Marshfield Clinic in Wisconsin. Pithy practical advice; Thou shall not expect someone else to reduce your stress, Remember what is holy to thee, Thou shall not kill or take it out on others, Seek to find joy and mastery in thy work, and six others. See HERE.
Lawson, K. (2011). Demystifying mindfulness. Minn Med, Jan. See HERE
- First of two articles I’ll highlight from a special issue of Minnesota Medicine on physician burnout/wellness. This article suggests specific practices related to mindfulness (“focus on one thing at a time,” “take a meal break without your computer, phone or reading material,” “practice gratitude, at the end of the day acknowledging one thing you are grateful for” etc.) which support well-being.
Longenecker R, Zink T, Florence J. (2012). Teaching and learning resilience: building adaptive capacity for rural practice. A report and subsequent analysis of a workshop conducted at the Rural Medical Educators Conference, Savannah, Georgia, May 18, 2010. J Rural Health, 28(2):122-7. See HERE.
- Ideas growing out of a day-long meeting of rural medical educators. Themes of hardship as an opportunity for growth and adaptability (flexibility, “bending without breaking”) being more important than hardiness. Recognition and emphasis also that resilience is “both an individual and community property;” that finding and nurturing supportive community is indispensable to sustainability of rural practice.
Manahan, B. (2011). Eight suggestions for promoting physician well-being; Ways to make medicine more satisfying for doctors and better for their health. Minn Med, Jan. See HERE
- Second of two articles from the special issue of Minnesota Medicine on physician burnout/wellness. This is a very different article, not suggesting wellness practices per se, but rather some healthful and freeing perspectives on being a doctor and practicing medicine. “”View medicine as a calling, as well as a business.” “Emphasize both the art and the science of medicine.” “ Set realistic expectations about what medicine can do for patients.” “Accept illness and death as a normal part of life.” And several others.
Puchalski CM, Guenther M. (2012). Restoration and re-creation: Spirituality in the lives of healthcare professionals. Curr Opin Support Palliat Care, 6(2):254-8. See HERE.
- Medicine and other healing professions as vocations. Spiritual reflection and development, “broadly defined,” can help clinicians to maintain the perspective and energy of their vocation and to be more resilient in the face of professional and personal challenges. Nice description of sixteen spiritual/reflective practices… mentors, group participation, reading of sacred texts, gratitude practices, journaling, the arts and others.
Shanafelt TD. (2009). Enhancing meaning at work: A prescription for preventing physician burnout and promoting patient-centered care. JAMA, 302(12), 1338-40.
- Editorial comments about meaning as powerful, individually-understood factor that promotes well-being among medical professionals. “Often centers on being a healer, developing expertise, being a teacher, or making scientific discoveries.”
Shanafelt TD, Novotny P. (2005). The well-being and personal wellness promotion strategies of medical oncologists in the North Central Cancer Treatment Group. Oncology, 68(1), 23-32.
- 241 oncologists; well-being associated with developing an approach/philosophy to dealing with death and end-of-life care, using recreation/hobbies/exercise, taking a positive outlook and incorporating a philosophy of balance between personal and professional life.
Shanafelt TD, Sloane, JA, Habermann, TM. (2003). The well-being of physicians. Am J Med, 114/April 15, 513-9.
- Reviews individual strategies employed by physicians, as well as institutional and organizational factors that can support physician well-being. See HERE.
Shanafelt TD, West CP et al. (2008). Principles to promote physician satisfaction and work-life balance. Minnesota Med, December, 41-3.
- Principles for professional satisfaction and work-life integration from the Mayo Clinic Department of Medicine: meaningful work; challenges commensurate with skills, interests and resources; opportunities for professional development; a culture that cultivates professionalism and professional satisfaction; autonomy and flexible scheduling; a culture that values and encourages life outside of work; and a culture of wellness.
Shanafelt, T., Shein, E., Minor, L. B., Trockel, M., Schein, P., & Kirch, D. (2019). Healing the professional culture of medicine. Mayo Clinic Proceedings. doi: https://doi.org/10.1016/j.mayocp.2019.03.026
- Elegant description of the gaps between espoused and experienced values of medicine, and practical approaches to define and promote cultural change.
Sotile MO. (2002). The resilient physician: Effective emotional management for doctors and their medical organizations. AMA Press.
- Intrapersonal approaches to resilience for physicians, and interpersonal approaches to managing institutional challenges and creating positive interpersonal culture. Psychological consultant authors have published previous work (which they include here) on medical marriages.
Souba WW. (2002). Academic medicine and the search for meaning and purpose. Acad Med, 77(2):139-44.
- Case for “renewal of health care system” by having dialogue in under- and post-graduate medical education about what it means to be an academic physician and where one finds meaning and purpose. See HERE.
Stevenson AD, Phillips CB, Anderson KJ. (2011). Resilience among doctors who work in challenging areas: a qualitative study. Br J Gen Pract, 61(588). See HERE.
- Qualitative study in Australia with primary care physicians who work in areas of social disadvantage. Personal factors associated with resilience included commitment to social justice in choosing this work, appreciation and respect for patients, and abilities to create sustainable work arrangements. Also, mindset of being able to “celebrate small gains,” rather than being overwhelmed by enormity of social problems.
Swetz KM, Harrington SE et al. (2009). Strategies for avoiding burnout in hospice and palliative medicine: peer advice for physicians on achieving longevity and fulfillment. J Palliat Med, 12(9), 773-7.
- Wellness strategies of 40 hospice and palliative care physicians (in order of response); physical well-being, professional relationships, taking a transcendental perspective, talking with others, hobbies, clinical variety, personal relationships, personal boundaries, time away from work, passion for one's work, realistic expectations and use of humor and laughter, and remembering patients. See HERE
Weiner, EL. (2001). A qualitative study of physicians’ own wellness promotion practices. WJM, 174/January, 19-23.
- Thematic analysis of survey responses points to relationships, religion or spirituality, self-care practices, work attitudes and value-based approaches to life. See HERE.
West CP, Dyrbye LN et al. (2009). Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Int Med, 24(12), 1318-21.
- Single item measures tell the tale as well as longer inventories. Emotional exhaustion; “I feel burned out from my work.” Depersonalization: “I have become more callous toward people since I took this job.” See HERE
Zwack J, Schweitzer J. (2013). If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med, 88(3), 382-9.
- Compilation of interview data from 200 physicians in Germany. “Job-related gratifications,” (e.g., pt relationships) “resilience practices” (e.g., meaningful contact with colleagues) and “resilience atti5tudes” (e.g., acceptance and self-awareness. Nice description and examples of the resilience practices and attitudes. See HERE.
Finkelstein C. (2015). Improving physician resiliency. AMA Stepsforward.
- Online interactive module from AMA Stepsforward project. Evaluating burnout and well-being, exploring resilience, presenting 18 concrete approaches. In addition to enhancing your life, you get AMA credit. See HERE.
Morris CW et al. (2014). Behavioral health & wellness program: A work & well-being toolkit for physicians. School of Medicine, University of Colorado Anschutz Medical Campus.
- Several-dozen page interactive curriculum. Physician health and well-being, a model for whole health, self-assessment, mindfulness and building and sustaining a change plan. Well done. See HERE.
Institute for the Study of Health and Illness, Meaning in Medicine. (http://www.meaninginmedicine.org/home.html).
- Portal for Rachel Naomi Remen initiatives… Meaning in Medicine, Arts and Healing, and related links.