I.

Residency is a difficult time, in part, for the following reasons Loss of autonomy during intern year Extreme emotional situations Steep learning curve in knowledge acquisition Long hours on call sleep deprivation Profound increase in level of responsibility for the health of others II. Many experience mental health issues. Major depression affects ~16% of Americans at some point in life. Leading cause of lost worker productivity and days lost to disability (1, 2) and accounts for an annual capital loss of $36 billion A 2003 consensus statement by 15 experts on the subject of physician depression and suicide, as well as barriers to treatment that appeared in the Journal of the American Medical Association, noted that The culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and increased risk of suicide (3) Rates of depression among residents are elevated (7%-49%) (4-15) compared with graduate students and young adults in the general population (8-15%) (16) High rates of depression are concerning among training physicians given this populations professional responsibility, and a growing body of evidence indicates that depression causes significant cognitive dysfunction and work impairment. (17, 18) Among physicians in training, depression has been associated with reduced quality of life and increased burnout (19), resulting in poor quality of patient care and decline in the physician work force (20) Recently, investigators have established a strong association between depression and perceived medical errors (19, 21, 22) and noted that medical errors are of a magnitude relevant to patient safety (22). These studies suggest that reducing rates of depression among training physicians is a crucially important public health issue. Unfortunately, physicians are often reluctant to seek mental health treatment (23), and their peers are hesitant to intervene despite their professional responsibility to report impairment among their colleagues Physicians frequently seek treatment only when their psychological distress and suboptimal performance has garnered the attention of insurance companies, police, and review boards. (24) Despite the elevated prevalence of depression among physicians and its associated high costs to physicians and patients, one study found that barriers to seeking mental health treatment were lack of time (91.5%), preference to manage problems on their own (75.1%), lack of convenient access (61.8%), and concerns about confidentiality (57.3%). This study also found that interns who had previously sought treatment for depression were more likely to seek treatment during internship (25) In previous cohorts of the Intern Health Study, depressive sxs increased from 4% prior to internship to a mean of 26% during internship (26)

Interestingly, regarding the effects of the 2011 duty hour reforms on interns and their patients, although interns report working fewer hours under the new duty hour restrictions, this decrease has not been accompanied by an increase in hours of sleep or an improvement in depressive sxs or well-being but has been accompanied by an unanticipated increase in self-reported medical errors (27) III. Wellness helps In recent years, some have suggested that positive psychological characteristics may be a protective factor for depression distinct from the absence of negative characteristics (28,29) Well-being is a characteristic of positive psychological functioning that captures an individuals level of positive affect, life satisfaction, and sense of purpose in life (30) Research shows the intimate relationship between physician well-being and compassionate care for patients (31-35) However, many medical students and physicians today are neither adequately trained nor actively involved in their own care (36-41) Burnout and stress are serious concerns because, as research shows, these lead to a decline in quality of care an dincreased substance abuse, divorce, and even suicide. (42-52) However, physicians with regular wellness practices have improved psychological wellbeing (53, 54) Accordingly, student and physician health promotion and wellness education, with the aim of reversing burnout and stress, is becoming more common (55-58) Beginning such programs early in medical education can ingrain good habits as part of regular daily activities (59-61) and may prevent the common decline in health seen during residency Well-being has consistently been correlated with depression and other mental disorders in cross-sectional studies (62-64) but longitudinal studies are lacking. A 10 year longitudinal study found well-being was predictive of internalizing mental disorders (i.e. depression, generalized anxiety disorder) (65) The two longitudinal studies that have assessed the predictive value of well-being specifically on depression have had gaps of 10 (66) and 15 (67) years between assessments, limiting their applicability to clinical evaluations. In a study assessing for depression in interns, results indicate that well-being distinctly predicts future depression risk. Specifically, they found that individuals who reported lower well-being at baseline showed significant increases in depression symptom scores across time. Wellbeing remained a significant predictor of depression score trajectories even after accounting for other baseline variables, such as neuroticism, early childhood environment, and gender that are established risk factors for depression. Importantly, low well-being remained a predictor of increased future depressive sxs while also accounting for baseline depressive scores. (68) These findings suggest that assessing well-being may add important practical utility to assessing for and preventing depression (68) and that efforts specifically designed to increase well-being may be effective in protecting against depression.

Knowing that low well-being may increase the chances of developing depression could allow individuals and caregivers to take preventative steps before the onset of depressive sxs (69) In the field of psychiatry, we have a long hx of recognizing the importance of the health of the practitioner in delivering good care; however, we have not been at the forefront of addressing burnout or promoting wellness for our trainees Resident wellness programs as one way to promote resident health IV. Wellness enhances professionalism West CP, Shanafelt TD. Physician well-being and professionalism.Minn Med. 2007;90(8): 44-46. Text taken from above article: Professionalism is one of the fundamental competencies associated with being a physician. It encompasses the core principles of social justice, patient autonomy, and primacy of human welfare, and requires a commitment to competence, integrity, and humanistic care. Although much has been written about the characteristics of a professional, the factors contributing to the development and maintenance of professionalism are less well-defined. Organizational and personal factors influence professionalism, and physician well-being is one factor that is essential for professionalism to flourish. In this article, we review what is known about the relationship between physician well-being and professionalism and suggest ideas for future research on this relationship. Relationships between Distress, Well-being, and Professionalism The effect of distress on professionalism in medicine has become clear in recent years. The well-documented decline of crucial elements of professionalism, including empathy and humanism, during medical training appears to be related in part to personal distress experienced during medical school and residency.5,17,18 Unfortunately, this decline continues as physicians move into practice, where distress also is associated with decreased compassion and empathy.19,20 Among both trainees and practicing physicians, burnout and stress also have been shown to contribute to suboptimal patient care practices ranging from minor mistakes to potentially serious medical errors.4,19,21 Other practices related to distress include premature discharges, incomplete or rushed patient communication, and irritability with patients.4,5,19,20 As noted previously, some physicians develop depression or resort to maladaptive behaviors such as substance abuse that can further erode professionalism and result in poor patient care.4,19 On the other hand, it has been proposed that personal well-being may actually enhance aspects of professionalism such as empathy, compassion, and quality of care. These ideas are supported by a limited-but-emerging body of research using validated survey tools to show that increased well-being may promote professional attributes such as empathy and the ability to provide compassionate care.17,18 Concepts of mindfulness, self-awareness, and positive psychology have been suggested as being important to promoting well-

being, but little is known about the quantitative impact they may have on well-being or professionalism.22-24 The link between distress and well-being is further clarified by theories on optimal human functioning suggesting that burnout, depression, and anxiety represent only one end of a quality-of-life continuum (Figure 1). At the positive end of this continuum, wellbeing requires more than the absence of distress; it also involves satisfaction across multiple domains of life such as family, community, spirituality, and health, and experiences that stimulate personal and professional growth.25 Efforts to promote professionalism, therefore, not only must reduce distress but also promote well-being. Factors Contributing to Physician Well-being and Professionalism These relationships have led us to develop a broader list of factors that contribute to physician well-being and professionalism (Figure 2). Initiatives to promote professionalism will need to address the interactions among these factors to be effective. Reported approaches to fostering professionalism among physicians include formal coursework in ethics and humanism, development of role models, required community service activities, and personal and shared reflection.26-28 Organizational reforms that promote a true culture of caring and institutional policies consistent with this goal are also necessary. For example, policies that promote work-life balance and restore physician autonomy within the practice environment are important to maintaining physician well-being.8 Further research on effective methods for promoting well-being and professionalism is necessary, including outcomes studies evaluating the effect of these strategies. To further this goal, the Mayo Clinic Department of Medicine initiated its Program on Physician Well-being in July of 2007 to complement its existing Program in Professionalism. The goals of these programs include the development and testing of evidence-based interventions that promote both well-being and professionalism. These concepts are interrelated, and we believe each is integral to our ability as physicians to provide outstanding patient care. The Mayo Program on Physician Well-being will evaluate the full spectrum of personal, professional, and organizational elements that influence physician well-being, satisfaction, and productivity to identify factors that can be modified for the benefit of physicians and patients. Examples might include modifying physicians daily work schedules, providing curricula on well-being and professionalism, and offering training on awareness of distress and well-being. Other potential domains of study are suggested in Figure 2. We believe the lessons learned from these efforts may stimulate a revival of physician well-being and professionalism. References for the above text
References 1. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(1):354-73. 2. Hsu K, Marshall V. Prevalence of depression and distress in a large sample of Canadian residents, interns, and fellows. Am J Psychiatry. 1987;144(12):1561-6. 3. Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med. 2006;81(1):82-5. 4. West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, Shanafelt TD. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-8.

5. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5): 358-67. 6. Thomas NK. Resident burnout. JAMA. 2004;292(23):2880-9. 7. Goitein L, Shanafelt TD, Wipf JE, Slatore CG, Back AL. The effects of work-hour limitations on resident well-being, patient care, and education in an internal medicine residency program. Arch Intern Med. 2005;165(22):2601-6. 8. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114(6):513-9. 9. Gabbe SG, Melville J, Mandel L, Walker E. Burnout in chairs of obstetrics and gynecology: diagnosis, treatment, and prevention. Am J Obstet Gynecol. 2002;186(4):601-12. 10. Mirvis DM, Graney MJ, Ingram L, Tang J, Kilpatrick AO. Burnout and psychological stress among deans of colleges of medicine: a national study. J Health Hum Serv Adm. 2006;29(1):4-25. 11. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289(23):3161-6. 12. Linzer M, Visser MR, Oort FJ, Smets EM, McMurray JE, de Haes HC. Society of General Internal Medicine Career Satisfaction Study Group. Predicting and preventing physician burnout: results from the United States and the Netherlands. Am J Med. 2001;111(2):170-5. 13. Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc. 2005;80(12):1613-22. 14. Daugherty SR, Baldwin DC Jr, Rowley BD. Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions. JAMA. 1998;279(15):1194-9. 15. Caldicott CV, Faber-Langendoen K. Deception, discrimination, and fear of reprisal: lessons in ethics from third-year medical students. Acad Med. 2005;80(9): 866-73. 16. Ginsburg S, Hachan N, Lingard L. Before the white coat: perceptions of professional lapses in the pre-clerkship. Med Educ. 2005;39(1):12-9. 17. Shanafelt TD, West C, Zhao X, Novotny P, Kolars J, Habermann T, Sloan J. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005;20(7):559-64. 18. Thomas MR, Dyrbye LN, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, Shanafelt TD. How do distress and wellbeing relate to medical student empathy? A multicenter study. J Gen Intern Med. 2007;22(2):177-83. 19. Firth-Cozens J, Greenhalgh J. Doctors perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997;44(7):1017-22. 20. Haas JS, Cook EF, Puopolo AL, Busrtin HR, Cleary PD, Brennan TA. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15(2):122-8. 21. Baldwin PJ, Dodd M, Wrate RW. Young doctors health I. How do working conditions affect attitudes, health and performance? Soc Sci Med. 1997;45(1):35-40. 22. Epstein RM. Mindful practice. JAMA. 1999;282(9):833-9. 23. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278(6):502-9. 24. Yamey G, Wilkes M. Promoting well-being among doctors. BMJ. 2001;322(7281):252-3. 25. Spilker B. Quality of life and pharmacoeconomics in clinical trials. New York: Lippincott-Raven, 1996. 26. Wear D, Castellani B. The development of professionalism: curriculum matters. Acad Med. 2000;75(6):602-11. 27. Stephenson A, Higgs, R, Sugarman J. Teaching professional development in medical schools. Lancet. 2001;357(9259):867-70. 28. Gordon J. Fostering students personal and professional development in medicine: a new framework for PPD. Med Educ. 2003;37(4):341-9. 29. Joint Commission on Accreditation of Healthcare Organizations. Medical Staff Standards. MS.4.80. In: Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, Il: Joint Commission Resources, 2005.

Dyrbye LN, Massie FS Jr, Eacker A, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA. 2010;304:11731180.
Results: Of the students who responded to all the MBI items, 1354 of 2566 (52.8%) had burnout. Cheating/dishonest academic behaviors were rare (endorsed by <10%) in comparison to unprofessional conduct related to patient care (endorsed by up to 43%). Only 14% (362/2531) of students had opinions on relationships with industry consistent with guidelines for 6 scenarios. Students with burnout were more likely to report engaging in 1 or more unprofessional behaviors than those without burnout (35.0% vs 21.9%; odds ratio [OR], 1.89; 95% confidence interval [CI], 1.59-2.24). Students with burnout were also less likely to report holding altruistic views regarding physicians' responsibility to society. For example, students with burnout were less likely to want to provide care for the medically underserved than those without burnout (79.3% vs 85.0%; OR, 0.68; 95% CI, 0.55-0.83). After multivariable analysis adjusting for personal and professional characteristics, burnout was the only aspect of distress independently associated with reporting 1

or more unprofessional behaviors (OR, 1.76; 95% CI, 1.45-2.13) or holding at least 1 less altruistic view regarding physicians' responsibility to society (OR, 1.65; 95% CI, 1.35-2.01). CONCLUSION: Burnout was associated with self-reported unprofessional conduct and less altruistic professional values among medical students at 7 US schools.

Mareiniss DP. Decreasing GME training stress to foster residents professionalism. Acad Med. 2004; 79:825-831.
Abstract
The author evaluates current concerns over medical professionalism in residency training. The recent professionalism requirements for residents promulgated by the Accreditation Council for Graduate Medical Education (ACGME) are discussed in relation to the atmosphere of current training. The author first reviews a recent study showing that unprofessional behavior may significantly correlate with burnout, as evaluated by the Maslach Burnout Inventory. Among the elements of that inventory, depersonalization is shown to significantly correspond to unprofessional actions and behavior. Several surveys and studies evaluating residency treatment and stress are reviewed and three sources of training stress are identified: (1) abusive treatment of residents, (2) financial pressures, and (3) pessimism and uncertainty in the medical field. The extent and effects of these stressors are discussed and evaluated in relation to depersonalization, depression, and unprofessional behavior. Each of these pressures is found to correlate with negative effects on residents, such as depersonalization, decreased satisfaction, depression, and burnout. In turn, such effects are found to potentially cause unprofessional behavior among residents. In light of these findings, the author suggests several modifications to the current graduate medical training environment to mitigate such stressors, promoteprofessionalism, and increase morale. Prevention of abusive treatment of residents, alleviation of financial pressure, increased educational opportunities, and role modeling are suggested as beneficial interventions that may foster professionalism and prevent inappropriate behavior. The author indicates that such environmental changes would likely foster professionalism in young physicians more effectively than would ethics seminars or in-class training. Accordingly, the author suggests environmental changes to decrease residency stress as the most effective means of promoting the new ACGME requirements and the ideals ofprofessionalism.

West CP et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med 2014;
RESULTS Empowerment and engagement at work increased by 5.3 points in the intervention arm vs a 0.5-point decline in the control arm by 3 months after the study (P=.04), an improvement sustained at 12 months (+5.5 vs +1.3 points; P=.03). Rates of high depersonalization at 3 months had decreased by 15.5% in the intervention arm vs a 0.8% increase in the control arm (P=.004). This difference was also sustained at 12 months (9.6% vs 1.5% decrease; P=.02). No statistically significant differences in stress, symptoms of depression, overall quality of life, or job satisfaction were seen. In additional comparisons including the nontrial physician cohort, the proportion of participants strongly agreeing that their work was meaningful increased 6.3% in the study intervention arm but decreased 6.3% in the study control arm and 13.4% in the nonstudy cohort (P=.04). Rates of depersonalization, emotional

exhaustion, and overall burnout decreased substantially in the trial intervention arm, decreased slightly in the trial control arm, and increased in the nontrial cohort (P=.03, .007, and .002 for each outcome, respectively). CONCLUSIONS AND RELEVANCE An intervention for physicians based on a facilitated small-group curriculum improved meaning and engagement in work and reduced depersonalization, with sustained results at 12 months after the study.

Dyrbe LN, Harper W, Moutier C, Durning SJ, Power DV, et al. (2012) Multiinstitutional study exploring impact of positive mental health on medical student professionalism in era of high burnout. Acad Med 87: 10241031.
Results: A total of 2,682/4,400 (61%) responded. Prevalence of suicidal ideation (55/114 [48.2%], 281/1,128 [24.9%], and 127/1,409 [9.1%]) and serious thoughts of dropping out (15/114 [13.2%], 30/1,128 [2.7%], and 14/1,409 [1.0%]) decreased asmental health improved from languishing, moderate, and flourishing, respectively (all P < .0001); this relationship between personal experience and mental health persisted independent of burnout (all P < .001). As mental health improved, the prevalence of unprofessional behaviors (i.e., cheating and dishonest behaviors) also declined, whereas students' altruistic beliefs regarding physicians' responsibility toward society improved. For example, 33/113 (29.2%), 426/1,120 (38.0%), and 718/1,391 (51.6%) ofstudents with languishing, moderate, and flourishing mental health endorsed all five altruistic professional beliefs (P < .0001). The relationship between professional beliefs and mental health persisted among students with burnout, whereas fewer relationships were found among students without burnout. CONCLUSIONS: Findings suggest that positive mental health attenuates some adverse consequences of burnout. Medical studentwellness programs should aspire to prevent burnout and promote mental health.

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