Pub Date: Monday, Sep 19, 2022
Author: Ersilia M. DeFilippis, MD
Affiliation: Columbia University Irving Medical Center
In light of the COVID-19 pandemic, our community of healthcare professionals and larger health care ecosystem have been challenged in innumerable ways. Even before March of 2020, many had described a “burnout crisis” or “exhaustion epidemic” in academic medicine, that has only been accelerated by staff shortages and limited resources. Additionally, our medical education structures, care delivery, and other processes within health care have been transformed as we increasingly relied on remote learning and telemedicine. In studies of healthcare workers (HCW) in New York City, an early epicenter of the COVID-19 pandemic, 73% reported insomnia, 34% reported depressive symptoms, and 48% reported symptoms of anxiety.1 Therefore, this scientific statement on physician wellness in academic cardiovascular medicine is particularly salient.
More than one-fourth of cardiologists, including trainees, have been affected by burnout.2,3 Burnout encompasses emotional exhaustion, depersonalization and dissatisfaction with personal accomplishments which stem from excessive stress in the workplace. Burnout has significant implications for physicians themselves, inciting substance use, depression, and suicide, but also for our patients and health care system. These penalties include medical errors, lower quality patient care, decreased productivity and increasing healthcare system costs. Women and mid-career physicians are often disproportionally impacted. These are the same groups who have been shown in surveys to report higher rates of hostile work environments with sexual harassment, discrimination, and emotional harassment.4
The statement importantly focuses on unique aspects that affect fellows-in-training (FIT) and early career physicians. Exhaustion and stress may be compounded by high clinical demand, inflexible schedules for key life events including parental leave and family care, as well as substantial educational debt. A recent analysis by Dr. Martha Gulati and colleagues in the Journal of the American College of Cardiology highlighted that 37% of women cardiologists surveyed required extra service or call before maternal leave and 41% experienced a salary decrease during maternity leave, likely in violation of legal statutes.5 We also know from work led by Dr. Pamela Douglas that female internal medicine residents were more likely to value stable hours, family friendliness, female friendliness, and positive role models. Female residents were more likely than male residents to associate cardiology with adverse job conditions, interference with family life, and a lack of diversity.6 Therefore, in order to continue to attract medical students and medical residents into the field of cardiology, we must understand the perceived and real challenges that affect their decision-making as well as their emotional, physical, and psychological well-being.
There are various roles one may occupy within the academic health system including as the clinical academic physician, clinician-educator, and physician-scientist; each with a specific set of perceived and real barriers to career satisfaction and personal well-being. For example, the academic cardiovascular physician may be burdened by productivity-driven models, prior authorizations, and difficulty with reimbursement policies, as well as promotion systems that do not consider clinical as well as academic expectations. Meanwhile, the physician educator may lack protected time and fiscal support for curriculum development and participating in direct instruction. Lastly, the physician-scientist must operate within a challenging research infrastructure whereby securing funding is increasingly competitive, particularly for women and underrepresented minorities.
So how can we minimize burnout and foster a culture of wellness?
The authors provide practical tips that can be executed at the individual level to improve one’s work environment. Efficiency in the workplace can be created by limiting meetings, negotiating protected time, and completing tasks based on priority and importance. Clinicians may try increased use of telemedicine to enhance flexible work environments or negotiate for a scribe during their hiring processes. In addition, fellows-in-training and early career professionals should find their own healthy strategies to manage stress, build relationships outside of work, and maintain healthy nutrition and exercise schedules.
Clinicians, educators, and researchers must also recognize when an environment is “toxic” and is not conducive to achieving his or her goals. Furthermore, symptoms of burnout, anxiety or depression must be diagnosed and access to mental health services should be provided without stigma.
Still, there is increasing recognition that there need to be changes at the systemic and institutional level in order to improve physician well-being. As the authors write, “many [drivers] are external and beyond the control of a single individual.” Ancillary and administrative support systems should aim to relieve burden of academic clinician dealing with paperwork and reimbursement policies. This also extends to redesigning inefficient workflows and promoting teamwork. Larger systematic changes include dedicated department and divisional budgets to support educators, equitable compensation structures, support for early career physicians with respect to mentor identification, promotion coaching and faculty development. Together these changes can help team members find value and purpose.
Bradley EA, Winchester D, Alfonso CE, Carpenter AJ, Cohen MS, Coleman DM, Jacob M, Jneid H, Leal MA, Mahmoud Z, Mehta LS, Sivaram CA; on behalf of the American Heart Association Fellows in Training and Early Career Committee of the Council on Clinical Cardiology; Council on Cardiovascular Surgery and Anesthesia; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and Stroke Council. Physician wellness in academic cardiovascular medicine: a scientific statement from the American Heart Association [published online ahead of print September 19, 2022]. Circulation. doi: 10.1161/CIR.0000000000001093
- Diaz F, Cornelius T, Bramley S, Venner H, Shaw K, Dong M, Pham P, McMurry CL, Cannone DE, Sullivan AM, Lee SAJ, Schwartz JE, Shechter A, Abdalla M. The association between sleep and psychological distress among New York City healthcare workers during the COVID-19 pandemic. J Affect Disord. 2022;298:618–624.
- Mehta LS, Elkind MSV, Achenbach S, Pinto FJ, Poppas A. Clinician Well-Being: Addressing Global Needs for Improvements in the Health Care Field A Joint Opinion From the American College of Cardiology, American Heart Association, European Society of Cardiology, and the World Heart Federation. J Am Coll Cardiol. 2021;78:752–756.
- Mehta LS, Lewis SJ, Duvernoy CS, Rzeszut AK, Walsh MN, Harrington RA, Poppas A, Linzer M, Binkley PF, Douglas PS, American College of Cardiology Women in Cardiology Leadership Council. Burnout and Career Satisfaction Among U.S. Cardiologists. J Am Coll Cardiol. 2019;73:3345–3348.
- Sharma G, Douglas PS, Hayes SN, Mehran R, Rzeszut A, Harrington RA, Poppas A, Walsh MN, Singh T, Parekh R, Blumenthal RS, Mehta LS. Global Prevalence and Impact of Hostility, Discrimination, and Harassment in the Cardiology Workplace. J Am Coll Cardiol. 2021;77:2398–2409.
- Gulati M, Korn RM, Wood MJ, Sarma A, Douglas PS, Singh T, Merz NB, Lee J, Mehran R, Andrews OA, Williams JC. Childbearing Among Women Cardiologists: The Interface of Experience, Impact, and the Law. J Am Coll Cardiol. 2022;79:1076–1087.
- Douglas PS, Rzeszut AK, Bairey Merz CN, Duvernoy CS, Lewis SJ, Walsh MN, Gillam L, for the American College of Cardiology Task Force on Diversity and Inclusion and American College of Cardiology Women in Cardiology Council. Career Preferences and Perceptions of Cardiology Among US Internal Medicine Trainees: Factors Influencing Cardiology Career Choice. JAMA Cardiology [Internet]. 2018 [cited 2018 Jul 22];Available from:http://cardiology.jamanetwork.com/article.aspx?doi=10.1001/jamacardio.2018.1279
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-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --