Psychotherapist Perspectives on Resident Wellness Open Access

The academic community must prioritize resident wellness in order to minimize resident suffering and ensure that patient care is not compromised by the adverse effects of stress. A psychotherapy-informed approach to wellness, with a focus on residents' complex emotional lives within a medical community, offers a more comprehensive and nuanced approach compared with concrete program interventions. The following are 5 reflections on the ways in which training, health care systems, and wellness programs can affect resident well-being.

First, we consider that most physicians succeed by striving for excellence. This requires an obsessive mindset that promotes organization and focus, with a degree of healthy narcissism that maintains confidence and drive. When residents struggle, they suffer a narcissistic injury that calls their self-worth into question. These struggling residents may interpret a task-based approach to addressing wellness issues as yet another expectation that they must meet, with pressure to “be well” in response to their already diminished well-being. This can result in a paradoxical worsening of perceived well-being.

Second, we need to acknowledge that even the concept of “work-life balance” can be inherently problematic. The idea that work is depleting, while “life” outside of work is the only source of nourishment, can minimize the potential for fulfillment in the work environment.⁴  It is important that physician colleagues take the time to process both the rewarding and distressing aspects of the physician-patient relationship. These connections are the foundation for building professional identity, community, and purpose in their work. Cruess and colleagues⁵  advocated for a focus in medical education on the development of a professional identity that guides medical students to “think, act, and feel like…the good physician.” This emphasis on building a professional sense of self can also enhance the meaning in our work and the feeling of belonging in the health care community.

Third, we need to remember that wellness interventions must also address issues in the learning environment.⁶  For example, the hierarchical structure of medical training can contribute to a sense of inferiority and poor self-worth in residents. This hierarchy creeps into everyday courtesy and civility, further amplifying this perception of “less-than” status. Inui⁷  suggested that behavior modeled by faculty and residents in the clinical setting “constitutes the most powerful influence on students' understanding of professionalism in medicine.” Billings et al⁸  described the “hidden curriculum” of often-unintended cynicism and unprofessional conduct that can exacerbate resident burnout. Furthermore, Maslach and Leiter⁹  suggested that civility and attention to the social dynamics of health care teams can decrease physician burnout. When supervisors demonstrate a lack of respect for residents or patients, they reinforce the sense of insecurity that plagues struggling residents. Even subtle microaggressions, such as belittling comments or jokes, can be psychologically stifling and distracting, contributing to a sense of defeat and despair.

Fourth, we need to recognize the likely contributing role of the electronic health record (EHR). Many wellness experts argue that the EHR places more demands on physicians, because its availability offsite increases the time spent documenting at home. This detracts from personal time. In addition, we should recognize that the EHR is an extension of our overall reliance on technology. As we connect more with technological devices, connection with each other and our patients recedes. As psychotherapists know well, emotional closeness can feel frightening and risky. The physician-patient relationship amplifies these emotions when a patient is relying on his or her physician for medical treatment and emotional support. Young physicians may avoid the intimacy of such intense interactions by using the EHR as an acceptable venue behind which to distance themselves from a patient's vulnerability. As psychotherapists, we recognize the natural pull to avoid emotional closeness. However, we also understand the incredible power of connection as a basic human need. If residents were to emerge from behind the computer screen and be fully present, it would benefit patients while also cultivating their own calling to connect and care for others. As a result, they would feel more fulfilled, and ultimately more “well.”

Finally, we need to consider that even wellness programs can create barriers to professional connection. Implementing a didactic-based approach, rather than talking openly about the experience of training, oversimplifies suffering and misses opportunities to support each resident in his or her individual struggles. These well-intentioned efforts to improve wellness may paradoxically intensify the problems they intend to address.

We begin with basic civility. This includes respecting residents' time and contributions, expressing gratitude for their hard work, and avoiding subtle messages that seem to belittle their worth. We also acknowledge the inevitable stress that comes with medical training, and we support residents when they struggle.

We recognize the reality that residents, like all physicians, cannot actually “have it all,” thereby releasing them from an impossible expectation. None among us can simultaneously excel in residency; exercise regularly; practice mindfulness; be the perfect partner, parent, and friend; maintain hobbies; see a therapist; and travel the world. The pressure to do all these things adds additional stress to an already strained psyche.

There is ample opportunity to model compassion and empathy when we connect with struggling residents. In a psychotherapy session, the goals are to help patients feel understood, share their emotional load, and provide a safe space for self-reflection. As mentors, we can do something similar with residents by inviting them to share their professional experiences with us and with each other. We can empathize with their difficulties, validate their struggles, and reassure them that they are not alone. We can remind them that suppressing distressing feelings often makes things worse, and that those overwhelming emotions may even emerge in patient encounters. For residents who feel isolated and ashamed, the act of processing in a safe space with a trusted mentor can be therapeutic, ultimately improving their sense of well-being and enabling them to provide the best care for their patients.

Mindfulness may be helpful in improving resilience.¹⁰  Mindfulness can be taught in a personalized nondidactic setting by helping residents to be present in the moment, be aware of their emotions, and self-reflect. Such an approach is difficult to measure because it is not one-size-fits-all, but that also makes it more meaningful to residents and helps them to feel seen, understood, and cared for by their teachers.

Because of the many factors that affect resident well-being, simplistic wellness programs may neglect or even compound the problems they seek to address. Utilizing a psychotherapist's perspective, we understand that the day-to-day encounters between residents and faculty can provide a fruitful venue for teaching and modeling emotional connection and mindfulness within the work environment. This contact helps residents feel that they belong to the medical community, encourages the emotional closeness that comes with a physician's work, and provides an empathic space to process the struggles that we all endure in medical training. It can foster resilience in the face of adversity and an overall sense of well-being within a supportive professional family.