Leading the Department of Medicine is a privilege. There is the pride in seeing the accomplishments of our faculty, excitement in building new Divisions and launching new graduate training programs and a sense of future-building inspired by the training of talented young physicians. Above all I have the sense of being engaged in a dynamic and passionate team dedicated to achieving positive goals: preventing disease and healing people, teaching medical students and residents, and performing research that will improve the future. However, medicine is not an easy profession. Hospitals are crowded and busy. The doctoring part of the profession often seems to be the easiest part that’s only a matter of life or death! The hard part is often dealing with the resource constrained health care system, the physical and emotional demands of the job and the multitude of time-sensitive demands in our day with good humour, patience and calm -i.e.professionalism. The modern physician is not only busy with patient care, education and research; rather they are doing these things while being deluged with diverse demands. These stressors range from mastering electronic health records, dealing with privacy legislation, implementing new forms of medical education and the list goes on. The mounting demands on the attention of doctors, and the intrinsically demanding nature of Medicine, may cause stress or burnout. As Department Head I am concerned about physician wellness, both for the sake the physician and their families and because when wellness declines professionalism is often compromised and patient care suffers. It’s hard to care for dozens of patients each day if one is fatigued, unwell, particularly if one is ill or lacks a support system at home. Thus, the old adage, Physician heal thyself! Physician wellness and professionalism are like Janus, the two faced Roman God who looks both to the past and the future, presides over war and peace or, for the purposes of this blog, is either engaged in practices that promote physician wellness or spirals into behaviors that promote stress and burnout and compromise professionalism and quality care.
I am committed to promoting physician wellness both through treading lightly, knowing and supporting the faculty, and by promoting programs to enhance physician wellness and supporting physicians in distress. This guest blog was inspired when my friend and colleague Dr. Joneja and I were discussing ways the DOM team could foster a culture that promotes physician wellness. She reminded me that we should not forget to include consideration of the wellness of our residents and learners in these deliberations. These are our junior colleagues, equally as important and equally exposed to stressors (albeit some different variants) as our faculty members. An ardent advocate for health, work-life balance, and wellness for our physicians, Dr. Joneja took the opportunity to show me a draft of a poster series focused on professionalism from the perspective of CanMEDS. Seeing the words of our residents emblazoned on paper provided a powerful lens to the resident perspective of the CanMEDS Professionalism assessment. The realization that these were the words from our own resident reflections filled me with a sense of pride and optimism for the future. These posters are a graphic reminder that our residents understand and embrace the multiple nuances of a life in medicine, and have a sense of how to proactively work together to maintain their wellness and professionalism. Thanks to the work of faculty members who teach our residents in auditoriums, classrooms, hallways, and by the bedside, the message of professionalism in medicine is being driven home. The posters highlight the reception of this message and take it to the next level for all to see. Looking at the posters the words “empathy”, “self-care”, and “professionalism” stand out and serve as a reminder that we all need to focus on “Feeling another person’s struggle”. Be it a patient, a resident, an attending, or an administrative support colleague, empathy in medicine and connecting with others is imperative to a successful life and career. As we took a moment to reflect on our own approach to professionalism, Dr. Joneja explained to me, that during her review of resident self-assessments, she was impressed by the power and calibre of the content with regard to professionalism and decided to launch this poster series to share her observations. Read on for more about the poster project launched by Dr. Joneja who has authored the blog below with her resident colleagues.
During my tenure with the Department of Medicine I have had the pleasure of being involved in postgraduate medical education including the training and assessment of the Core Internal Medicine residents. During this time, I have approached the training of our residents with the full realization of the weight of residency that they carry on their shoulders. This period of time includes both professional and personal development and is filled with a tremendous amount of learning, hard work and stress. They are continually pushed in their quest for knowledge and skills, and continually assessed at each step of their education. The current framework for residency training is the CanMEDS framework which is used for both teaching and assessment. CanMEDS was adopted by the Royal College of Physicians and Surgeons of Canada (RCPSC) in 1996 and is used as an educational standard incorporated into accreditation, evaluation and examinations of residents. CanMEDS includes seven roles in which residents are assessed to ensure that they graduate residency as a competent physician in their field. While my poster series is focused on the role of professional, the seven CanMEDS roles are:
- Medical Expert
- Health Advocate
During residency, the core internal medicine residents are asked to reflect on each of the CanMEDS roles. Part of my role is to review their reflections and provide feedback. During the years that I have reviewed these reflections, I am continually awed at the level of insight and knowledge that the residents show. Specifically, I have been impressed by the high-quality reflections around the CanMEDS role of professional, and how the residents have described working their knowledge of professionalism into their day-to-day work in the teaching hospital. With the feeling that this must be showcased, I decided to create a poster series based on the residents reflections for others to view. Each poster provides a word cloud of themes that were present in many of the professionalism reflections as written by our residents. My colleagues across the Department of Medicine, and Queen’s University at large, try to model professionalism daily in their interactions with colleagues, patients and learners. To further drive home the importance of this aspect of residency education it is talked about and highlighted continually. I have seen that many senior residents are already excellent role models in professionalism for junior residents. As part of this project we asked the Chief Residents to review the poster series and each write a report from their perspective on the individual CanMEDS Professionalism Role they were assigned. Hearing the resident perspective around learning is important to our faculty members and provides a reminder as to the challenges of residency training. For our community partners, administrators, and patients, the resident perspective is a reminder that our young physicians are learning about more than the medical expert role. They are in fact learning how to become a well-rounded physician who can provide excellent care for the patient population whilst also taking care of themselves. A focus on self-care is an important aspect of the CanMEDS professionalism role, especially in the current era of attention being given to physician health. The posters and the blog contributions remind us that residents are human just like the patients they look after, and just like the faculty they learn from. The goal of the Department of Medicine, in approaching residency training, is to teach the next wave of physicians how to care for others, whilst also caring for themselves. Let’s hear our Chief residents’ perspectives on how to be well, survive and thrive in residency, and thus how to generate resilient professionalism.
Residency can be at once an incredibly rewarding and incredibly challenging experience. Many of us will not be strangers to the challenges encountered: long hours, the stress of making important patient care decisions in the middle of the night (whether on our first call shifts or later on in training), the emotional upheavals from poor patient outcomes, from difficult conversations with patients or their families or from making mistakes. These are a handful of the difficulties residents face on a day-to-day and week-to-week basis. Additionally, we are trying to establish work-life balance, maintain healthy relationships and practice self-care, all goals that can at times feel like moving targets. Simultaneously however, residency can be one of the most rewarding periods of our career. The joy of getting an elusive diagnosis correct, of treating patients and seeing dramatic improvements in quality of life, and of learning to trust our own clinical judgmentas we gain knowledge and experience are all amongst the thrilling expects of training that residents get to experience. Navigating these valleys of challenges and victories would not be possible without the mentors who guide us through our learning process and certainly not without our peers who are learning alongside us. Remembering that we are not alone and that our attending staff are looking out for us and happy to teach us are ways that we, as residents, can get through residency successfully. Don’t be afraid to ask for help and, by the same token, don’t hesitate to offer help if a colleague appears to be struggling. This is a unique period in our careers when we are part of a close-knit community of practice and that is our key to success. Looking back, I certainly could not have come through the last three years without the incredible attendings who’ve taught me or the phenomenal nurses, respiratory therapists and other health professionals who’ve been with me at a sick patient’s bedside in the middle of the night. But most of all, I’ve relied on my colleagues who’ve taught me, listened to me when I’ve had a difficult day, motivated me to study on a weekend off, supported me when something didn’t go as predicted or rejoiced with me when things went better than expected. I’m confident in the training I’ve received and the clinical knowledge I’ve gained, but I’m truly grateful for the people I’ve had the opportunity to share this experience with.
Medical professionalism is difficult to define succinctly. In their description of the CanMEDS “professional” role, the Royal College calls professionalism “the basis of the implicit contract between society and the medical profession.” Put another way, professionalism is everything we do as physicians to deserve the incredible trust our patients put in us every single day. It is often said that part of what makes clerkship and residency so stressful is the lack of control medical learners have over their lives. This is true. But this is not to say that clerks and residents do not have choices. My day is made up of choices. Do I sleep in an extra 10 minutes, or do I get up now and make sure that I’m on time for rounds? Do I speak sharply to my nursing colleague who hasn’t carried out an order the way I wanted, or do I engage them respectfully to figure out why? Do I rush through my admission orders because, after all, my senior or staff is going to look over them and catch my mistakes, or do I make the effort to get everything right the first time? Consistently making the choice that is best for my patient is what makes me a professional. It is not always easy, and I admit that there have been times when I have been tired and drained and have not made the choice I would have made under other circumstances. There is such a thing as giving too much of yourself to the job, and part of being a professional resident is recognizing when you have reached your limit and need to recharge. This allows you to come back with the resources and determination to do it right the next time. As residents advance through our training and take on more and more responsibility, our actions are scrutinized less closely. As we move up in the hierarchy, there are fewer people who are likely to call out lapses in professionalism. Each resident therefore owes it to themselves and to their patients to ask, “What choices am I going to make today?”
Dr. Marie Leung
The Royal College has determined the promotion of self-care to be a skill that must be developed: (1) in building self-awareness, including managing influences on one’s personal well-being and professional performance, and (2) promotion of a culture that recognizes and supports colleagues in crisis. In the most primitive sense, we know that self-care encompasses taking time to eat healthy, exercise, get enough sleep, and spend time with family & friends. The challenge of encompassing self-care into our day-to-day lives is that implicitly, there exists mental incongruity between how we perceive taking time for care for oneself to be taking away time from care of the patient. In developing our professional identity, we wear a badge of honour for the sacrifices that we make, the hours we put in and the work we accomplish. We talk about pulling through sleepless nights as if it were a heroic feat. The challenge with truly actualizing self-care is that it must stem from our ideology: that self-care is as important a part of our professional identity as our care of our patients. Self-care is currently viewed as a bottom-up approach in meeting our physiological needs first - such as adequate sleep, healthy foods, and exercise. We must in turn view self-care from a top-down approach - we must first actualize that self-care is in truth, caring about everyone - leveling the playing field that our care of ourselves is on par with care for others. Just as we practice kindness and compassion to our colleagues, our families, and our patients, we must so be kind and compassionate to ourselves.
Caring for patients as an internal medicine resident requires me to do a lot of problem solving. Seeing patients, making diagnoses and initiating management plans are standard practices to a resident. To a patient, these diagnoses, treatments and procedures may be life changing. Our job entails more than simply putting pieces of the puzzle together to come to the correct diagnosis and develop the optimal management plan. It also requires a connection with another human being and developing a rapport. This connection requires me to understand their point of view and try to understand how they feel; in other words, to have empathy for their situation. The Royal College states that physicians should be able to "communicate using a patient-centred approach that encourages patient trust and autonomy and is characterized by empathy, respect, and compassion." It has been shown that empathy enhances patient satisfaction, comfort and trust. When trust is obtained, they are more likely to provide information that can lead to diagnosis and be compliant with treatments. The benefit goes both ways as empathetic doctors experience greater job satisfaction and psychological well-being. Understanding the importance of the development of empathy and strong communication skills in medical training is crucial. Can empathy be taught? As we advance more through our training there is less direct supervision. Should it be assessed more in residency? How do we assess it? For me, connecting with another person, feeling their struggle and working to improve their situation, while working with colleagues with the same goal provides immense satisfaction and is the reason I go to work.
I would like to express my thanks to Dr. Joneja, and her colleagues Drs. Chris Smith, former Core Program Director, David Taylor current Core Program Director and Barry Chan, Associate Program Director, for focusing on creating a culture where the well-being of residents is held to be important and is seen as a condition which must be achieved to ensure that professionalism flourishes and that stress and burnout are minimized (and dealt with when they emerge).
While these leaders are crucial to our training program’s success (recent 100% match on the first iteration of the CARMS match and full accreditation for 8 years), the culture is built by the residents themselves and our entire faculty. Years of investment in our training program has culminated in these and other accolades, including recognition of the Core Internal Medicine Training Program as a national leader in resident training by receipt of the 2018 PARO Award. This award is given for outstanding achievements in medical education and is a testament to the hard work and dedication of our Core Internal Medicine Team. A final thank you to the residents in the Core Internal Medicine Program and their administrative team: Claudia and Genevieve who are part of the village that cares for our residents.
The training to become a physician is an intense but rewarding journey, and one that our residents are well on their way to mastering. The future looks bright for the Department of Medicine and our patients as our trainees develop ways of coping and creating a culture of resiliency that will optimize their wellness and promote professionalism. This attention to self-care and support of one another will help them have career satisfaction and ensure they provide the best care to all patients.