Resilience training for healthcare providers: an Asian perspective

Introduction

The level of burnout has been found to be high in medical students, alongside maladaptive coping behaviours such as heightened alcohol and drug intake and mental health issues (1-3). Most recently, a systematic review showed that at least half of all medical students in the US are affected by burnout during their medical education, and that burnout may persist beyond medical school, potentially causing psychiatric disorders (3). Dyrbye and Shanafelt (4) also stated that: “We must help students to recognize that caring for oneself is an essential part of being a doctor” (p. 344). Interventions have been designed to help medical students acquire resilience (5-7). Howe et al. (8) called for an understanding of resilience and its relevance to medical training. While burnout and resilience in medicine have been extensively researched in western culture, there is a paucity of data in Asia pertaining to these factors. In this article, we review stressors in medicine, specifically during medical school training, the consequences of burnout on physicians’ health and patient care, and the interventions that might expound resilience among students. Finally, we review potential solutions within an Asian context.

Stressors

Work-related stressors abound within the medical profession, such as excessive workload, fatigue, difficult relationships with peers and supervisors, and organisational issues within increasingly complex healthcare systems (1,2,7,9). In a medical school setting, sleep loss and physical exhaustion have implications on the cognitive abilities, empathy, and physical and mental health of students (6,7). Studies have shown that personality traits, coping skills, gender and culture contribute to stress perception and responses (2,10). Furthermore, specific personality traits have been shown to be related to stress vulnerability in medical students (11).

Students’ stress can be compounded by latent values disseminated during training and by the stigma associated with revealing coping problems (5,7,12). Paradoxically, specific aspects of the medical profession induce maladaptive outcomes such as ignoring one’s emotions, concealing a lack of understanding, and denying the need for help (13). This is particularly salient within certain specialties, such as surgery. Surgical students are greatly influenced by the way in which senior members respond to errors (13), and adopt the values openly endorsed by senior doctors (14).

The inculcation of socialisation and values occurring within medical school is a powerful force that shapes the attitudes and beliefs of future physicians regarding professional behaviours (15). Professionalism is developed through observations of senior doctors and role modelling. Students are conflicted between patient-centred empathetic care and tacit expectations of self-denial. Banja (16) observed that “the contribution of these kinds of events to a nascent narcissism consists in how they present a schizoid message to physicians who are told to be empathetic, caring, and available, and yet are made to work incredibly gruelling hours and tolerate emotional anguish that exists in no other profession” (p. 65).

Currently, the acquisition of resilience is left to physicians themselves, with no systematic training in coping strategies offered at institutional levels. Students should be taught ways of acquiring and maintaining resilience via evidenced-based training. Information about the potential physiological and psychological manifestations of stress, maladaptive coping and burnout on health should be integrated within curricula.

Consequences of burnout on physicians’ health and patient care

Considerable research exists on the health consequences of chronic stress. Stress responses are influenced by a variety of genetic and epigenetic factors in a complex chain of reactance (17). The cumulative effects of chronic activation of stress responses have been researched within the field of neural science. The hippocampus is particularly exposed to the dysregulation of glucocorticoid production (excess and hypo-production), potentially contributing to hippocampal atrophy and long-term deficits in memory and cognition (18). These physiological changes have been associated with a deterioration in immune function, obesity, metabolic syndrome, hypertension, cardiovascular disease and chronic inflammation (17,19-21).

Sleep regulation is another system that is highly susceptible to chronic stress exposure. Research has shown a relationship between sleep reduction, obesity and increased body mass index (19,22). Chronic sleep disruption and circadian dysregulation—both common in the practice of medicine—have been shown to be related to oxidative stress and cancers, heart disease, diabetes, ageing and neurodegenerative diseases (23). Several studies have reported sleep disturbances, insomnia and poor sleep quality in their burnout medical professionals (23,24).

The relationship between physicians’ stress and performance is important because of its association with quality of care, safety and work satisfaction. Physicians’ burnout has been found to correlate with increased incidences of medical errors (2,25), medical malpractice suits (26), diminished levels of patient compliance (16) and reduced patient satisfaction (27). Chronic stress and burnout also affect the level of empathy expressed by physicians. Compassion fatigue and chronic stress can contribute to suboptimal patient care (28).

The cultivation of resilience in Asia

Examining coping skills and resiliency through cultural specificities is significant because the appraisal of stressors and engagement in coping strategies is influenced by cultural factors (7,29). Chun et al. (29) remarked that “physician stress research needs to increase its attention to the influence of culture on stress and coping experiences” (p. 589). Slavin et al. (30) noted that “some behaviors that are normative within one cultural group may be perceived as pathological in another” (p. 160). Studies relating to the cultivation of resilience have been culturally circumscribed, predominantly, to western countries. Recently, studies have investigated physicians’ stress in Asian countries (31-33). A review of these studies showed the importance of internal factors such as personality traits (34,35), appraisal and coping strategies or coping styles, gender and culture in the cultivation of resilience (36-39).

Kirkbride et al. (40) observed that: “The traditional Chinese respect for age and status also has a bearing upon conflict situations (…) that awareness will affect the manner in which the situation will be handled. Relationships with older people and those of higher status will be more highly valued and there will be greater attempts to maintain guanxi and to protect face in such circumstance” (p. 370). According to Chun et al. (29), in Asia, the group forms the central unit of society, binding individuals to its needs, goals and fate. Yeh et al. (41) noted that: “Collectivist coping may include (…) family support, respect for authority figures, intracultural coping, relational universality, forbearance, social activity, and fatalism” (p. 59).

The support of medical schools in the promotion of health maintenance is central to the cultivation of coping strategies in students. Coherence between curriculum content and systematic support for the health of medical students is necessary for the future wellbeing of healthcare professionals (42). Robiner, Lazear and Duffy (43) noted that: “Medical students and health professionals should be encouraged, or even obliged, where medically, psychologically and socially appropriate, to develop and practice effective dietary and exercise regimens for a sufficient duration to attain basic competence” (p. 162). The authors concluded that: “Addressing health-related behaviors that are critical to health outcomes requires doctors and other professionals to help patients realize how to act in healthy ways more consistently. Preparing health professionals to do this would arguably be improved by encouraging them to engage in the healthy behaviors themselves, and to commit to sustained efforts (…) what better time and place is there to acquire sound health habits and demonstrate effective self-care than during the education and training of doctors and health professionals?” (p. 163). However, to promote healthy behaviours, medical schools should provide exercise facilities and healthy food options, which have been found lacking in some Asian countries (44).

Interventions

Improve job satisfaction

Job stress and job satisfaction are inversely related, with greater professional satisfaction representing a significant protective factor against the effects of job stress and emotional exhaustion (45). Organisational support reduces physical, psychological and behavioural reactions to stressors (46). Physicians’ satisfaction is associated not only with their health, but also with prescribing behaviour, patient adherence to medication, patient satisfaction, physician turnover, staff morale and overall quality of care (47,48). It is essential to consider the implications of job dissatisfaction on patient care (49). Job satisfaction is affected by poor health and lower standards of professionalism (50). Feelings of competency, skill use, levels of demands, control, work clarity, relations with colleagues and spill-over effects of work in one’s personal life all influence physicians’ satisfaction (10).

Physician dissatisfaction has raised healthcare expenditures worldwide (51). Relying exclusively on “the intrinsic motivation of physicians may be an obsolete and detrimental training and management strategy” (p. 364) (52), as a result, organisations should take action to maintain satisfaction in the providers. The global dearth of physicians coupled with significant levels of attrition and burnout represent considerable challenges for healthcare organisations and physicians.

Monitoring and maintaining physicians’ health is in the best interest of healthcare organisations in terms of litigation, quality of care, reduction of errors, and cost control (10). Shanafelt, Sloan and Habermann (25) stated that distress has been identified in the literature in almost “every group of physicians that has been studied from interns in training to department chairs” (p. 516). The literature has underscored the economic and ethical rationale for keeping doctors healthy (53,54). Spickard et al. (55) noted that healthcare organisations have an economic stake in the wellbeing of physicians. Workers who are satisfied tend to be more productive. Moreover, evidence exists that the wellbeing of physicians is related to patient satisfaction—a key outcome variable tracked by most healthcare organisations.

As stated by Shanafelt et al. (25), the responsibility to defend and actively promote the health of physicians and healthcare professionals also extends to medical schools: “Academic medical centers have an additional obligation to promote the wellbeing of physicians in training, and unique interventions may be needed. Medical educators underestimate distress in residents and curricula are needed that promote self-awareness and healthy approaches to balancing personal and professional life” (p. 517). Organisations can assist in the development of intervention programmes, policies and educational courses to improve work-related stress (22,56).

Support healthy behaviours

Exercise and physical fitness have been shown to be effective in maintaining and improving physiological and psychological health (26,57,58). Other researchers have underscored the cumulative benefits accrued by physical exercise through affect regulation (57,59). Physical fitness and regular exercise have been proven to increase resilience in extreme environments, promoting improved performance and inducing lasting neuro-protective effects (60). Physical fitness has also been shown to act to “blunt stress reactivity in response to both physical and psychological stressors” through the mediation of the hypothalamic-pituitary-adrenal (HPA) axis and the fight or flight response (60) (p. 25). Comprehensive Soldier Fitness (CSF), intended to improve the resilience of US Army service personnel, uses physical fitness as a regulator of cognitive and behavioural health (61). Other studies have also shown the physiological effects of physical fitness in reducing oxidative stress (62), cognitive decline and the ageing process (63). Huang et al. (57) noted consistent findings for associations between acute aerobic exercise and peripheral brain-derived neurotrophic factors (BDNF); BDNF concentrations are a crucial mediator of brain health (p. 2).

Integrate health issues into the Asian medical education curriculum

The support of medical schools in the promotion of health behaviour is central to cultivating coping strategies in students. Integrating health behaviour promotion into medical curriculum is necessary for students’ future wellbeing as healthcare professionals (42). Robiner, Lazear and Duffy (43) noted that: “Medical students and health professionals should be encouraged, or even obliged, where medically, psychologically and socially appropriate, to develop and practice effective dietary and exercise regimens for a sufficient duration to attain basic competence” (p. 162). Dyrbye et al. (4) noted that: “promoting and nurturing well-being during medical school and equipping graduates with the skills necessary to recognize personal distress, to determine when they need to seek assistance, and to develop strategies to promote their own well-being is essential to promoting professionalism and laying the foundation for resilience through the course of a career” (p. 1617). Research from Japan (64) and the West (65) highlighted the importance of curriculum-based health programmes.

Integrate digital micro-health management systems to enhance resilience

In the digital era, which defines our daily lives, medicine has, so far, only integrated technology at the levels of patients’ care, diagnostics and research. The significant potential represented by wearable devices and their numerous data aggregations and analytics have yet to be applied for the benefits of medical staff and students’ wellbeing. Topol, Steinhubl and Torkamani (66) noted: “sensors have already been used for activity tracking by more than 1 in 4 individuals” (p. 353). Simple digital platforms could help healthcare professionals and medical students manage their health and stress more actively, and with the right support contribute actively and simply to their enhanced resilience.

Conclusions

The health of medical students and physicians remains an afterthought, unless sub-optimal performance becomes salient. Physical and mental resilience must be fully integrated into curricula, otherwise medical education will contribute to, or augment, the attrition of the physicians it trains.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

References

1. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med 2014;89:443-51. [Crossref] [PubMed]
2. Firth-Cozens J, Greenhalgh J. Doctors' perceptions of the links between stress and lowered clinical care. Soc Sci Med 1997;44:1017-22. [Crossref] [PubMed]
3. Ishak W, Nikravesh R, Lederer S, et al. Burnout in medical students: a systematic review. Clin Teach 2013;10:242-5. [Crossref] [PubMed]
4. Dyrbye LN, Shanafelt TD. Physician burnout: a potential threat to successful health care reform. JAMA 2011;305:2009-10. [Crossref] [PubMed]
5. Dahlin ME, Runeson B. Burnout and psychiatric morbidity among medical students entering clinical training: a three year prospective questionnaire and interview-based study. BMC Med Educ 2007;7:6. [Crossref] [PubMed]
6. Papp KK, Stoller EP, Sage P, et al. The effects of sleep loss and fatigue on resident-physicians: a multi-institutional, mixed-method study. Acad Med 2004;79:394-406. [Crossref] [PubMed]
7. Jennings HF. The view from within: understanding medical officers’ adaptation to hospital demands. Available online: http://researchoutputs.unisa.edu.au/1959.8/117164
8. Howe A, Smajdor A, Stöckl A. Towards an understanding of resilience and its relevance to medical training. Med Educ 2012;46:349-56. [Crossref] [PubMed]
9. Shirom A, Nirel N, Vinokur AD. Overload, autonomy, and burnout as predictors of physicians' quality of care. J Occup Health Psychol 2006;11:328-42. [Crossref] [PubMed]
10. Firth-Cozens J. Doctors, their wellbeing, and their stress. BMJ 2003;326:670-1. [Crossref] [PubMed]
11. Mayer JD, Salovey E. Personality moderates the interaction of mood and cognition. In: Fiedler K, Forgas J, editors. Affect, cognition and social behavior: new evidence and integrative attempts. Toronto: Hogrefe & Huber Pub, 1988; 87-99.
12. Chew-Graham CA, Rogers A, Yassin N. 'I wouldn't want it on my CV or their records': medical students' experiences of help-seeking for mental health problems. Med Educ 2003;37:873-80. [Crossref] [PubMed]
13. Martinez W, Lehmann LS. The "hidden curriculum" and residents' attitudes about medical error disclosure: comparison of surgical and nonsurgical residents. J Am Coll Surg 2013;217:1145-50. [Crossref] [PubMed]
14. Hamstra SJ, Woodrow SI, Mangrulkar RS. Feeling pressure to stay late: socialisation and professional identity formation in graduate medical education. Med Educ 2008;42:7-9. [Crossref] [PubMed]
15. Myers MF. Physician impairment: is it relevant to academic psychiatry? Acad Psychiatry 2008;32:39-43. [Crossref] [PubMed]
16. Banja JD. Medical errors and medical marcissism. Burlington: Jones and Bartlett Publishers, 2005;65.
17. Sapolsky RM. Why zebras don’t get ulcers: A guide to stress, stress related diseases, and coping. New York: Holt Paperbacks, 2004;368.
18. McEwen BS. Central effects of stress hormones in health and disease: Understanding the protective and damaging effects of stress and stress mediators. Eur J Pharmacol 2008;583:174-85. [Crossref] [PubMed]
19. McEwen BS. Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol Rev 2007;87:873-904. [Crossref] [PubMed]
20. Chou LP, Li CY, Hu SC. Job stress and burnout in hospital employees: comparisons of different medical professions in a regional hospital in Taiwan. BMJ Open 2014;4:e004185. [Crossref] [PubMed]
21. Mompoint-Williams D, Brooks A, Lee L, et al. Using high-fidelity simulation to prepare advanced practice nursing students. Clinical Simulation in Nursing 2014;10:e5-10. [Crossref]
22. McEwen BS. Protective and damaging effects of stress mediators: central role of the brain. Dialogues Clin Neurosci 2006;8:367-81. [PubMed]
23. Reutrakul S, Van Cauter E. Interactions between sleep, circadian function, and glucose metabolism: implications for risk and severity of diabetes. Ann N Y Acad Sci 2014;1311:151-73. [Crossref] [PubMed]
24. Rosen IM, Gimotty PA, Shea JA, et al. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med 2006;81:82-5. [Crossref] [PubMed]
25. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med 2003;114:513-9. [Crossref] [PubMed]
26. Jones JW, Barge BN, Steffy BD, et al. Stress and medical malpractice: organizational risk assessment and intervention. J Appl Psychol 1988;73:727-35. [Crossref] [PubMed]
27. Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med 2000;15:122-8. [Crossref] [PubMed]
28. El-Bar N, Levy A, Wald HS, et al. Compassion fatigue, burnout and compassion satisfaction among family physicians in the Negev area - a cross-sectional study. Isr J Health Policy Res 2013;2:31. [Crossref] [PubMed]
29. Chun CA, Moos RH, Cronkite RC. Culture: a fundamental context for the stress and coping paradigm. Wong PT, Wong LC, editors. Handbook of Multicultural Perspectives on Stress and Coping. New York: Springer, 2006;29-53.
30. Lane JL, Slavin S, Ziv A. Simulation in medical education: a review. Simul Gaming 2001;32:297-314. [Crossref]
31. de Grave WS, Dolmans DH, van Der Vleuten CP. Student perceptions about the occurrence of critical incidents in tutorial groups. Med Teach 2001;23:49-54. [Crossref] [PubMed]
32. Wu S, Zhu W, Wang Z, et al. Relationship between burnout and occupational stress among nurses in China. J Adv Nurs 2007;59:233-9. [Crossref] [PubMed]
33. Saijo Y, Chiba S, Yoshioka E, et al. Job stress and burnout among urban and rural hospital physicians in Japan. Aust J Rural Health 2013;21:225-31. [Crossref] [PubMed]
34. Folkman S, Moskowitz JT. Coping: pitfalls and promise. Annu Rev Psychol 2004;55:745-74. [Crossref] [PubMed]
35. Lazarus RR, Folkman S. Transactional theory and research on emotions and coping. Eur J Pers 1987;1:141-69. [Crossref]
36. Bazargan M, Makar M, Bazargan-Hejazi S, et al. Preventive, lifestyle, and personal health behaviors among physicians. Acad Psychiatry 2009;33:289-95. [Crossref] [PubMed]
37. DuPont RL, McLellan AT, White WL, et al. Setting the standard for recovery: Physicians' Health Programs. J Subst Abuse Treat 2009;36:159-71. [Crossref] [PubMed]
38. Rutter M. Understanding and testing risk mechanisms for mental disorders. J Child Psychol Psychiatry 2009;50:44-52. [Crossref] [PubMed]
39. Rutter M. Genes and behavior: nature-nurture interplay explained. Malden: Blackwell, 2006.
40. Kirkbride PS, Tang SF, Westwood RI. Chinese conflict preferences and negotiating behaviour: cultural and psychological influences. Organ Stud 1991;12:365-86. [Crossref]
41. Yeh CJ, Arora AK, Wu KA. A new theoretical model of collectivistic coping. In: Wong PT, Wong LC, editors. Handbook of multicultural perspectives on stress and coping. New York: Springer, 2006;55-72.
42. Slavin SJ, Schindler DL, Chibnall JT. Medical student mental health 3.0: improving student wellness through curricular changes. Acad Med 2014;89:573-7. [Crossref] [PubMed]
43. Robiner W, Lazear S, Duffy B. Promoting health behaviours in medical education. Clin Teach 2013;10:160-4. [Crossref] [PubMed]
44. Chang EC, Tugade MM, Asakawa K. Stress and coping among Asian Americans: Lazarus and Folkman’s model and beyond. In: Wong PT, Wong LC, editors. Handbook of multicultural perspectives on stress and coping. New York: Springer, 2006;439-55.
45. Russell GM, Roach SM. Occupational stress: a survey of management in general practice. Med J Aust 2002;176:367-70. [PubMed]
46. Cullen JC, Silverstein BA, Foley MP. Linking biomechanical workload and organizational practices to burnout and satisfaction. J Bus Psychol 2008;23:63-71. [Crossref]
47. Bovier PA, Perneger TV. Predictors of work satisfaction among physicians. Eur J Public Health 2003;13:299-305. [Crossref] [PubMed]
48. Lee HY, Park SE, Park EC, et al. Job satisfaction and trust in Health Insurance Review Agency among Korean physicians. Health Policy 2008;87:249-57. [Crossref] [PubMed]
49. Zuger A. Dissatisfaction with medical practice. N Engl J Med 2004;350:69-75. [Crossref] [PubMed]
50. Pitkanen M, Hurn J, Kopelman MD. Doctors' health and fitness to practise: performance problems in doctors and cognitive impairments. Occup Med (Lond) 2008;58:328-33. [Crossref] [PubMed]
51. Bodenheimer T, Fernandez A. High and rising health care costs. Part 4: can costs be controlled while preserving quality? Ann Intern Med 2005;143:26-31. [Crossref] [PubMed]
52. Janus K, Amelung VE, Gaitanides M, et al. German physicians "on strike"--shedding light on the roots of physician dissatisfaction. Health Policy 2007;82:357-65. [Crossref] [PubMed]
53. Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med 2005;20:559-64. [Crossref] [PubMed]
54. Ward RK. Family medicine training and the salutogenic perspective: are we providing our residents with the tools to survive in the evolving healthcare system? A Commentary on Rabin et al. (2005). Fam Syst Heal 2005;23:103-7. [Crossref]
55. Spickard A Jr, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA 2002;288:1447-50. [Crossref] [PubMed]
56. Lovell BL, Lee RT, Frank E. May I long experience the joy of healing: professional and personal wellbeing among physicians from a Canadian province. BMC Fam Pract 2009;10:18. [Crossref] [PubMed]
57. Huang T, Larsen KT, Ried-Larsen M, et al. The effects of physical activity and exercise on brain-derived neurotrophic factor in healthy humans: A review. Scand J Med Sci Sports 2014;24:1-10. [Crossref] [PubMed]
58. McEwen BS. Interacting mediators of allostasis and allostatic load: towards an understanding of resilience in aging. Metabolism 2003;52:10-6. [Crossref] [PubMed]
59. Tsatsoulis A, Fountoulakis S. The protective role of exercise on stress system dysregulation and comorbidities. Ann N Y Acad Sci 2006;1083:196-213. [Crossref] [PubMed]
60. Deuster PA, Silverman MN. Physical fitness: a pathway to health and resilience. US Army Med Dep J 2013.24-35. [PubMed]
61. Cornum R, Matthews MD, Seligman ME. Comprehensive soldier fitness: building resilience in a challenging institutional context. Am Psychol 2011;66:4-9. [Crossref] [PubMed]
62. Aschbacher K, Kornfeld S, Picard M, et al. Chronic stress increases vulnerability to diet-related abdominal fat, oxidative stress, and metabolic risk. Psychoneuroendocrinology 2014;46:14-22. [Crossref] [PubMed]
63. Berchicci M, Lucci G, Perri RL, et al. Benefits of physical exercise on basic visuo-motor functions across age. Front Aging Neurosci 2014;6:48. [Crossref] [PubMed]
64. Fujisawa D, Suzuki Y, Kato TA, et al. Suicide intervention skills among Japanese medical residents. Acad Psychiatry 2013;37:402-7. [Crossref] [PubMed]
65. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med 2014;174:527-33. [Crossref] [PubMed]
66. Topol EJ, Steinhubl SR, Torkamani A. Digital medical tools and sensors. JAMA 2015;313:353-4. [Crossref] [PubMed]