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Organizational Health in Our Educational System
EDITORIAL
Organizational Health in Our Educational System John A. Weigelt, MD,*, Richard M. Bell, MD† *Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin and †Department of Surgery, University of South Carolina, Columbia, South Carolina Stress in the workplace is a common topic.1,2 Although some stress is inherent in any activity, excessive stress in the workplace has a negative effect on productivity and on an individual's health. In medicine, burnout describes a physician who has simply had enough of the profession and has lost the ability to cope or face the daily activities of being a health care provider. Burnout is an end point or sequela of stress. Tools such as the Maslach Burnout Inventory are commonly used to measure burnout in 3 domains: emotional exhaustion, depersonalization, and personal accomplishment. Measuring burnout is great, but we should be identifying stress before it assaults our educational leaders. Numerous stressors in our workplace are recognized. These include poor communication, excessive workload, professional changes, job insecurity, lack of trust, and socioeconomic factors. In addition, stress is magnified by the current uncertainty of how postgraduate surgical education will evolve in the future. Institutional focus is changing, as the demand for revenue generation appears to be trumping educational activities as a priority. How these and other stressors affect our roles as surgical educators is a question worth exploring. We had the opportunity to test a new workplace stress tool, a proprietary product offered by Target Training International as a part of a Beta testing analysis. We asked program directors (PDs) to voluntarily and anonymously answer the survey. A total of 69 PDs graciously responded. The results are preliminary, but it appears that PDs are a stressed group of individuals (Cronbach α ¼ 0.858). The most prominent stressors were related to issues involving social support on the job, such as frustration and trust among colleagues and institutional issues surrounding organizational communication and vision. There appeared to be a disconnection between individual and institutional vision, whether real or perceived. Job demands and time management were also commonly mentioned. All this may not be surprising considering the changes postgraduate medical education is facing, but the degree of stress discovered by this survey is alarming. Approximately 3 of 4 (71%) PDs reported some degree of symptoms that they thought were related to stress. The overall results are shown in the Table.
On the positive side, PDs feel supported by their supervisors and feel that their job was meaningful despite the frustrations. This suggests that PDs find value in their efforts and that the current rewards within the job are on parity with the effort expended. Perhaps we can take a lesson from high-performance athletes (we are certain that many of us consider ourselves in this category). Olympians face many similar internal and external stresses that PDs face.3 Internal issues include the desire to perform at one's personal best, relationship/family issues, a strong sense of vision/direction, and the desire to reach one's personal goals. External stressors include expectations, commitment to the team, interactions with and expectations of coaches (supervisors), as well as relationships with colleagues. The resilience of high-performance athletes is being studied. Positive factors include adaptive perfectionism (positive attitude while not obsessing with failure or mistakes), optimism, hope, proactivity, motivation (selfdetermination), confidence, focus, and social support. Response to the stress questionnaire suggests that PDs are solidly grounded in some of these areas but are deficient in others. PDs feel their jobs are meaningful, rewarding, and worth the effort. Reliance on social support and collegial trust issues are perceived as wanting. Organizational vision and communication appear to be problematic. Addressing these issues with concrete solutions to resolve these deficiencies is a necessary component of a healthy environment for learning. Another finding from studies of the resilience of Olympic athletes is the importance of stress buffering.3 The results of the survey of PDs suggest that the perception of support by managers/supervisors (presume this to be department chairpersons or division chiefs) is perceived to be helpful. Only 14% of PDs who responded placed managerial characteristics as contributing to significant or extreme stress of the job (Table). Furthermore, even those who indicated high levels of stress in other aspects of the survey generally found adequate support from their supervisors. Vanderbilt University and the University of St. Louis have implemented programs that have demonstrated a positive effect on reducing the stress of medical students.4 These programs take a proactive approach, rather than
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.06.010
1
TABLE. Group Quadrants
Stress level is the vertical axis. The degree of stress is based on this scale: The shaded areas represent the highest percentage for each domain. 0–20 ¼ Little to Minimal Stress 21–40 ¼ Limited Stress. 41–60 ¼ Moderate Stress. 61–80 ¼ Significant Stress. 81–100 ¼ Extreme Stress.
therapeutic counseling, to teach students how to deal with the stress encountered and develop resilience skills during their medical education. Curricular changes refocusing on content and importance have been implemented. More time was allotted to explore individual curiosities and for the identification of mentors who share similar interests. Other changes included a less-threatening grading system, as well as reduction in the competitive atmosphere in educational activities. Preliminary results indicated that the levels of stress and anxiety were reduced. The long-term effect of these changes is yet to be determined. Perhaps there are lessons here worth exploring. We may not agree with the specifics of these programs, but there is an important message. It is time that we as surgical educators begin to address our own workplace stress. This discussion requires abandoning our distaste for
the “softer” sciences and begin to accept stress as a serious issue with important negative consequences, including disillusionment, attrition, medical error, and probably the failure to provide our trainees with the quality educational experience they deserve. The issues regarding organizational vision and communication may be more difficult to address, as the crystal ball for the future of postgraduate medical education remains cloudy in this era of declining resources for educational activities. Many programs and institutions are stumbling along, and the analogy may be similar to the 3 blind men feeling the elephant. The conversation regarding a healthy workplace in which we can train our future surgeons is a priority. The preliminary findings from our survey suggest that we are similar to other workplaces regarding stress, and PDs may not be any more stressed than other members of the
2
Journal of Surgical Education Volume ]/Number ] ] 2015
workforce.5,6 It makes sense to learn more about the stressors that affect our educational efforts, given the negative effects of stress on individuals. Just as we are learning how to teach our residents within a new and changing educational system, we must learn to provide a healthy workplace for those of us tasked with providing a healthy learning environment. Proactively addressing these issues may help mitigate stress in the workplace. Maybe it is time we learned how to apply these principles to our educational programs, for the sake of our trainees and ourselves. By doing so, we may become stronger educational Olympians.
ACKNOWLEDGMENT We are grateful to the program directors who graciously gave of their time in answering the questionnaire and to Target Training International, Ltd, Phoenix AZ, for providing the assessments.
REFERENCES
Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health; May 1987, [DHHS (NIOSH), Publication No: 87-111]. 2. Ruotselainen JH, Verbeek JH, Mariné, Serra C.
Preventing occupational stress in healthcare workers. Cochrane Database Syst Rev. 2015(Issue 4): [Review. The Cochrane Collection]. 3. Sarkear M, Fletcher D. Psychological resilience in sports
performers: A review of stressors and protective factors. J Sports Sci. 2014;32(5):1419-1434. 4. Slavin SJ, Schindler DL, Chibnall JT. Medical student
mental health: improving student wellness through curricular change. Acad Med. 2014;89(4):573-577. 5. Shanafelt TD, Boone S, Tan L, et al. Burn out and
satisfaction with work-balance among US physicians relative to the US general population. Arch Intern Med. 2012;172(18):1377-1385. http://dx.doi.org/10.1001/ archinternmed.2012.3199. 6. Vagg PR, Spielberger CD. Occupational stress: measur-
work setting. US Department of Health and Human
ing job pressure and organizational support in the workplace. J Occup Health Psychol. 1998;3(4):294-305.
Journal of Surgical Education Volume ]/Number ] ] 2015
3
1. Murphy LR, Schoenborn TF. Stress management in the
Organizational Health in Our Educational System John A. Weigelt, MD,*, Richard M. Bell, MD† *Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin and †Department of Surgery, University of South Carolina, Columbia, South Carolina Stress in the workplace is a common topic.1,2 Although some stress is inherent in any activity, excessive stress in the workplace has a negative effect on productivity and on an individual's health. In medicine, burnout describes a physician who has simply had enough of the profession and has lost the ability to cope or face the daily activities of being a health care provider. Burnout is an end point or sequela of stress. Tools such as the Maslach Burnout Inventory are commonly used to measure burnout in 3 domains: emotional exhaustion, depersonalization, and personal accomplishment. Measuring burnout is great, but we should be identifying stress before it assaults our educational leaders. Numerous stressors in our workplace are recognized. These include poor communication, excessive workload, professional changes, job insecurity, lack of trust, and socioeconomic factors. In addition, stress is magnified by the current uncertainty of how postgraduate surgical education will evolve in the future. Institutional focus is changing, as the demand for revenue generation appears to be trumping educational activities as a priority. How these and other stressors affect our roles as surgical educators is a question worth exploring. We had the opportunity to test a new workplace stress tool, a proprietary product offered by Target Training International as a part of a Beta testing analysis. We asked program directors (PDs) to voluntarily and anonymously answer the survey. A total of 69 PDs graciously responded. The results are preliminary, but it appears that PDs are a stressed group of individuals (Cronbach α ¼ 0.858). The most prominent stressors were related to issues involving social support on the job, such as frustration and trust among colleagues and institutional issues surrounding organizational communication and vision. There appeared to be a disconnection between individual and institutional vision, whether real or perceived. Job demands and time management were also commonly mentioned. All this may not be surprising considering the changes postgraduate medical education is facing, but the degree of stress discovered by this survey is alarming. Approximately 3 of 4 (71%) PDs reported some degree of symptoms that they thought were related to stress. The overall results are shown in the Table.
On the positive side, PDs feel supported by their supervisors and feel that their job was meaningful despite the frustrations. This suggests that PDs find value in their efforts and that the current rewards within the job are on parity with the effort expended. Perhaps we can take a lesson from high-performance athletes (we are certain that many of us consider ourselves in this category). Olympians face many similar internal and external stresses that PDs face.3 Internal issues include the desire to perform at one's personal best, relationship/family issues, a strong sense of vision/direction, and the desire to reach one's personal goals. External stressors include expectations, commitment to the team, interactions with and expectations of coaches (supervisors), as well as relationships with colleagues. The resilience of high-performance athletes is being studied. Positive factors include adaptive perfectionism (positive attitude while not obsessing with failure or mistakes), optimism, hope, proactivity, motivation (selfdetermination), confidence, focus, and social support. Response to the stress questionnaire suggests that PDs are solidly grounded in some of these areas but are deficient in others. PDs feel their jobs are meaningful, rewarding, and worth the effort. Reliance on social support and collegial trust issues are perceived as wanting. Organizational vision and communication appear to be problematic. Addressing these issues with concrete solutions to resolve these deficiencies is a necessary component of a healthy environment for learning. Another finding from studies of the resilience of Olympic athletes is the importance of stress buffering.3 The results of the survey of PDs suggest that the perception of support by managers/supervisors (presume this to be department chairpersons or division chiefs) is perceived to be helpful. Only 14% of PDs who responded placed managerial characteristics as contributing to significant or extreme stress of the job (Table). Furthermore, even those who indicated high levels of stress in other aspects of the survey generally found adequate support from their supervisors. Vanderbilt University and the University of St. Louis have implemented programs that have demonstrated a positive effect on reducing the stress of medical students.4 These programs take a proactive approach, rather than
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.06.010
1
TABLE. Group Quadrants
Stress level is the vertical axis. The degree of stress is based on this scale: The shaded areas represent the highest percentage for each domain. 0–20 ¼ Little to Minimal Stress 21–40 ¼ Limited Stress. 41–60 ¼ Moderate Stress. 61–80 ¼ Significant Stress. 81–100 ¼ Extreme Stress.
therapeutic counseling, to teach students how to deal with the stress encountered and develop resilience skills during their medical education. Curricular changes refocusing on content and importance have been implemented. More time was allotted to explore individual curiosities and for the identification of mentors who share similar interests. Other changes included a less-threatening grading system, as well as reduction in the competitive atmosphere in educational activities. Preliminary results indicated that the levels of stress and anxiety were reduced. The long-term effect of these changes is yet to be determined. Perhaps there are lessons here worth exploring. We may not agree with the specifics of these programs, but there is an important message. It is time that we as surgical educators begin to address our own workplace stress. This discussion requires abandoning our distaste for
the “softer” sciences and begin to accept stress as a serious issue with important negative consequences, including disillusionment, attrition, medical error, and probably the failure to provide our trainees with the quality educational experience they deserve. The issues regarding organizational vision and communication may be more difficult to address, as the crystal ball for the future of postgraduate medical education remains cloudy in this era of declining resources for educational activities. Many programs and institutions are stumbling along, and the analogy may be similar to the 3 blind men feeling the elephant. The conversation regarding a healthy workplace in which we can train our future surgeons is a priority. The preliminary findings from our survey suggest that we are similar to other workplaces regarding stress, and PDs may not be any more stressed than other members of the
2
Journal of Surgical Education Volume ]/Number ] ] 2015
workforce.5,6 It makes sense to learn more about the stressors that affect our educational efforts, given the negative effects of stress on individuals. Just as we are learning how to teach our residents within a new and changing educational system, we must learn to provide a healthy workplace for those of us tasked with providing a healthy learning environment. Proactively addressing these issues may help mitigate stress in the workplace. Maybe it is time we learned how to apply these principles to our educational programs, for the sake of our trainees and ourselves. By doing so, we may become stronger educational Olympians.
ACKNOWLEDGMENT We are grateful to the program directors who graciously gave of their time in answering the questionnaire and to Target Training International, Ltd, Phoenix AZ, for providing the assessments.
REFERENCES
Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health; May 1987, [DHHS (NIOSH), Publication No: 87-111]. 2. Ruotselainen JH, Verbeek JH, Mariné, Serra C.
Preventing occupational stress in healthcare workers. Cochrane Database Syst Rev. 2015(Issue 4): [Review. The Cochrane Collection]. 3. Sarkear M, Fletcher D. Psychological resilience in sports
performers: A review of stressors and protective factors. J Sports Sci. 2014;32(5):1419-1434. 4. Slavin SJ, Schindler DL, Chibnall JT. Medical student
mental health: improving student wellness through curricular change. Acad Med. 2014;89(4):573-577. 5. Shanafelt TD, Boone S, Tan L, et al. Burn out and
satisfaction with work-balance among US physicians relative to the US general population. Arch Intern Med. 2012;172(18):1377-1385. http://dx.doi.org/10.1001/ archinternmed.2012.3199. 6. Vagg PR, Spielberger CD. Occupational stress: measur-
work setting. US Department of Health and Human
ing job pressure and organizational support in the workplace. J Occup Health Psychol. 1998;3(4):294-305.
Journal of Surgical Education Volume ]/Number ] ] 2015
3
1. Murphy LR, Schoenborn TF. Stress management in the