- Email: [email protected]
Use of a Physical Education and Nutrition Program to Improve Outcomes
C H A P T E R
22 Use of a Physical Education and Nutrition Program to Improve Outcomes Alejandro M. Spiotta1, Raymond D. Turner Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States 1 Corresponding author e-mail: [email protected]
O U T L I N E Introduction
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Deterioration of Personal Health During Residency Training
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Burnout and Resident Attrition
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Exercise Effects on Sleep, Distress, and Fatigue
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Benefits of a Balanced Lifestyle in Physicians and Trainees
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The MUSC Pilot Initiative Health Screening Sleep Quality Physical Fitness Assessments Activity Tracking Psychological Assessments End of Year One Results Interpretation Take-Home Points
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Challenges and Pitfalls
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Summary
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References
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Quality and Safety in Neurosurgery https://doi.org/10.1016/B978-0-12-812898-5.00024-2
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© 2018 Elsevier Inc. All rights reserved.
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INTRODUCTION Placing the needs of the patient above one’s own needs has long been the call of duty badge worn by the physician. Indeed, emergent patient care needs trump immediate personal needs such as sleep, fatigue, hunger, and family commitments. However, personal health and well-being are paramount to leading long and productive careers. Balancing the demands of a busy medical career with personal wellness is a daunting but necessary skill to acquire, yet there is little education of these principles available to physicians in training. For the most part, organized exercise, diet, and personal fitness programs are entirely lacking in modern graduate medical education. The Accreditation Council for Graduate Medical Education (ACGME) requires the mastery of 7 core competencies among physicians in training. The goal of modern graduate medical education should be to instill its trainees not only with medical knowledge and procedural competency that allows individuals to function as independent physicians, but also the importance of lifelong learning, interpersonal skills, and personal well-being that will ensure career success, longevity, and satisfaction.
DETERIORATION OF PERSONAL HEALTH DURING RESIDENCY TRAINING Medical students are, in general, active individuals and exercise more frequently than the general population. In fact, most exercise routinely with moderate-intensity activity of at least 2.5–4 h per week.1,2 Most studies evaluating the exercise habits of resident physicians have demonstrated a significant reduction in exercise during graduate medical education compared to medical school.1,3–5 In addition, dietary habits may deteriorate during the long hours of residency training. In association with changes in sleep patterns, this may predispose resident physicians to weight gain.6 A Brazilian study of resident physicians showed that many were overweight or obese and many self-reported weight gain during residency, particularly males. However, both male and female residents reported poor diets with high intake of sweets and saturated fats with low intake of vegetables and fruits.7 Sleep deprivation and poor sleep quality from long work hours, rotating shifts, and interrupted sleep are commonplace.8 With changes in resident duty hour regulations to help limit fatigue and reduce medical errors, there has been an unclear effect on resident sleep quality.9 In the context of long hours and alternating shift and sleep cycles, the lack of
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EXERCISE EFFECTS ON SLEEP, DISTRESS, AND FATIGUE
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exercise and poor dietary choices may have negative short- and long-term consequences on physician physical and mental health.
BURNOUT AND RESIDENT ATTRITION The percentage of resident physicians reporting burnout during training is unacceptably high. Burnout, a term used to describe feelings of emotional exhaustion, low self-accomplishment, and depersonalization associated with the work environment, is gaining ground as an important marker for resident well-being. Unfortunately, burnout is reported in the majority of resident physicians on surveys, regardless of the specialty. Anywhere from 47% to 70% of residents report burnout during training.10–15 Residents who report burnout and personal distress are probably more likely to make medical errors16,17 and report suboptimal care for their patients.18 Residents with burnout may be more likely to display unprofessional behaviors.19 In addition, burnout and personal distress is associated with resident attrition (quitting or changing residency programs or specialties). Attrition among surgical residents is not uncommon. In the specialty of general surgery, it has been suggested that about 1 in 5 residents fail to complete residency training.20,21 One study of attrition rates across clinical specialties demonstrated rates 2%–7%.22 In neurosurgeons, attrition rates 15%.23 In one survey of general surgery residents, nearly 60% of residents strongly considered leaving their program. Sleep deprivation was the most cited reason for considering leaving, while support from other residents was one of the most common reasons for deciding to stay.20 These studies suggest that programs that help to improve team building support structures and mitigate poor quality sleep may potentially reduce resident distress and attrition.
EXERCISE EFFECTS ON SLEEP, DISTRESS, AND FATIGUE There is no question that exercise is important for physical health. Exercise is an effective means of losing weight, maintaining a healthy body weight, and preventing disease.24 In fact, lack of exercise has clearly been linked to the development of chronic diseases.25 The beneficial effects of exercise on health-related quality of life are well documented.26–30 Exercise is an effective therapy for depression in young adults.31 Exercise interventions may be beneficial in reducing the symptoms of depression.32 Patients who engage in regular exercise often report improved sleep quality, higher sleep efficiency, and shorter sleep latencies.33–36
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Further, exercise is beneficial in reducing the symptoms of fatigue in certain patient populations, such as those with cancer-related fatigue.37,38 In addition, physical activity may improve self-esteem and feelings of self-worth in young adults.39 These studies suggest that subjects engaging in routine physical activity may benefit from improved self-esteem, decreased depressive symptoms, reduced fatigue, and better quality sleep. Finally, evidence supports the benefit of interventions designed specifically for increasing physical activity and healthy behaviors. Systematic reviews of interventions that promote physical activity have a positive effect on self-reported activity40 and may result in persistent improvements in physical and mental quality of life in healthy individuals.41 Similar to exercise, dietary interventions may also improve quality of life.42
BENEFITS OF A BALANCED LIFESTYLE IN PHYSICIANS AND TRAINEES While there are limited published data on the health and well-being benefits of physical activity on physicians, there are some data supporting a positive effect of exercise. Physicians with healthy behaviors are more likely to be satisfied with their occupation.43 A study has suggested that restful sleep and exercise have a positive effect on personal well-being in residents.44 Further, physicians who are engaged in regular exercise are more likely to counsel their patients regarding the benefits of physical fitness.45 Historically, a “resident” physician lived in the hospital and was entirely devoted to caring for their patients; thus, personal health was abandoned in the pursuit of a medical education. We now teach residents in the context of enforced duty hour restrictions. However, it is commonplace for physicians (residents and faculty) to be “too busy” to frequent the doctor for routine visits such as health screenings that they themselves would outline for their own patients. Chronic diseases with courses that can be either modified or entirely prevented can thus go unnoticed for many years, causing irreparable damage; for example, undiagnosed hypertension or hypercholesterolemia leading to cardiovascular disease or stroke. In addition, there are increasing data suggesting that psychological distress and burnout are common among physicians and other health care providers. An alarming majority of residents report burnout during training,9–14 but these issues do not end with completion of residency. Nearly 50% of US physicians report symptoms of burnout.17 With an expanding understanding of the health consequences of medicine on the provider, there has been an increasing focus on improving physician well-being.46–48
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THE MUSC PILOT INITIATIVE
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THE MUSC PILOT INITIATIVE To address these alarming baseline traits of young physicians, we implemented a voluntary wellness initiative involving both faculty and residents of the Department of Neurosurgery at the Medical University of South Carolina. This quality improvement initiative encourages and educates participants on the importance of a balanced lifestyle emphasizing exercise and nutrition and provides support and resources to achieve such goals.49 The primary goals of the wellness initiative are twofold: (1) establish lifelong habits of personal health and (2) build resiliency among the resident core. The wellness program was implemented in July of 2015 and available on a voluntary basis to all faculty and resident physicians, advanced practice providers, and other staff members within the department. Weekly wellness lectures on exercise, diet, alcohol avoidance, and mental health are incorporated into weekly departmental conferences. Healthy food choices were provided at these lectures and at conferences. Team-based 1-h exercise sessions under the guidance of strength and conditioning trainers were incorporated into the work week. Gym memberships along with team uniforms were provided to participants to promote camaraderie and attendance. A detailed description of the program and its goals may be found elsewhere.49 This program encourages and educates participants in the importance of regular exercise, balanced nutrition, stress management, and adequate sleep, among others, in a team-based approach with scheduled exercise sessions and team building activities. The aim is to increase awareness of the importance of a balanced lifestyle and provide support and resources to establish lifelong habits of personal health. All participants underwent baseline health screening information (vital signs, serum lipid panel, etc.) as well as body composition analysis (InBody, Cerritos, California). General fitness assessments were obtained as well as psychological and sleep instruments. Six faculty neurosurgeons (mean age 37.7 6.4 years) and 9 neurosurgery resident physicians (mean age 30 2.8 years) volunteered to participate in the Wellness Initiative. Resident participation includes those in postgraduate years 1–7. Faculty participants include both junior and senior faculty members. All participants indicated that they wished they had more time to take better care of themselves (Fig. 22.1). Further, all believed exercise and nutrition are important aspects of a healthy lifestyle and would prioritize incorporating 30 min of exercise into their daily lifestyle if they had more time in their schedule. Over half (n ¼ 7; 54%) of the respondents considered themselves out of shape, and only 38% (n ¼ 5) considered themselves to have an active lifestyle. The vast majority (n ¼ 11; 84%) of respondents indicated that work frequently gets in the way of exercising and eating well.
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FIG. 22.1 Survey responses of resident physician participants of the “La Sierra” wellness initiative (n ¼ 11).
Health Screening Health screening demonstrated abnormalities in 80% (n ¼ 12) of participants. These included an elevated resting systolic blood pressure in 60% (n ¼ 9), elevated resting diastolic blood pressure in 67% (n ¼ 10), elevated serum fasting total cholesterol (hyperlipidemia, HLP) in 2 individuals (13 %), elevated serum low-density lipoprotein (LDL) in over half of the participants (n ¼ 8; 53%), and elevated serum triglycerides (TG) in one participant (7%). Body composition analysis demonstrated body weight higher than ideal in 69% (n ¼ 9). Body fat percentage was 21.5% 8.6% (range 10.7%–38.2%) and visceral fat level was 8 5.4 (range 3–20). Average body mass index (BMI) was 27.6 4.6 (range 23.3–40.3). Of the participants, 47% were overweight based on BMI criteria while 13% were defined as obese. Recommended average body fat mass reduction, calculated by InBody as the fat reduction required to reach ideal weight, was 25.4 27.4 lbs (range 0.4–86 lbs) (Fig. 22.2).
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FIG. 22.2
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Participants in the MUSC La Sierra program.
Sleep Quality About 36% (n ¼ 5) of respondents indicated a possible sleep disorder, defined by a score of 10 or greater out of a maximum score of 24. The mean Epworth Sleepiness Scale score was 8 3.7 (range 0–15). The average amount of sleep obtained per resident per day was 6.5 22. 9 h (range 6.2–8.4 h) as determined by Fitbit measurements during sleep.
Physical Fitness Assessments Participants exhibited a wide range of baseline fitness levels as evidenced by the baseline fitness testing. The mean time to run one mile was 7 min and 59 s (range 5:59–15 min). The average number of push-ups completed in 2 min was 45 (range 0–75), average sit-ups performed in 2 min was 52 (range 1–84), and mean number of pull-ups completed was 8 (range 0–18).
Activity Tracking Fourteen days of activity were tracked continuously (for nine residents) with Fitbits, with the exception of time scrubbed into an operation. Participants walked an average of 10,030.6 4717.3 steps daily, translating to walking 6.2 2.9 miles. On average, 7761.9 4139.7 steps (4.8 2.6 miles)
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were performed during hours at work, representing 77% of the steps taken. Thus, only 2268.7 steps on average were taken during off hours. Average caloric expenditure was 3153.3 1552.1 calories daily. The average basal metabolic rate (BMR) was 1906.6 198.6 calories; therefore, the net daily difference was 1246.7 276.5 calories. Average basal heart rate (HR) was 61.2 7.0 beats per minute (BPM). Average HR at work was 79.0 11.9 BPM. On average, HR at work increased by 17.8 5.0 BPM.
Psychological Assessments Baseline psychological assessment results are shown in Table 22.1. The mean score on the PHQ-8 was 5 4.3 (range 1–18) out of a possible 24 points. Results from the survey indicate 62% of residents and faculty (n ¼ 8) with minor or no depression (score of 1–4), 38% (n ¼ 5) with mild depression (score of 5–9), and 1 (7%) with moderately severe depression (score of 15–19). None scored with severe depression (20–27). Over threequarters of residents and faculty (n ¼ 11; 79%) reported below average quality of life compared to a healthy adult mean of 90 points.1 Importantly, one individual (7%) reported moderately severe depression, the presence of generalized anxiety disorder, and a below-average quality of life score.
END OF YEAR ONE RESULTS Over the course of the first year of the program, resident physicians experienced improvements in psychological assessments of generalized anxiety and quality of life from baseline to final assessment. The Generalized Anxiety Disorder 7-item scale demonstrated significant improvement with scores decreasing from 4 to 2.1 (P ¼ .04). The Quality of Life Scale demonstrated significant improvement of scores (P ¼ .007) and a lower percentage of participants with scores below the general public average, improving from 77.8% to 33.3%. The Epworth Sleepiness Scale demonstrated significant improvement of scores (P ¼ .019) and a lower percentage of participants with abnormal scores, improving from 33.3% to 10%.
Interpretation Baseline health and psychological screenings have demonstrated alarmingly prevalent abnormalities on cardiovascular screenings, body composition, and mental health status of the neurosurgery residents at
3. THE PRACTICE OF QUALITY AND SAFETY IN NEUROSURGERY
Assessmenta
Scoring range b
General population mean score (SD)
Abnormal range
Baseline sample mean score (SD)
Baseline range
Baseline % abnormal scores
Final sample mean score (SD)
Final range
Final % abnormal scores
P-value
2.7 (3.2)
0–10
10
0.1360
2.1 (3.1)
0–9
0
PHQ-8
0–27
6.6 (5.5)
10+
4.1 (2.4)
1–9
0
GAD-7
0–21
3.0 (3.4)
8+
4 (2.7)
0–7
0
c
QOLS
16–112
90
Epworth
0–24
4.6 (2.8)
d
0.0390 d
Not defined
82.4 (10.1)
72–103
77.8
95.4 (12.3)
73– 112
33.3
0.0066
11+
8.3 (2.7)
4–12
33.3
5.7 (4.1)
0–14
10
0.0185
END OF YEAR ONE RESULTS
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TABLE 22.1 Results of Psychological Surveys and the Epworth Sleepiness Scale
a
PHQ-8, Personal Health Questionnaire Depression Scale; GAD-7, Generalized Anxiety Disorder 7-item Scale; QOLS, Quality of Life Scale. b Minor or no depression (score 1–4), mild depression (5–9), moderate depression (10–14), moderately severe depression (15–19), severe depression (20–27). c Mean score of 90 in the general (healthy) population. Mean scores for patients with rheumatoid arthritis are 83, fibromyalgia 70, and posttraumatic stress disorder 61. d Percentage of sample with QOLS scores below the general population average.
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our institution. Further, surveys have identified physician obstacles to leading a healthier lifestyle. It became evident that a change in culture is required to achieve wellness among neurosurgery physicians at our institution, which may also be applicable to other centers across the country. These results are particularly concerning given the fact that four of the residents were former scholarship collegiate athletes, two had a former military background, and all played competitive individual or team sports at some point in their higher education. Thus, we described a striking phenomenon: young physicians, who were previously scholar-athletes and had successfully achieved a balanced lifestyle (mind and body), undergo very rapid and drastic physiological, psychological, and biochemical changes in response to the current conditions they are exposed to during neurosurgery training. These maladaptive changes only serve to weaken the disposition of the resident physician and do not support career productivity and longevity.
TAKE-HOME POINTS Paradoxically, there has been little emphasis on physician wellness in organized medicine until very recently. Health care providers traditionally have been expected, under external and/or internal forces, to neglect their own personal health to place the well-being of patients first. This certainly holds true in the field of Neurosurgery. Evolving societal and professional attitudes, generational differences, and patient expectations (e.g., public outcry for work hour regulations during residency) have led to the broader realization that physician wellness may benefit not just the provider but also the patient under their care. This recent interest is reflected in the burgeoning implementation of “wellness” programs throughout medical institutions across the country. The ACGME has begun to focus on means of improving trainee well-being,47 with a few programs around the country introducing wellness initiatives on a small scale. A “resiliency” program to help family medicine residents at risk for burnout has been described50 as well as a wellness initiative for psychiatry residents51 and our own program in neurosurgery.49 Studies have found that resident physicians significantly reduce regular exercise during graduate medical education compared to medical school1,3–5 due to long work hours, resulting in lack of energy and time to participate in exercise.5 In addition, dietary habits deteriorate during the long hours of residency training which contribute to weight gain.6,7 Sleep deprivation with poor sleep quality are also commonplace.8 The psychological consequences of work-related stress are becoming well established. Burnout, a term used to describe feelings of emotional
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CHALLENGES AND PITFALLS
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exhaustion, low self-accomplishment, and depersonalization associated with the work environment, is gaining ground as an important marker for resident well-being. Physician burnout and depression is a known contributor to suboptimal patient care10–18 and displays of unprofessional behaviors that disrupt team dynamics.19 In some instances, burnout leads to physicians quitting or changing specialties. In the specialty of general surgery, 1 in every 5 residents fails to complete residency training.20,21 Among neurosurgeons, attrition rates 15%.23 The challenge to resident educators is to devise a learning environment wherein the necessary medical and surgical skills can be acquired while building resiliency. Only then can we truly prepare our graduating residents for a lifelong productive career. To this aim, we devised our wellness initiative; thus far, the results have been positive and have encouraged its continued implementation as well as possible dissemination to other training programs. Regular group exercise, team building, and promoting a change in culture led to improvements in team camaraderie, quality of life, anxiety, depression, and sleep. The majority of participants felt it exerted a positive influence on their own physical and mental well-being, was a positive addition to our department, and believed it ought to be incorporated into other residency training programs. Furthermore, the majority reported that participating in the wellness program did not interfere with either clinical or academic responsibilities.
CHALLENGES AND PITFALLS There were several challenges to the implementation of this program. Although every program at every institution will face unique obstacles, some are universal. First, the “old guard” culture. Some attendings, especially of older generations, may oppose the notion of a wellness program for its residents. Similar initiatives may be dismissed as a lack of commitment to the field or a perceived “weakness.” Results such as those achieved and described in this study contradict this notion; we are building resiliency in our residents. This “toughness” and “grit” will equip them with the necessary mental and physical reserve to persevere under any adverse conditions (resiliency). Establishing a balanced lifestyle will serve them well in the future when faced with other challenges relating to being an academician including balancing clinical, academic, teaching, and family responsibilities. Participation by the chairman and program director in our own department greatly helped to drive the change in culture required to gain acceptance of this novel initiative (“lead by example”). Secondly, the costs of implementing a wellness program may be prohibitive at some institutions. We funded the initiative with educational
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grants and philanthropy. We have kept our hospital administration updated on our progress and now plan to present our data to justify an incentive plan that would make it self-funded for years to come. Third, resident availability, especially in neurosurgery, is always a challenge to participation. Our advice is to do the best you can as a group, realizing that some weeks’ participation may be less than ideal. Celebrate the weeks with full participation rather than be frustrated at the weeks with poor turnout. Protected time in the real-world delivery of patient care is a falsehood. While the availability of advanced practice practitioners can help free the residents, emergent patient care matters remain the priority. Participation in the weekly group workout is only available to residents who do not have any pressing clinical matters to attend to. Fourth, risk of injury may deter some institutions and participants. Beginning an exercise regimen will inevitably predispose to musculoskeletal injuries, some of which could temporarily affect a resident’s ability to participate in their daily duties such as perform surgery. Risk of injury should be managed at all times. We have done so by incorporating workouts directed by certified physical trainers and avoiding activities that are higher risk.
SUMMARY While the sample of physicians in our study is small and in a specialty characterized by high stress, we believe the results are generalizable. Given the significant percentage of resident and attending physicians with symptoms of burnout, it is likely that similar patterns may be seen in other specialties, both surgical and medical. Our data suggest that voluntary wellness programs that provide physical and psychological assessments may be helpful in identifying previously undiagnosed physical or mental conditions and in promoting healthy choices that improve physician productivity, happiness, and satisfaction. We believe a wellness program such as the one implemented in our institution may have universal benefits in residency training programs and may serve as a template for other programs interested in enhancing physician wellness.
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47. Daskivich TJ, Jardine DA, Tseng J, et al. Promotion of wellness and mental health awareness among physicians in training: perspective of a national, multispecialty panel of residents and fellows. J Grad Med Educ. 2015;7(1):143–147. 48. Lefebvre DC. Perspective: resident physician wellness: a new hope. Acad Med. 2012; 87(5):598–602. 49. Spiotta AM, Fargen KM, Denham SL, et al. Incorporation of a physical education and nutrition program into neurosurgery: a proof of concept pilot program. Neurosurgery. 2016;79(4):613–619. https://doi.org/10.1227/NEU.0000000000001358. 50. Brennan J, McGrady A. Designing and implementing a resiliency program for family medicine residents. Int J Psychiatry Med. 2015;50(1):104–114. 51. Feeley RJ, Ross DA. The creation and implementation of a wellness initiative in a large adult psychiatry residency program. Acad Psychiatry. 2016;40(1):100–104. https://doi. org/10.1007/s40596-015-0304-2.
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22 Use of a Physical Education and Nutrition Program to Improve Outcomes Alejandro M. Spiotta1, Raymond D. Turner Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States 1 Corresponding author e-mail: [email protected]
O U T L I N E Introduction
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Deterioration of Personal Health During Residency Training
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Burnout and Resident Attrition
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Exercise Effects on Sleep, Distress, and Fatigue
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Benefits of a Balanced Lifestyle in Physicians and Trainees
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The MUSC Pilot Initiative Health Screening Sleep Quality Physical Fitness Assessments Activity Tracking Psychological Assessments End of Year One Results Interpretation Take-Home Points
281 282 283 283 283 284 284 284 286
Challenges and Pitfalls
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Summary
288
References
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Quality and Safety in Neurosurgery https://doi.org/10.1016/B978-0-12-812898-5.00024-2
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© 2018 Elsevier Inc. All rights reserved.
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INTRODUCTION Placing the needs of the patient above one’s own needs has long been the call of duty badge worn by the physician. Indeed, emergent patient care needs trump immediate personal needs such as sleep, fatigue, hunger, and family commitments. However, personal health and well-being are paramount to leading long and productive careers. Balancing the demands of a busy medical career with personal wellness is a daunting but necessary skill to acquire, yet there is little education of these principles available to physicians in training. For the most part, organized exercise, diet, and personal fitness programs are entirely lacking in modern graduate medical education. The Accreditation Council for Graduate Medical Education (ACGME) requires the mastery of 7 core competencies among physicians in training. The goal of modern graduate medical education should be to instill its trainees not only with medical knowledge and procedural competency that allows individuals to function as independent physicians, but also the importance of lifelong learning, interpersonal skills, and personal well-being that will ensure career success, longevity, and satisfaction.
DETERIORATION OF PERSONAL HEALTH DURING RESIDENCY TRAINING Medical students are, in general, active individuals and exercise more frequently than the general population. In fact, most exercise routinely with moderate-intensity activity of at least 2.5–4 h per week.1,2 Most studies evaluating the exercise habits of resident physicians have demonstrated a significant reduction in exercise during graduate medical education compared to medical school.1,3–5 In addition, dietary habits may deteriorate during the long hours of residency training. In association with changes in sleep patterns, this may predispose resident physicians to weight gain.6 A Brazilian study of resident physicians showed that many were overweight or obese and many self-reported weight gain during residency, particularly males. However, both male and female residents reported poor diets with high intake of sweets and saturated fats with low intake of vegetables and fruits.7 Sleep deprivation and poor sleep quality from long work hours, rotating shifts, and interrupted sleep are commonplace.8 With changes in resident duty hour regulations to help limit fatigue and reduce medical errors, there has been an unclear effect on resident sleep quality.9 In the context of long hours and alternating shift and sleep cycles, the lack of
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exercise and poor dietary choices may have negative short- and long-term consequences on physician physical and mental health.
BURNOUT AND RESIDENT ATTRITION The percentage of resident physicians reporting burnout during training is unacceptably high. Burnout, a term used to describe feelings of emotional exhaustion, low self-accomplishment, and depersonalization associated with the work environment, is gaining ground as an important marker for resident well-being. Unfortunately, burnout is reported in the majority of resident physicians on surveys, regardless of the specialty. Anywhere from 47% to 70% of residents report burnout during training.10–15 Residents who report burnout and personal distress are probably more likely to make medical errors16,17 and report suboptimal care for their patients.18 Residents with burnout may be more likely to display unprofessional behaviors.19 In addition, burnout and personal distress is associated with resident attrition (quitting or changing residency programs or specialties). Attrition among surgical residents is not uncommon. In the specialty of general surgery, it has been suggested that about 1 in 5 residents fail to complete residency training.20,21 One study of attrition rates across clinical specialties demonstrated rates 2%–7%.22 In neurosurgeons, attrition rates 15%.23 In one survey of general surgery residents, nearly 60% of residents strongly considered leaving their program. Sleep deprivation was the most cited reason for considering leaving, while support from other residents was one of the most common reasons for deciding to stay.20 These studies suggest that programs that help to improve team building support structures and mitigate poor quality sleep may potentially reduce resident distress and attrition.
EXERCISE EFFECTS ON SLEEP, DISTRESS, AND FATIGUE There is no question that exercise is important for physical health. Exercise is an effective means of losing weight, maintaining a healthy body weight, and preventing disease.24 In fact, lack of exercise has clearly been linked to the development of chronic diseases.25 The beneficial effects of exercise on health-related quality of life are well documented.26–30 Exercise is an effective therapy for depression in young adults.31 Exercise interventions may be beneficial in reducing the symptoms of depression.32 Patients who engage in regular exercise often report improved sleep quality, higher sleep efficiency, and shorter sleep latencies.33–36
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Further, exercise is beneficial in reducing the symptoms of fatigue in certain patient populations, such as those with cancer-related fatigue.37,38 In addition, physical activity may improve self-esteem and feelings of self-worth in young adults.39 These studies suggest that subjects engaging in routine physical activity may benefit from improved self-esteem, decreased depressive symptoms, reduced fatigue, and better quality sleep. Finally, evidence supports the benefit of interventions designed specifically for increasing physical activity and healthy behaviors. Systematic reviews of interventions that promote physical activity have a positive effect on self-reported activity40 and may result in persistent improvements in physical and mental quality of life in healthy individuals.41 Similar to exercise, dietary interventions may also improve quality of life.42
BENEFITS OF A BALANCED LIFESTYLE IN PHYSICIANS AND TRAINEES While there are limited published data on the health and well-being benefits of physical activity on physicians, there are some data supporting a positive effect of exercise. Physicians with healthy behaviors are more likely to be satisfied with their occupation.43 A study has suggested that restful sleep and exercise have a positive effect on personal well-being in residents.44 Further, physicians who are engaged in regular exercise are more likely to counsel their patients regarding the benefits of physical fitness.45 Historically, a “resident” physician lived in the hospital and was entirely devoted to caring for their patients; thus, personal health was abandoned in the pursuit of a medical education. We now teach residents in the context of enforced duty hour restrictions. However, it is commonplace for physicians (residents and faculty) to be “too busy” to frequent the doctor for routine visits such as health screenings that they themselves would outline for their own patients. Chronic diseases with courses that can be either modified or entirely prevented can thus go unnoticed for many years, causing irreparable damage; for example, undiagnosed hypertension or hypercholesterolemia leading to cardiovascular disease or stroke. In addition, there are increasing data suggesting that psychological distress and burnout are common among physicians and other health care providers. An alarming majority of residents report burnout during training,9–14 but these issues do not end with completion of residency. Nearly 50% of US physicians report symptoms of burnout.17 With an expanding understanding of the health consequences of medicine on the provider, there has been an increasing focus on improving physician well-being.46–48
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THE MUSC PILOT INITIATIVE To address these alarming baseline traits of young physicians, we implemented a voluntary wellness initiative involving both faculty and residents of the Department of Neurosurgery at the Medical University of South Carolina. This quality improvement initiative encourages and educates participants on the importance of a balanced lifestyle emphasizing exercise and nutrition and provides support and resources to achieve such goals.49 The primary goals of the wellness initiative are twofold: (1) establish lifelong habits of personal health and (2) build resiliency among the resident core. The wellness program was implemented in July of 2015 and available on a voluntary basis to all faculty and resident physicians, advanced practice providers, and other staff members within the department. Weekly wellness lectures on exercise, diet, alcohol avoidance, and mental health are incorporated into weekly departmental conferences. Healthy food choices were provided at these lectures and at conferences. Team-based 1-h exercise sessions under the guidance of strength and conditioning trainers were incorporated into the work week. Gym memberships along with team uniforms were provided to participants to promote camaraderie and attendance. A detailed description of the program and its goals may be found elsewhere.49 This program encourages and educates participants in the importance of regular exercise, balanced nutrition, stress management, and adequate sleep, among others, in a team-based approach with scheduled exercise sessions and team building activities. The aim is to increase awareness of the importance of a balanced lifestyle and provide support and resources to establish lifelong habits of personal health. All participants underwent baseline health screening information (vital signs, serum lipid panel, etc.) as well as body composition analysis (InBody, Cerritos, California). General fitness assessments were obtained as well as psychological and sleep instruments. Six faculty neurosurgeons (mean age 37.7 6.4 years) and 9 neurosurgery resident physicians (mean age 30 2.8 years) volunteered to participate in the Wellness Initiative. Resident participation includes those in postgraduate years 1–7. Faculty participants include both junior and senior faculty members. All participants indicated that they wished they had more time to take better care of themselves (Fig. 22.1). Further, all believed exercise and nutrition are important aspects of a healthy lifestyle and would prioritize incorporating 30 min of exercise into their daily lifestyle if they had more time in their schedule. Over half (n ¼ 7; 54%) of the respondents considered themselves out of shape, and only 38% (n ¼ 5) considered themselves to have an active lifestyle. The vast majority (n ¼ 11; 84%) of respondents indicated that work frequently gets in the way of exercising and eating well.
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FIG. 22.1 Survey responses of resident physician participants of the “La Sierra” wellness initiative (n ¼ 11).
Health Screening Health screening demonstrated abnormalities in 80% (n ¼ 12) of participants. These included an elevated resting systolic blood pressure in 60% (n ¼ 9), elevated resting diastolic blood pressure in 67% (n ¼ 10), elevated serum fasting total cholesterol (hyperlipidemia, HLP) in 2 individuals (13 %), elevated serum low-density lipoprotein (LDL) in over half of the participants (n ¼ 8; 53%), and elevated serum triglycerides (TG) in one participant (7%). Body composition analysis demonstrated body weight higher than ideal in 69% (n ¼ 9). Body fat percentage was 21.5% 8.6% (range 10.7%–38.2%) and visceral fat level was 8 5.4 (range 3–20). Average body mass index (BMI) was 27.6 4.6 (range 23.3–40.3). Of the participants, 47% were overweight based on BMI criteria while 13% were defined as obese. Recommended average body fat mass reduction, calculated by InBody as the fat reduction required to reach ideal weight, was 25.4 27.4 lbs (range 0.4–86 lbs) (Fig. 22.2).
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FIG. 22.2
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Participants in the MUSC La Sierra program.
Sleep Quality About 36% (n ¼ 5) of respondents indicated a possible sleep disorder, defined by a score of 10 or greater out of a maximum score of 24. The mean Epworth Sleepiness Scale score was 8 3.7 (range 0–15). The average amount of sleep obtained per resident per day was 6.5 22. 9 h (range 6.2–8.4 h) as determined by Fitbit measurements during sleep.
Physical Fitness Assessments Participants exhibited a wide range of baseline fitness levels as evidenced by the baseline fitness testing. The mean time to run one mile was 7 min and 59 s (range 5:59–15 min). The average number of push-ups completed in 2 min was 45 (range 0–75), average sit-ups performed in 2 min was 52 (range 1–84), and mean number of pull-ups completed was 8 (range 0–18).
Activity Tracking Fourteen days of activity were tracked continuously (for nine residents) with Fitbits, with the exception of time scrubbed into an operation. Participants walked an average of 10,030.6 4717.3 steps daily, translating to walking 6.2 2.9 miles. On average, 7761.9 4139.7 steps (4.8 2.6 miles)
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were performed during hours at work, representing 77% of the steps taken. Thus, only 2268.7 steps on average were taken during off hours. Average caloric expenditure was 3153.3 1552.1 calories daily. The average basal metabolic rate (BMR) was 1906.6 198.6 calories; therefore, the net daily difference was 1246.7 276.5 calories. Average basal heart rate (HR) was 61.2 7.0 beats per minute (BPM). Average HR at work was 79.0 11.9 BPM. On average, HR at work increased by 17.8 5.0 BPM.
Psychological Assessments Baseline psychological assessment results are shown in Table 22.1. The mean score on the PHQ-8 was 5 4.3 (range 1–18) out of a possible 24 points. Results from the survey indicate 62% of residents and faculty (n ¼ 8) with minor or no depression (score of 1–4), 38% (n ¼ 5) with mild depression (score of 5–9), and 1 (7%) with moderately severe depression (score of 15–19). None scored with severe depression (20–27). Over threequarters of residents and faculty (n ¼ 11; 79%) reported below average quality of life compared to a healthy adult mean of 90 points.1 Importantly, one individual (7%) reported moderately severe depression, the presence of generalized anxiety disorder, and a below-average quality of life score.
END OF YEAR ONE RESULTS Over the course of the first year of the program, resident physicians experienced improvements in psychological assessments of generalized anxiety and quality of life from baseline to final assessment. The Generalized Anxiety Disorder 7-item scale demonstrated significant improvement with scores decreasing from 4 to 2.1 (P ¼ .04). The Quality of Life Scale demonstrated significant improvement of scores (P ¼ .007) and a lower percentage of participants with scores below the general public average, improving from 77.8% to 33.3%. The Epworth Sleepiness Scale demonstrated significant improvement of scores (P ¼ .019) and a lower percentage of participants with abnormal scores, improving from 33.3% to 10%.
Interpretation Baseline health and psychological screenings have demonstrated alarmingly prevalent abnormalities on cardiovascular screenings, body composition, and mental health status of the neurosurgery residents at
3. THE PRACTICE OF QUALITY AND SAFETY IN NEUROSURGERY
Assessmenta
Scoring range b
General population mean score (SD)
Abnormal range
Baseline sample mean score (SD)
Baseline range
Baseline % abnormal scores
Final sample mean score (SD)
Final range
Final % abnormal scores
P-value
2.7 (3.2)
0–10
10
0.1360
2.1 (3.1)
0–9
0
PHQ-8
0–27
6.6 (5.5)
10+
4.1 (2.4)
1–9
0
GAD-7
0–21
3.0 (3.4)
8+
4 (2.7)
0–7
0
c
QOLS
16–112
90
Epworth
0–24
4.6 (2.8)
d
0.0390 d
Not defined
82.4 (10.1)
72–103
77.8
95.4 (12.3)
73– 112
33.3
0.0066
11+
8.3 (2.7)
4–12
33.3
5.7 (4.1)
0–14
10
0.0185
END OF YEAR ONE RESULTS
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TABLE 22.1 Results of Psychological Surveys and the Epworth Sleepiness Scale
a
PHQ-8, Personal Health Questionnaire Depression Scale; GAD-7, Generalized Anxiety Disorder 7-item Scale; QOLS, Quality of Life Scale. b Minor or no depression (score 1–4), mild depression (5–9), moderate depression (10–14), moderately severe depression (15–19), severe depression (20–27). c Mean score of 90 in the general (healthy) population. Mean scores for patients with rheumatoid arthritis are 83, fibromyalgia 70, and posttraumatic stress disorder 61. d Percentage of sample with QOLS scores below the general population average.
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our institution. Further, surveys have identified physician obstacles to leading a healthier lifestyle. It became evident that a change in culture is required to achieve wellness among neurosurgery physicians at our institution, which may also be applicable to other centers across the country. These results are particularly concerning given the fact that four of the residents were former scholarship collegiate athletes, two had a former military background, and all played competitive individual or team sports at some point in their higher education. Thus, we described a striking phenomenon: young physicians, who were previously scholar-athletes and had successfully achieved a balanced lifestyle (mind and body), undergo very rapid and drastic physiological, psychological, and biochemical changes in response to the current conditions they are exposed to during neurosurgery training. These maladaptive changes only serve to weaken the disposition of the resident physician and do not support career productivity and longevity.
TAKE-HOME POINTS Paradoxically, there has been little emphasis on physician wellness in organized medicine until very recently. Health care providers traditionally have been expected, under external and/or internal forces, to neglect their own personal health to place the well-being of patients first. This certainly holds true in the field of Neurosurgery. Evolving societal and professional attitudes, generational differences, and patient expectations (e.g., public outcry for work hour regulations during residency) have led to the broader realization that physician wellness may benefit not just the provider but also the patient under their care. This recent interest is reflected in the burgeoning implementation of “wellness” programs throughout medical institutions across the country. The ACGME has begun to focus on means of improving trainee well-being,47 with a few programs around the country introducing wellness initiatives on a small scale. A “resiliency” program to help family medicine residents at risk for burnout has been described50 as well as a wellness initiative for psychiatry residents51 and our own program in neurosurgery.49 Studies have found that resident physicians significantly reduce regular exercise during graduate medical education compared to medical school1,3–5 due to long work hours, resulting in lack of energy and time to participate in exercise.5 In addition, dietary habits deteriorate during the long hours of residency training which contribute to weight gain.6,7 Sleep deprivation with poor sleep quality are also commonplace.8 The psychological consequences of work-related stress are becoming well established. Burnout, a term used to describe feelings of emotional
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exhaustion, low self-accomplishment, and depersonalization associated with the work environment, is gaining ground as an important marker for resident well-being. Physician burnout and depression is a known contributor to suboptimal patient care10–18 and displays of unprofessional behaviors that disrupt team dynamics.19 In some instances, burnout leads to physicians quitting or changing specialties. In the specialty of general surgery, 1 in every 5 residents fails to complete residency training.20,21 Among neurosurgeons, attrition rates 15%.23 The challenge to resident educators is to devise a learning environment wherein the necessary medical and surgical skills can be acquired while building resiliency. Only then can we truly prepare our graduating residents for a lifelong productive career. To this aim, we devised our wellness initiative; thus far, the results have been positive and have encouraged its continued implementation as well as possible dissemination to other training programs. Regular group exercise, team building, and promoting a change in culture led to improvements in team camaraderie, quality of life, anxiety, depression, and sleep. The majority of participants felt it exerted a positive influence on their own physical and mental well-being, was a positive addition to our department, and believed it ought to be incorporated into other residency training programs. Furthermore, the majority reported that participating in the wellness program did not interfere with either clinical or academic responsibilities.
CHALLENGES AND PITFALLS There were several challenges to the implementation of this program. Although every program at every institution will face unique obstacles, some are universal. First, the “old guard” culture. Some attendings, especially of older generations, may oppose the notion of a wellness program for its residents. Similar initiatives may be dismissed as a lack of commitment to the field or a perceived “weakness.” Results such as those achieved and described in this study contradict this notion; we are building resiliency in our residents. This “toughness” and “grit” will equip them with the necessary mental and physical reserve to persevere under any adverse conditions (resiliency). Establishing a balanced lifestyle will serve them well in the future when faced with other challenges relating to being an academician including balancing clinical, academic, teaching, and family responsibilities. Participation by the chairman and program director in our own department greatly helped to drive the change in culture required to gain acceptance of this novel initiative (“lead by example”). Secondly, the costs of implementing a wellness program may be prohibitive at some institutions. We funded the initiative with educational
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grants and philanthropy. We have kept our hospital administration updated on our progress and now plan to present our data to justify an incentive plan that would make it self-funded for years to come. Third, resident availability, especially in neurosurgery, is always a challenge to participation. Our advice is to do the best you can as a group, realizing that some weeks’ participation may be less than ideal. Celebrate the weeks with full participation rather than be frustrated at the weeks with poor turnout. Protected time in the real-world delivery of patient care is a falsehood. While the availability of advanced practice practitioners can help free the residents, emergent patient care matters remain the priority. Participation in the weekly group workout is only available to residents who do not have any pressing clinical matters to attend to. Fourth, risk of injury may deter some institutions and participants. Beginning an exercise regimen will inevitably predispose to musculoskeletal injuries, some of which could temporarily affect a resident’s ability to participate in their daily duties such as perform surgery. Risk of injury should be managed at all times. We have done so by incorporating workouts directed by certified physical trainers and avoiding activities that are higher risk.
SUMMARY While the sample of physicians in our study is small and in a specialty characterized by high stress, we believe the results are generalizable. Given the significant percentage of resident and attending physicians with symptoms of burnout, it is likely that similar patterns may be seen in other specialties, both surgical and medical. Our data suggest that voluntary wellness programs that provide physical and psychological assessments may be helpful in identifying previously undiagnosed physical or mental conditions and in promoting healthy choices that improve physician productivity, happiness, and satisfaction. We believe a wellness program such as the one implemented in our institution may have universal benefits in residency training programs and may serve as a template for other programs interested in enhancing physician wellness.
References 1. Stanford FC, Durkin MW, Blair SN, Powell CK, Poston MB, Stallworth JR. Determining levels of physical activity in attending physicians, resident and fellow physicians and medical students in the USA. Br J Sports Med. 2012;46:360–364. 2. Frank E, Carrera JS, Elon L, Hertzberg VS. Basic demographics, health practices, and health status of U.S. medical students. Am J Prev Med. 2006;31:499–505. 3. Levey RE. Sources of stress for residents and recommendations for programs to assist them. Acad Med. 2001;76:142–150.
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4. Suskin N, Ryan G, Fardy J, Clarke H, McKelvie R. Clinical workload decreases the level of aerobic fitness in housestaff physicians. J Cardpulm Rehabil. 1998;18:216–220. 5. Williams AS, Williams CD, Cronk NJ, Kruse RL, Ringdahl EN, Koopman RJ. Understanding the exercise habits of residents and attending physicians: a mixed methodology study. Fam Med. 2015;47:118–123. 6. Mota MC, Waterhouse J, De-Souza DA, et al. Sleep pattern is associated with adipokine levels and nutritional markers in resident physicians. Chronobiol Int. 2014;31:1130–1138. 7. Mota MC, De-Souza DA, Rossato LT, et al. Dietary patterns, metabolic markers and subjective sleep measures in resident physicians. Chronobiol Int. 2013;30:1032–1041. 8. Mansukhani MP, Kolla BP, Surani S, Varon J, Ramar K. Sleep deprivation in resident physicians, work hour limitations, and related outcomes: a systematic review of the literature. Postgrad Med. 2012;124:241–249. 9. Reed DA, Fletcher KE, Arora VM. Systematic review: association of shift length, protected sleep time, and night float with patient care, residents’ health, and education. Ann Intern Med. 2010;153:829–842. 10. Gelfand DV, Podnos YD, Carmichael JC, Saltzman DJ, Wilson SE, Williams RA. Effect of the 80-hour workweek on resident burnout. Arch Surg. 2004;139:933–938 [discussion 938-940]. 11. Ripp JA, Bellini L, Fallar R, Bazari H, Katz JT, Korenstein D. The impact of duty hours restrictions on job burnout in internal medicine residents: a three-institution comparison study. Acad Med. 2015;90:494–499. 12. Ripp J, Babyatsky M, Fallar R, et al. The incidence and predictors of job burnout in firstyear internal medicine residents: a five-institution study. Acad Med. 2011;86:1304–1310. 13. Kimo Takayesu J, Ramoska EA, Clark TR, et al. Factors associated with burnout during emergency medicine residency. Acad Emerg Med Off J Soc Acad Emerg Med. 2014;21: 1031–1035. 14. Yost MG, Johnson JC, Johns 3rd MM, Burchett KD. Burnout among osteopathic otolaryngology residents: identification during formative training years. J Am Osteopath Assoc. 2014;114:632–641. 15. Campbell J, Prochazka AV, Yamashita T, Gopal R. Predictors of persistent burnout in internal medicine residents: a prospective cohort study. Acad Med. 2010;85:1630–1634. 16. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296: 1071–1078. 17. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302:1294–1300. 18. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358–367. 19. Dyrbye LN, Harper W, Moutier C, et al. A multi-institutional study exploring the impact of positive mental health on medical students’ professionalism in an era of high burnout. Acad Med. 2012;87:1024–1031. 20. Gifford E, Galante J, Kaji AH, et al. Factors associated with general surgery residents’ desire to leave residency programs: a multi-institutional study. JAMA Surg. 2014;149:948–953. 21. Burkhart RA, Tholey RM, Guinto D, Yeo CJ, Chojnacki KA. Grit: a marker of residents at risk for attrition? Surgery. 2014;155:1014–1022. 22. Kennedy KA, Brennan MC, Rayburn WF, Brotherton SE. Attrition rates between residents in obstetrics and gynecology and other clinical specialties, 2000-2009. J Grad Med Educ. 2013;5:267–271. 23. Lynch G, Nieto K, Puthenveettil S, et al. Attrition rates in neurosurgery residency: analysis of 1361 consecutive residents matched from 1990 to 1999. J Neurosurg. 2015;122:240–249.
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