From the Grassroots on Up: A Focus on Well-being

In this month’s letter, Dr. Rick Valachovic shares news of the movement to build resilience among health professionals.

The statistics are alarming. So many physicians commit suicide that in any given year it could take up to four medical school classes of 100 graduates to replace them. No one tracks the number of physicians in training who end their own lives, but a systematic review and meta-analysis published last December in JAMA, the Journal of the American Medical Association reported that 11% of medical students consider taking this action.

Compared with the general public, physicians are roughly twice as likely to commit suicide, and for decades we’ve assumed that dentists were also at higher risk, even though studies in the 1970s and ‘80s found no evidence to support that assumption. Does that mean our profession doesn’t have a problem? Hardly. It simply means our profession lacks definitive data about what is truly happening with students, residents, fellows and practitioners when it comes to burnout, depression and suicide.

What we have studied is dental student stress—undoubtedly a precursor to these other phenomena. In 2014, researchers at McGill University Faculty of Dentistry conducted a systematic review of the literature on stress in dental students. The researchers found that considerable amounts of stress emanate from the demanding nature of dental education, specifically examinations, grades and workload. Interestingly, dental students reported higher levels of stress than their medical school counterparts—reason enough for ADEA to give serious consideration to how we can promote wellness, well-being and resilience among faculty and students.

Definitions of wellness vary and can be extensive, but for simplicity’s sake, the Merriam-Webster dictionary defines it as “the quality or state of being in good health.” Wellness is also a component of well-being, which comprises not just physical health, but (depending on which definition you use) social, psychological, financial, spiritual, career and other dimensions of health. Resilience is defined as “an ability to recover from or adjust easily to misfortune or change.”

We used the ADEA Joint Council Administrative Boards (ADEA JCAB) annual business meeting at the ADEA offices in Washington, DC, earlier this year to begin discussing how we might foster these qualities in our members. ADEA Chief Policy Officer Denice Stewart, D.D.S., M.H.S.A., organized that meeting, and she will also be presenting on becoming a resilient leader at the 2017 ADEA Sections on Business and Financial Administration and Clinic Administration (ADEA BFACA) Meeting this coming October.

But this is not just a top-down initiative. Wellness, well-being and resilience have also been on the minds of ADEA Council of Faculties members over the past year. Inspired by what they learned at the ADEA JCAB meeting, some of these individuals decided to take action. As a first step, they developed a common understanding of what these concepts are all about and used a portion of their ADEA Annual Session & Exhibition business meeting to share what the literature says on wellness, well-being and resilience with the rest of their Council.

“We wanted people to leave with long-term, short-term and in-the-moment strategies they could employ immediately,” says Sophia Saeed, D.M.D., Associate Professor of Preventive and Restorative Sciences at the University of California, San Francisco, School of Dentistry (UCSF SOD). Sophia took the lead in developing the training. “We wondered,” she told me, “could we take small steps in our own behaviors, in the way we react to certain situations, so that we are better to ourselves and better role models for our students?”

Forty people attended the session and found it useful, as did a smaller group at UCSF SOD, so the Council is now partnering with the ADEA Council of Deans and the ADEA Council of Students, Residents and Fellows to develop new programming with a broader goal.

“This will be more of a dialogue,” Sophia told me. “Depression, burnout, suicide—these things are still stigmatized topics. Our goal for the Annual Session meeting will be to hear about these issues from the perspectives of the students, the faculty and the administrators and to ask, ‘How can we all work together to solve this problem?’”

Sophia believes that everyone, not just those in formal leadership positions, can make a contribution. “The way you behave has an impact on everybody around you. We know that from science,” she says. “A grassroots movement where everyone made a commitment to being kinder to each other, that could really have a huge impact on educational and health care institutions.”

That’s a compelling vision, and individuals who embrace it should find considerable institutional support. In the last year alone, major entities have publicly expressed their concern that stress among health professionals is taking too great a toll on providers and putting the quality of care at risk.

• The National Academy of Medicine has convened the Action Collaborative on Clinician Well-Being and Resilience to study the problem. Last month, the ADEA Board of Directors approved ADEA’s participation as a sponsoring member. As part of this initiative, I was privileged to be part of an interprofessional group that authored a discussion paper laying out a systems approach to addressing these issues in both education and practice.
• The Accreditation Council for Graduate Medical Education has begun studying deaths among residents to gain insight into the phenomenon and how it might be prevented.
• Our sister organization, the Association of American Medical Colleges, convened a meeting to address burnout, depression and suicide among physicians.
• More than 62,000 people signed a petition calling on medical associations to address the “culture of abuse” that contributes to these problems.
• The CEOs of 10 health care delivery organizations held a summit, which concluded, “[P]hysician burnout is a pressing issue of national importance for patients and the health care delivery system.” They urged their peers to “embrace physician well-being as a critical factor in the long-term clinical and financial success of our organizations.”

These efforts build on earlier work, including an effort by the American Dental Association (ADA) to help practicing dentists build resilience. In the spring issue of the ADEA CCI Liaison Ledger, ADA Executive Director and Chief Operating Officer, Kathleen O’Loughlin, D.M.D., describes her own commitment to fostering wellness among practicing dentists and its relevance for dental students and faculty members. (Two other articles describe related work by our colleagues at the Dental College of Georgia at Augusta University and at the University of Kentucky College of Dentistry.)

I hope by now most of you have heard of the IHI Triple Aim initiative, a framework developed by the Institute for Healthcare Improvement. The framework’s three goals—better patient care, improved population health, and reduced health care costs—have been a beacon for health systems that want to do better. Since 2014, we’ve heard calls for adding a fourth aim: improving the work life of health care providers to address burnout and restore feelings of joy and satisfaction in work. Those calls are growing louder by the day.

It is possible to live with stress and find professional fulfillment, as Kathy’s essay beautifully articulates, but for most people, finding that balance is a challenge. This reality became painfully evident for many in our community with the passing of Jiwon Lee, a predoctoral student at Columbia University College of Dental Medicine who was known to many through her role as President of the American Student Dental Association. And each of us has suffered the loss of other less-familiar individuals as well. I am heartened that our community—and the health professions generally—are now focused on averting future tragedies and restoring balance to the lives of students, residents, fellows, faculty and practitioners. These steps are essential—not just to each individual’s personal health, but to the long-term health of our professions and ultimately, our patients.