The Moral Imperative to Promote Well-Being in our Learners

 From the 9/3/2020 newsletter

Guest Director’s Corner

The Moral Imperative to Promote Well-Being in our Learners

Cassie Ferguson, MD - Kern Institute Student Pillar Director

Dr. Ferguson shares her work exploring the gaps between what we know about well-being and our ability to reliably intervene with our learners …

Early in my career as a physician, I learned about the intimate connection between our own individual well-being and the quality and safety of care we provide to our patients. My interest developed out of my work in quality improvement and patient safety. Over the past ten years, this has led me to focus on the critical importance of promoting well-being among medical students, trainees, and physicians.

As I've learned about the depths of our un-wellness as a profession, my interests have shifted to advocacy; I now see the promotion of well-being and the support of those of us caring for others in the health profession as a moral issue.

Identifying the scope of the problem

It is unconscionable that nearly 40% of medical students are depressed. It is unfathomable that over 400 physicians die by suicide every year. And it is unjustifiable that we have neither centralized the efforts to improve well-being nor pushed them to the forefront of every leader’s strategic plan. As we attempt to understand and work toward solutions, we must begin by acknowledging that many of the drivers of unwellness exist at organizational and societal levels; when the canary dies in the coal mine, you don’t blame the canary’s lack of resilience.

Organizational and environmental factors – like productivity-driven staffing models, lack of diversity, cultures of blame, and workplace violence – absolutely drive our unwellness. Societal factors like systematic oppression and structural violence may impact us personally, particularly if we are a member of a marginalized community, and bear witness to this type of violence regularly.

When we think of interventions, however, we tend to dichotomize well-being into those aspects driven by systemic factors and those driven by individual factors. In reality, these cannot be separated. They are inextricably linked. What this means is that we cannot expect that the impacts of workload, inequitable compensation, or tolerance of institutional prejudice and microaggression will be mitigated by lunch hour meditation for students or yoga classes for clinicians. By the same token, it is just as important to understand that our individual well-being – our capacity for compassion and empathy for our colleagues, our ability to self-regulate, our recognition of the impact that our presence, our biases, our attitudes have on those around us – collectively contributes to the learning environment and workplace culture and thereby the well-being of the entire institution.

I do not define well-being by the absence of depression or suicidality, but rather by a more holistic vision that assumes that, as physicians and physicians-in-training, we might flourish; a vision that leads to encompassing physical, mental and emotional health, embracing joy, and finding meaning.

Recognizing the gaps in our understanding of wellness

To realize that vision, many have called for to shift the focus from what drives our unwellness to what may help keep us whole. To that end, the National Academy of Medicine (NAM) launched the Action Collaborative on Clinician Well-Being and Resilience in 2017; one of their goals is to “advance evidence- based, multidisciplinary solutions to improve patient care by caring for thecaregiver.” The ACGME has partnered with the AAMC and the NAM to co-chair this action collaborative to help “create a healthier, safer medical community.” Leading researchers in this realm continue to call for more robust research studies designed to evaluate interventions aimed at improving well-being.

Despite these efforts, there are still no multi-center, randomized, placebo- controlled studies that definitively point to interventions that, if implemented, will make us all well. Frankly, I do not believe that even the most perfectly designed study will ever reveal the value of such an intervention. In the studies we have done with medical students at MCW through the Kern Institute, it is quite clear that what works for one student may not work for another. And my three-year experience as the chair of the professional health committee atChildren’s Wisconsin has helped me to understand how local, even systemic, drivers act.

Understanding this, I propose that, in our quest to elucidate effective well- being interventions, we shift from asking, “what works?” to “what works for whom, under what circumstances, and why?”

To this end, our team has shifted to using Design Thinking tools, quality improvement methodology, and profile analysis in this work. Although we can efficiently summarize testing results from students on psychological, behavioral, or social measures into a “mean score,” it is fair to say that the mean often provides very limited information in helping students, because it masks differences that exist in student trajectories. That is, the mean can often hide the trajectories of students who have different patterns, needs, strengths, and weaknesses, hiding heterogeneity by homogenizing everyone to one value. As educators, the differences in trajectories is where our first lever of facilitating change lies.

Expanding the analyses of student wellness diversity

We need to go beyond the mean by focusing on analyses that will allow us to understand groups of students with similar patterns of responses across a variety of important behavioral, cognitive, and social dimensions. This is where analyses like latent profiles analysis (LPA) comes into play. LPA is a statistical analysis that helps researchers identify groups of individuals that have similar and different responses patterns on measures or tests. Combining LPA with trajectory analysis (time series/growth modeling) results in a very powerful way to look at students over time. These types of analyses help uncover sub- groups of students, map their trajectories over their medical school careers, and provide a way to understand what helped students improve, decline, feel joy, or struggle. Supplementing these analyses with student voices through open-ended questions, focus groups, and interviews creates a deeper understanding of our students. This information can help educators design and enhance curricula that support students with various needs, leaving no student behind on either end of the distribution, with a long-term focus on supporting their growth over time.

Ultimately in our well-being work at MCW, the goal is to combine LPA, growth trajectories and qualitative analyses to understand how a number of psychological (e.g., mindfulness), social (e.g., perceived social support) and behavioral measures (e.g., intrinsic/extrinsic motivation) relate to skills fundamental to the practice of medicine: how students’ communicate with patients and colleagues, how they work in teams, and how they navigate the complexities of being present for the suffering of other humans.

Acknowledgement: Thank you to Tavinder Ark, PhD of the Kern Institute for her contributions to this article and for her consistent and innovative work in the study of student well-being.

Cassie Ferguson, MD is an Associate Professor of Pediatrics (Emergency Medicine) at MCW. She leads the MCW M1 and M2 REACH curriculum focused on promoting wellness. She is the director of the Student Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.