It was still dark when the vascular surgeon awoke to bicycle for an hour and then prep a quick breakfast for the kids. On the way into UPMC Presbyterian, he dropped his teenage daughter off at her babysitting job. By 7:15 a.m., he was already in the OR, head bent over the table, beginning the first of the day’s 11 operations.
Some surgeries were scheduled outpatients. Others were emergencies that required triaging cases. One patient was at risk of hemorrhaging with a life-threatening aneurysm. Breaks were unpredictable and a luxury when they came.
During his return commute around 6 p.m., Rabih Chaer, a professor of surgery at the University of Pittsburgh, logged onto a conference call with a research committee. At home, he put a chicken pot pie from Costco into the oven for his three teenage children. They tossed up a salad. It was a simple meal. Still, eating dinner together was a blessing, especially in the year 2020.
A decade ago, Chaer’s work days were just as busy, but often less pleasant. Chaer tended to be easily irritated. An OR delay was intolerable. He was short with his colleagues. Distant from his family. As a junior faculty member working long hours to prove himself in his career, he says in retrospect, he expected perfectly executed plans from everyone around him so that his time was never wasted.
Chaer was burned out and going through a divorce when he did a routine procedure on a marathon runner and saved the man’s legs.
The patient, Sam Madow (not his real name), was the organizer of an annual race in Indiana, Pennsylvania, that raised funds for veterans. At a follow-up appointment, Madow invited Chaer to run.
“Me?” Chaer thought. The idea was almost laughable. He was overweight. Hadn’t exercised in years.
“C’mon, Doc,” Madow said. “I’ll run with you.”
Chaer ran a relay segment at Madow’s race.
A couple of years later, he and Madow ran the Pittsburgh half-marathon together.
Chaer kept at it. He became an Ironman, competing in triathlons and even a 220-mile race across Haiti. He’s now in better mental and physical shape than he’s been in years.
“[Sam] thinks he may have owed me because I saved his legs,” Chaer says. “But I owe him big time.”
A 2009 study on career satisfaction asked vascular surgeons who are parents whether they would recommend their job to their children. More than half said no.
In the past decade, studies in the Journal of the American Medical Association, New England Journal of Medicine, Nursing and elsewhere have confirmed what many knew anecdotally: Workers in hospitals and clinics around the country experience alarming rates of burnout and depression. All generations are experiencing this: trainees, leaders with decades of experience and students, as well.
In 2018, Chaer delivered a presidential address on burnout to the Eastern Vascular Society. He relayed data from recent literature: The prevalence of burnout for health care professionals was higher than the general population; depression or depressive symptoms among medical students was 27%; 39% of residents were experiencing burnout and 48% of them were at elevated risk of depression.
As director of Pitt Med’s vascular residency program, Chaer found the results of one study to be particularly concerning: Although residents correctly estimated how many of their peers were experiencing burnout, faculty incorrectly guessed a much lower rate. He pointed out that consequences of burnout can include medical errors, reduced professionalism, reduced patient satisfaction, staff turnover, depression, suicidal ideation and car crashes.
“We have a professional obligation to act,” he told the audience.
Chaer shared his personal story of how running with Madow helped him move beyond burnout. It’s not like everything turned to gold under winged running shoes, but his lifestyle change has been transformative. He can sleep through the night. His mind is calmer. He’s more attentive to his kids. He’s more efficient at work.
Chaer knew he wasn’t alone in his struggle to balance his life. He wanted to help colleagues. Last year, with a grant from the UPMC Physician THRIVE program, he started his first research project related to physician wellness. He’s interested in simple solutions to the stress that cardiologists, as well as vascular and cardiac surgeons, deal with.
“This group of physicians essentially deals with stressful situations on a daily basis because of the acuity of the medical problems their patients can have. We’re dealing with life and death situations.”
He’s interested in helping with physical stressors, too: “We are sometimes wearing a lead apron to protect against radiation exposure because we work with X rays. That can put a bit of stress on the neck and the physician’s spine. Physicians are also oftentimes wearing magnifying loupes, and your neck is bent for several hours at a time,” Chaer says.
Throughout the yearlong study, participants will complete questionnaires and provide hair samples to be tested for levels of stress-induced cortisol. Chaer and his team had planned to launch the study in . . . 2020. Yeah. It launched later than expected, in part because the team added a parallel study to address even more critical needs. “We decided to do a similar intervention targeted toward providers taking care of patients who have COVID-19, because one can only imagine the amount of stress they are under,” Chaer says.
"Managing the emotional experience of working in the ICU is part of the job,” says Ian Barbash, Pitt assistant professor of medicine in the Division of Pulmonary, Allergy and Critical Care Medicine, who treats COVID-19 patients. It’s a challenging part of the work in normal times—all the more so in the pandemic. “The scale, the volume and the acuity of the patients is something that is not familiar to most, even experienced clinicians,” he says.
Many COVID-19 patients are more alert than other patients typically entering the ICU, in part because COVID-19 evolves in a way that other diseases like pneumonia do not, Barbash explains. It means the care team gets to know many patients, making it even harder to watch some of them decline.
Staff get to know family members, but often only virtually. Ed Zettl, a nurse in the first dedicated COVID unit at UPMC Mercy, said that when he does rounds at the beginning of each shift, he asks patients about their families or talks virtually with family members because, inevitably, others are also sick or in quarantine. He educates everyone as best as he can about staying safe and gives referrals to the social work team.
Zettl has been a nurse for 12 years.
“I love what I do,” he says. In some ways, life has been more challenging outside work without his usual extracurriculars—hitting the gym, heading to the ballpark for Pirates games.
Barbash says that before the pandemic, he was able to maintain a reasonable separation between work and home life. Then, the whole family was home on lockdown. It was hardest for his wife, who suddenly had to work from home while taking on most of the care for their three children. Barbash was not only working some shifts in the ICU at UPMC Presbyterian, but also working from his basement with two computer monitors and a headset to help build the new UPMC TeleICU program that gives virtual support to providers on the front lines.
Barbash is the medical director of the TeleICU. He has put in long hours getting the system up and running, but the work has been meaningful, he says. The program is designed to help bedside providers at hospitals where there isn’t an ICU doctor available at night.
Barbash is on a team that rotates the night shifts for TeleICU, so that has made his schedule more manageable.
Sadness and grief are feelings Barbash has experienced at work before, he says, but now those feelings are combined with anger at the scale of suffering in a pandemic that was potentially avoidable. He bristles at being called a hero; his says his work before the pandemic and in the future is equally important to the patients he serves.
Connecting with colleagues, even remotely, is important for his well-being, he says.
“Feeling like a part of a large group of people—all of whom are committed to an organizational mission to take care of this large population of critically ill patients—that feeling of connectedness does, to some extent, help to mitigate some of the other [negative] emotions,” he says.
Sharing feelings, Barbash adds, helps clinicians validate one another’s experiences: I, too, cried on the way home in the car. Or: Thank goodness, I got my vaccine today!
Zettl points out that there was a lot of public attention for frontline workers in spring 2020. The constant acknowledgment in the form of pizzas and fruit platters has diminished as the pandemic has gone on, so his team has come up with other ways to keep spirits up. One of the most uplifting routines ICU staff added is a Covid Champion celebration for patients as they are discharged. With a congratulatory poster, horn and a bell, staff whoop up some fun. The patients love it, he says.
The self-care folder that appeared at the nurses’ station in the oncology division in 2017 didn’t get a lot of use. The hope was that the folder filled with resources—like free passes for tai chi classes and phone numbers for mental health professionals—would help oncology nurses reduce their risk for compassion fatigue. (Symptoms can include nausea, headaches, insomnia, depression and anxiety.)
Nurses participating in focus groups said they didn’t have much time to look through the folder at work and would have felt guilty taking time away from patient care. At home, they preferred to cherish time with loved ones and follow self-care routines they’d already established. They appreciated the thoughtfulness behind putting together the folder and the resources for providers in crisis, but these gestures didn’t relieve their particular work stressors.
“They said: ‘I’m not minimizing that you put resources into giving us passes to go to yoga or tai chi, but boy, if I would have had an extra nursing assistant to help me . . . I could feel better about the work I do for my patients,’” says Judith Zedreck, Pitt professor of nursing, who researches issues related to nursing retention; she copublished a study on the self-care folder in Nursing last year.
Nurses told her: “What I need from my leadership is acknowledgment of the work I do, and the tools to do my job.”
They expressed a number of ideas for improvement: By all means, hire new staff with signing bonuses, but continue to acknowledge the work of loyal staff; establish a more consistent schedule so that staff aren’t flip-flopping between day shifts and night shifts; and have a leadership presence on night and weekend shifts, not only during business hours.
“A lot of what we can do goes back to those basic principles of leadership,” says Zedreck, coordinator of Pitt’s Health Systems Executive Leadership program for doctoral nursing students. She says the same goes in a pandemic. She held a discussion in July 2020 with current doctoral students and alumni from her executive leadership program who are serving in management roles around the country; they talked about upheaval amid COVID-19 challenges. Their conversation ranged from how PPE distorts interactions with patients to the importance of “consistent communication, even if the message may be different daily.”
A few years ago, Sansea Jacobson, an attending psychiatrist at UPMC Western Psychiatric Hospital, had an idea: We “knew that residents were not immune to stress and burnout, especially those covering the overnight medical call” in the free-standing psychiatric hospital with more than 200 beds. So, she and her colleagues thought they’d offer a workshop with guided sessions on mindfulness and at-work yoga.
“They didn’t want it,” says Jacobson, Pitt associate professor of psychiatry and associate program director in the Office of Residency Training. It was another well-intentioned idea that wasn’t really going to meet anyone’s needs.
“Our initial push to help made us take a step back,” Jacobson says.
So they conducted an assessment that led to a number of actions: Faculty set up simulation training for residents to practice running codes specific to their setting at Western Psychiatric. A physician extender was hired for overnight physicals so residents could focus on patients with urgent needs. A new position was created for a chief resident of well-being (whose role, among other charges, includes regauging the email firehose by compiling announcements into one weekly email).
Jacobson points out that these changes are at the systems level.
The responsibility for well-being, she says, should not be pinned on individual clinicians. Helping to build personal resilience amid the demands of being a clinician is important, but it can’t be the only solution offered by institutions.
For instance, Jacobson and colleagues are exploring systematic ways to reduce stress over the use (some say “bane”) of electronic medical record (EMR) systems. EMR is often partially blamed for the concerns raised in the literature on provider well-being.
“I don’t think I’ve ever read an article [on clinician wellness] that does not focus on [EMR systems],” said Loren Roth, Distinguished Professor Emeritus of Psychiatry, when he interviewed Jacobson for his Psychiatry Advances podcast in October 2020. “Physicians experience the feeling of being cut off from their patients—not exactly what they thought they were bargaining for.”
On the podcast, Jacobson described a project that pairs millennial residents with senior faculty to help them “become more efficient and effective so they can spend more time doing work that is meaningful to them.”
Jacobson also told Roth about a curriculum she and her departmental colleagues are developing to help address systemic racism in graduate medical education.
“There really can’t be well-being” without anti-racism solutions, Jacobson adds.
Jacobson has a reputation as a witty host for UPMC’s Physician Connection Series—she’s an Oprah of sorts, interviewing physician leaders on stage at an evening soiree. The psychiatrist asks them about their lives, including how they built their careers and how they’ve handled missteps and challenges over the years. When she interviewed UPMC Magee-Womens Hospital President Richard Beigi at the 2019 event while they sat in comfy sofa chairs, she noted that there were many wellness champions in the audience.
“A dirty little secret is the word ‘wellness’ makes me cringe,” she said to laughs.
“I find it quite polarizing, and I think a lot of times it’s interpreted in a way that makes physicians feel uneasy—a blaming-the-victim type of issue.” She credited UPMC for recognizing that well-being needs to be addressed at the organizational level.
Jacobson has not only contributed to change within the psychiatry department, which now uses assessments every other year to address well-being needs as they evolve. She has established a framework for all trainee programs across Pitt and UPMC as cochair of the Graduate Medical Education WELL (Well-Being, Education, Learning and Living) committee.
Calls for action from around the country to improve physician well-being led to new national requirements for graduate medical programs by the Accreditation Council for Graduate Medical Education (ACGME). The requirements went into effect in July 2019, mandating that attendings, residents and fellows need be able to recognize symptoms—and know how to seek care for themselves or colleagues—in six areas: burnout, depression, fatigue, substance use, risk for suicide and risk for violence.
At Pitt, Jacobson’s committee launched the online WELL Toolkit (gmewellness.upmc.com) with resources on those six topics gathered from more than 80 clinician educators and experts across the country. Jacobson emphasizes that it was assembled “by physicians for physicians,” with evidence-based content.
The assessment tools and educational modules aren’t designed for individuals per se, but for unit chiefs, program directors and other leaders to use at group sessions. ACGME plans to use it as a national model.
“My favorite part of it, really, is the introduction section where we try to help physicians overcome the stigma related to help-seeking,” Jacobson says. “Physicians are expected to be perfect. That’s self-driven, but it’s also culturally expected. We wanted to help physicians know that it is OK to be human. It’s OK to seek help.”
“Stop the stigma” is a plea from physician alumni around the country who have themselves struggled with burnout and depression. Several spoke anonymously for this story, describing the creeping toll of long hours and the feeling that corporate-minded employers only pretend to care about them. Some are haunted by tragic patient deaths or their own personal traumas like sexual violence. Still, they are committed to their patients. For years they operated as if everything was perfect—until they reached out for help because they couldn’t function in the face of a parent’s death, divorce, cancer diagnosis or other triggering event on top of their work.
Jacobson says getting help is not only a matter of confronting “maladaptive perfectionism,” but also offering answers to practical questions that can overwhelm someone who is struggling to get through their days: Will getting help jeopardize their medical license? Can they afford to pay student loans if they take time off? Who will need to know?
One physician we spoke with feared that speaking publicly could lead to trouble with licensing boards. He recalled being scared when he applied for his medical license because he had to supply documentation from a therapist about a mental health crisis he had been treated for decades prior.
“You work so hard to obtain a professional credential,” he says, adding that it was terrifying that a committee could unnecessarily take away everything he’d worked for. He received his license, but he felt the process was an invasion of privacy, not to mention legally fraught. Many medical state licensing questions violate the Americans with Disabilities Act because they ask about mental health struggles beyond current impairment. Only seven states do not ask mental health questions for licensure, as of 2018. Pennsylvania is one of them.
The physicians welcomed the new national requirements. One alumnus says that based on stories from older colleagues about working around the clock, he doesn’t think he would have made it through residency if national requirements hadn’t limited residents to 80-hour workweeks before he went through training.
Physicians should be better role models when it comes to mental health, he adds, and hopes that the new requirements will help reduce stigma. Physicians are typically first adopters when it comes to healthy living, he said. He doesn’t know any colleagues who smoke. Many exercise regularly and avoid red meat. But those same physicians may hesitate to seek counseling, despite the fact that physicians have higher risks for depression and suicide.
Jacobson’s academic expertise is suicide prevention. She emphasizes that suicide, while relatively rare, is a risk that physicians need to be aware of. One study found that male physicians had a risk 1.4 times higher than men do generally and female physicians had a risk 2.2 times higher than women do in the general population.
The primary risk factor for suicide is an underlying mental health condition, usually untreated depression. Jacobson says clinicians need to be reminded that depression is treatable. And there are treatments that work. (If you’re having harmful thoughts, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text the Crisis Text Line at 741741. See the resource box on page 29.)
Those who get help are almost always glad they did and wish they had done so sooner. Jacobson says there is evidence that, even among doctors who are required to receive treatment (say, for a substance use disorder), the majority are satisfied with their treatment and are practicing five years later.
Often, the first call for help is the hardest. One unit chief recalled diligently writing mental health hotlines on meeting agendas for her staff for years. She never expected that she would need to call the hotline herself. Then one day she did.
Jacobson understands. “When it’s you, you might not see it,” she says.
Several years ago, Jacobson’s marriage dissolved, and she was figuring out how to be a single parent and maintain her career. She thought she could explain away her struggles because of the circumstances. Of course, I should feel sad, she thought.
Finally, her own mother pointed out to her that getting therapy would be beneficial. Her first thought was that she didn’t have time. (In one study referenced in the WELL Toolkit, 92% of physicians said time was a reason why they weren’t seeking mental health care.)
Then she realized her mother was right. The signs were there: Poor sleep. Mind-wandering. Less joy. Feeling muted and subdued, which was unfamiliar to her. It seems so obvious in retrospect that she needed care. She sees patients all day who experience this, but, “I didn’t see it in myself,” she admits.
She is grateful that she sought help. Years later, she’s still a single parent with a busy academic and clinical schedule, but she feels like herself again. She’s more efficient. And she’s a role model for mentees and colleagues.
In the late ’70s, Joseph Maroon, today a renowned neurosurgeon, found himself pumping gas at his family’s truck stop in West Virginia. He was 41 years old. His father died and his wife left him in the same month, and he was trying to keep the business afloat.
“One day I was doing brain surgery at Pitt, and the next week I was flipping hamburgers and filling up 18-wheelers at a truck stop,” Maroon told the Tribune-Review. “I just had no idea how to get out.”
He eventually returned to his career as a neurosurgeon. The Pitt clinical professor and Heindl Scholar in Neuroscience has been speaking publicly for decades about his battle with depression. (He too is an Ironman competitor.) In 2017, he published the book “Square One: A Simple Guide to a Balanced Life” to share what he’s learned.
Jacobson’s WELL committee cochair is Vu Nguyen, associate professor in the Department of Plastic Surgery. He directs the department’s residency program; recruiting is a concern for Nguyen because surgeons aren’t known to have the best work-life balance, and younger physicians are more attuned to not letting work take over their lives. “Surgery will lose out to attracting the future,” he says, if he and his peers don’t take action.
Nguyen says he is inspired by Maroon, who won the 2020 UPMC Clinician of Courage Award; that award is given to a UPMC physician and leader in the community who has overcome adversity.
When mentors like Maroon or Jacobson or Chaer acknowledge that they had challenges and sought help, it’s a powerful affirmation for many colleagues and mentees. The WELL Toolkit cites two studies indicating that “more than 90% of medical students agreed that if they knew doctors further along in their careers who struggled with mental health issues, got treatment and are now doing well, they would be more likely to access care if they needed it.”
In his presidential address, Chaer reminded his audience that clinicians are “uniquely privileged to make a difference, just by showing up to work.”
And when they do report to work, institutions need to make sure that it’s a place where people can find meaning and contribute to a higher purpose, says Jacobson. Everyone should be able to uphold their oaths to heal minds and bodies, she adds, including their own.
As Pitt Med students make their way, they can turn to a number of school programs and resources if they’re struggling:
- Pitt Med’s Student Health Advocacy Resource Program (SHARP) has served as a model for other academic institutions since it was created in the 1990s. In monthly meetings, class representatives and faculty advisors discuss anonymous concerns from classmates. Lauren Auster, a fourth-year SHARP representative, says discussions range from imposter syndrome to equity in medicine to financial instability to grief over patient deaths. Students and faculty not only brainstorm resources and action plans for concerned individuals, but they also put together programming on topics like cognitive behavioral therapy techniques for stressful situations.
- In the ’80s, Pitt Med was one of the first medical schools to hire an in-house counselor for students; several years later, a psychiatrist was added. The counseling staff has since expanded, including the recent hire of a dedicated counselor for PhD students.
- Advisory “houses” assign incoming students to a faculty member and a group of students from every class. This way, first-years already know a second-year who can give advice, and the third-years can, in turn, send advice down the line.
- In 2020, Evelyn Reis, professor of pediatrics, was appointed to the newly established role of associate dean for the learning environment, to support a culture rooted in human dignity for students, faculty and patients.
Beyond these initiatives, Alda Maria Gonzaga, the new associate dean for student affairs, says it’s important for faculty to talk to students about what activities they’re doing to refresh themselves so they can come back to their studies renewed. “The bigger overarching concern is this reality that medicine is expansive, and one could spend all their time trying to learn it,” says Gonzaga.
“That should be a lifelong goal, rather than a short-term goal.” —CM
How Clinicians Can Get Help
Resident and Fellow Assistance Program (LifeSolutions): 412-647-3669
Physicians for Physicians: 412-647-3669
GME Professionalism Concern Line: 1-844-463-4362 (GME-4DOC)
UPMC Threat Assessment and Response Team: 412-647-4969
Local 24/7 resolve Crisis Services: 1-888-796-8226 (7-YOU-CAN)
National Suicide Prevention Lifeline: 1-800-273-TALK (8225)
National Crisis Text Line: Text HELP to 741-741
New Standards for Students
Studies show that students enter medical school with higher levels of well-being than their age-group peers, but then those stats flip in medical school. Learner well-being was the lead topic of the 2020 Association of American Medical Colleges (AAMC) conference. Med students and school administrators nationwide want systems-level changes to prevent and address burnout, notes Joan Harvey, recently retired associate dean of student affairs at Pitt Med.
One national action item that has been checked off: The Step 1 medical licensing exam will soon be evaluated in a pass/fail format, rather than graded, to reduce pressure. Other topics highlighted by the AAMC conference: addressing racism and adding more flexibility to the academic calendar and residency start dates.
Practicing mindfulness meditation sounds lovely, but many go-getters like high-achieving medical students struggle to slow down.
“The thought of sitting still is just a very high barrier to entry,” says Catherine Pressimone, a med student who serves as a co-organizer of the Empowerment Series for Pitt Med’s Wellness Committee.
So Pressimone is setting up art therapy sessions to help her peers (and herself) learn mindfulness techniques that involve keeping their hands busy and their minds present. “If you focus on what’s in front of you, and only what’s in front of you . . . you don’t even realize you’re relaxing,” she says. “And then you’re like, ‘Oh! I feel great now!’”
Pressimone has coordinated sessions on mindfulness in collage art and creative writing and hopes to arrange future classes with community artists.
“Mindfulness is a practice, as in something you do routinely,” she says. “But then practicing also means it’s something that you get better at.” —CM