Fellow's Corner: Bringing Wellness Initiatives into Fellowship Training

Burnout is a well-recognized problem that transcends all fields of medicine. There has been much discussion about burnout in medical students, residents, and attendings. However, pediatric fellows—often board-certified pediatricians but still trainees in their designated subspecialty, couched between medical student, resident and early career physician—have historically been left out of the burnout conversation. As former Children's Hospital of Philadelphia (CHOP) residents and now senior CHOP fellows, we have participated in and benefited from wellness initiatives within the Pediatric Residency Program and have witnessed similar initiatives develop to reduce burnout among faculty in our respective divisions.

Recently, however, the conversation has shifted toward burnout prevention and promotion of wellness among CHOP fellows, largely due to the alarming results of a recent survey of fellows at our institution performed by our colleagues. More than 50% of fellows who responded to the survey met the threshold for burnout, defined as work-related emotional exhaustion, feelings of cynicism and detachment toward patients, and a low sense of personal accomplishment.

Additionally, those who experienced burnout were more likely to report stigma and fear of disclosure of seeking mental health resources. While identifying such trends in our institution is shocking and unsettling, we are proud to discuss the collaborative response to address these concerns.

As co-chairs of the Fellows’ Association, a committee that seeks to support fellow trainees, we have partnered with program leaders to identify drivers of burnout among fellows at our institution with a plan to implement tangible changes. Although the Fellows’ Association sponsors events aimed at bringing fellows together, there is a significant need for support at the institutional level to prevent burnout and promote wellness among fellows. A systematic review and meta-analysis attributes greater success in reducing burnout to “organization-directed interventions” compared to “physician-directed interventions.”

Meanwhile, a recent publication takes this a step further, suggesting that we must identify the “avoidable” and “unavoidable” causes of burnout. The unavoidable causes may be best addressed through resilience training while the avoidable causes require the backing of the institution and system-wide changes.

“Resilience training is not our only hammer, and not every problem that leads to physician burnout is a nail.” -Alan J. Card, PhD, MPH

Although we have dug through the literature, brainstormed individually, and identified potential initiatives to reduce burnout, we recognize the critical importance of listening directly to the voices of fellows themselves to better understand the causes of burnout, to identify strategies to mitigate it and to determine how we can make mental health resources more accessible and acceptable to fellow trainees.

To this end, we aim to bring fellows to the conversation table, and we have embarked on a series of focus groups with fellows across the institution. Our goal in this initiative is to ensure our fellows have the resources to practice at the top of their license, the opportunity to work in collaborative environments, and the ability to seek mental health resources without the fear of stigma. We are excited to learn more from our upcoming focus groups with the hope we may identify specific program and institutional initiatives to enact change.

Contributed by: Colleen Bennett, MD, and Marissa Kilberg, MD

References and Suggested Readings

Shanafelt, T.D., Sloan, J.A. & Habermann, T.M. The well-being of physicians. Am J Med 114, 513-519 (2003).

Weiss, A., Quinn, S., Danley, A., Wiens, K. & Mehta, J. The Effects of Stress & Burnout on Perceptions of Stigma and Help-Seeking Behavior Among Pediatric Fellowship Trainees.(Association of Pediatric Program Directors Annual Meeting, 2019).

Panagioti, M., et al. Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis. JAMA Intern Med 177, 195-205 (2017).

Card, A.J. Physician Burnout: Resilience Training is Only Part of the Solution. Ann Fam Med 16, 267-270 (2018).