University of Nebraska Medical Center (UNMC) Chancellor Jeffrey P. Gold, MD’s, spring graduation speech briefly acknowledged the wisdom and skills medical students gained. It made mention of the long-term achievements that await.
But the final message to students was one about the importance of guarding their own well-being. Not forgetting the stamina, perseverance and tenacity that propelled them through the tough times on their path to graduation day. Dr. Gold told the future physicians just how essential those resiliency skills would be in their careers, as each of them will confront failure and times of doubt at some point.
“We cannot give full dedication to healing as we have sworn an oath to do if we ourselves are not truly resilient, if we are hurting, if we no longer have the very best of ourselves to give to others,” Dr. Gold told the newest MDs. “We have recognized this here at UNMC. This is why we have made mental health wellness and stress management one of our greatest emphases, a set of foundational principles.”
Sending UNMC graduates off with a reminder that their own mental health is paramount is just one way physician wellness is an increasing part of the culture at UNMC. It’s an example of how UNMC leaders are toppling the stigma and barriers that have for so long stopped physicians from seeking help when they need it most.
The journey to change the status quo started about five years ago when news of internal medicine trainees’ suicides jolted Dr. Gold, a past chair of the AMA’s Council on Medical Education.
He was part of the conversations taking place at the Accreditation Council for Graduate Medical Education (ACGME) and the Association of American Medical Colleges (AAMC) about the learning environment where future physicians are trained.
He had read study after study coming out about physician burnout. He had personally seen the administrative burdens that electronic health records were putting on practicing physicians. And he had seen the stress that was added to the profession as the nation’s health care payment system was in flux while the Affordable Care Act went into effect.
Dr. Gold—at the helm of seven colleges, overseeing staff and faculty of about 5,000 and the school’s 3,800 students, as well as Nebraska Medicine’s more than 6,500 employees—knew something needed to change at the organizational level. This wasn’t about just adding a stress-management class or bringing in a speaker to talk about taking care of yourself. This was about changing the culture for students, physicians in-training, practicing physicians and staff. It was about finding better ways for physicians and other health care professionals to function in their day-to-day responsibilities. It was about providing physicians with the resources they need.
He convened a taskforce whose goal was to understand the strains on students and faculty at the medical and health science schools that comprise UNMC and to understand what was going on with Nebraska Medicine’s physicians, nurses and staff that provide patient care.
Out of that effort came a multi-pronged approach that makes well-being and resiliency part of the conversation at every level and in every corner of UNMC campuses and Nebraska Medicine’s health care centers. Mental health resources continue to become more easily accessible and even in the palm of student, faculty and staffs’ hands through smartphone apps.
And in February 2018, Dr. Gold named Steven P. Wengel, MD, who had chaired UNMC’s Department of Psychiatry for more than a decade, to a newly created position: assistant vice chancellor for campus wellness for UNMC and the University of Nebraska at Omaha. His job, in part, is to investigate and implement the best practices to enhance student, faculty, staff and patient wellness. That includes assessing stress and burnout levels, developing new curricula for trainees, organizing workshops on stress management and promoting environmental changes that improve well-being.
Wellness has even been incorporated into UNMC’s strategic plan and has its own scorecard to ensure goals are being met and to ensure that it continues to permeate all aspects of the organization.
“There is a limit to how many activities an organization can focus on. But this is not a flavor of the month. It is not a box we check off. This is ongoing,” Dr. Gold says. “We’ve started to do the deep dive into what is causing this problem and finding ways to make changes.”
Changing the culture
Perhaps one of the most fundamental things that needs to change is eliminating the stigma attached to seeking mental health care and the worries physicians face if they come forward saying they need help.
“People are reluctant to come forward because of the career impact they fear it will have,” says Dr. Gold. “We have been afraid to talk about it on an organizational level. And there is a fear on the individual level that if we talk about it, that we are somehow weak.”
So, Dr. Gold is trying to change that on the organizational and individual level by talking about it. A lot. It is the thrust of his graduation speech, and a part of the conversation just about everywhere he goes. He’s encouraging others to talk about it at the faculty level, the administrative level and the student level.
A big part of elevating the conversation is inviting people to talk about wellness and bringing in experts to help foster the discussion.
UNMC in February hosted its 4th Annual Elevating the Conversation event, a symposium about health professionals’ well-being. This year Nancy Nankivil, the AMA’s director of professional satisfaction and practice sustainability was the keynote speaker for the day where physicians and other health professionals explored factors that hinder or build organizational well-being.
“When people are burned out, they may be the last person to see it,” Dr. Gold says. “We are promoting a see something, say something environment: If you see a colleague who does not seem themselves, say something. You may not get the response you want, but just say you are concerned. It could make a difference.”
Providing the needed resources
Beyond making people more aware and open to talking about challenges they may be facing, UNMC is putting resources in place to connect physicians with the help they need.
UNMC has a number of smartphone apps for students, faculty and staff to download. One app asks the person how they are doing and is an assessment tool for well-being. If needed, the app will prompt you to talk to someone. There are phone numbers and other resources built into the app to connect users with the right professionals.
UNMC has an Employee Assistant Program (EAP), a voluntarily work-based program that offers free and confidential assessments, short-term counseling, referrals and follow-up services for personal and work-related problems.
It offers a student counseling center that is discreet and gets students in for an appointment quickly.
There also is a less formal student wellness advocate who has an office where students can drop in for a cup of coffee and chat about what is on their mind. For some students, Dr. Wengel says, that may be all they need. For those who need more, the wellness advocate can link them with the right resources.
And UNMC makes everyone aware of the Metro Omaha Medical Society’s (MOMS) online assessment tool physicians can use to determine if they need help. In addition to helping physicians find help, MOMS links physicians with peers to share their challenges and start thoughtful conversations.
“You will never be able to prevent all mental health issues. Depression and anxiety are always going to be there. It’s about having the resources there to help people,” Dr. Wengel says. “We are trying to have as many resources available as possible.”
Connecting with others
A geriatric psychiatrist since 1991, Dr. Wengel has studied and seen the importance meditation and stress management play in the health and well-being of his patients. He writes prescriptions for patients to practice meditation at home. He also practices meditation himself.
About four years ago, he began teaching a class at UNMC to help doctors in-training better manage their stress. It was popular from day one. And it was not just popular with senior medical students who were interested in psychiatry, but also with those looking to go into primary care, anesthesiology and other specialties who wanted to be good coaches in helping patients manage stress and who wanted to learn how to better manage their own stress.
To build resiliency in other ways, Dr. Wengel is helping create opportunities for students and faculty to interact with or partake in the different branches of the humanities.
“We organically know it is good to have a life outside of medicine, but there also is scientific data now that shows that the more exposure a medical student has to the humanities, the less burnout he or she felt,” Dr. Wengel says.
In addition to showing that medical students exposed to the humanities were less likely to report burnout, the study found that the exposure led to higher tolerance of ambiguity and empathy. That increase in the tolerance for ambiguity “is good for doctors because patients come in and not always present the way physicians were taught in the textbook,” Dr. Wengel says.
One way UNMC and Nebraska Medicine is giving its faculty, staff and students a chance to take part in the humanities is through a campus orchestra formed in the Summer of 2018. UNMC’s Department of Neurological Science Chair Matt Rizzo, MD, a cellist who saw an orchestra contribute to the morale at the University of Iowa, approached Dr. Wengel about forming the orchestra as an outlet for professionals in Nebraska.
Dr. Wengel helped forge a partnership with University of Nebraska Omaha School of Music director Washington Garcia and now about 50 people from UNMC and Nebraska Medicine are part of the Nebraska Medical Orchestra. The group’s composition is about 50% students, 20% faculty and 30% staff or others tied to UNMC or Nebraska Medicine. Their first concert was Dec. 5 and they held a second one this spring.
Anecdotally, Dr. Wengel says, they know the program is having a positive impact. The musicians have said it is a stress reliever and it’s allowed orchestra members to forge friendships outside of the classroom or workplace. A wellness survey is underway to more formally assess the program’s impact.
After the orchestra formed, a third-year medical school student approached Dr. Wengel about creating a UNMC acapella group. The “Doc’Apella” group has done a number of performances for hospitalized patients and also sang at a recent memorial service for families who have donated loved ones’ bodies for medical students to study.
Another creative outlet for students that helps their own well-being and their future patients’ well-being is culinary school.
Fourth year medical students have the opportunity to take a class at the Metropolitan Community College’s Institute for the Culinary Arts. Students spend time learning about the science behind the benefits of the Mediterranean Diet and then get to take hands-on cooking classes at the culinary school, learning how to prepare healthy meals and increasing their confidence on counseling on nutrition.
Solving underlying problems
While teaching resiliency is an important piece, so too is changing the system-issues in medicine that are causing physician burnout in the first place.
UNMC and Nebraska Medicine are working to streamline their bureaucracy and they are also looking for ways to improve electronic health records.
It’s well-documented that electronic health records are a big contributor to the stress that physicians feel today. Doctors are trying to catch up at 10 p.m. and on the weekend, disrupting their work-life balance. Dr. Gold said they are searching for ways to make the process more efficient. For example, he noted that computers being able to listen to conversations may be one way to reduce the time physicians spend on the task.
Never declaring victory
While UNMC has made great strides in making wellness an integral part of campus life, Drs. Gold and Wengel say their work is far from over.
Wellness needs to be a continuous part of the conversation, Dr. Gold says. To see what in-roads they have made and determine what needs must still be met, UNMC students, faculty and staff recently completed a wellness survey. It asked people to rate how much they believe their personal wellness is valued at UNMC, to gauge their level of burnout, if any, and to tell administrators if they believe they have access mental health supports if necessary.
“We are looking to it for direction,” Dr. Gold says. “This journey will require changes.”
Forging this path and making wellness such large part of campus life provides people hope that things are moving in the right direction, Dr. Wengel says.
“At their heart, physicians love taking care of patients. It’s exciting and fulfilling, yet other obligations in medicine have distracted from what attracted physicians to medicine,” he says, noting though, that the wellness movement “is bringing back the joy in medicine.”
As Dr. Gold sent the spring graduates off to the next stage of their careers this year, he reminded them that at some point in their journey it will be important for them to think back upon the excitement they brought with them to medical school. To go back and read the personal essays they wrote about why they wanted to come to medical school.
“You must realize that sometimes the surest indication of individual strength and your true resiliency is the willingness to depend upon others in order to get the job done and to maintain your stamina and your perseverance,” Dr. Gold told the 2019 graduates. “And so, just as we prepare our students and residents for untold clinical complexities and high-risk and life altering clinical care, we also have worked to prepare you to handle stress, to stave off burnout, to build resiliency and to know when and how to depend upon others and when to ask for help.”
A lesson those at UNMC will continue to pursue relentlessly, no matter how much progress they’ve made.