Answers to residents' questions on advocacy, wellness and health equity

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

In the last episode of AMA Resident Recognition week, three health care leaders answer questions from residents about issues amplified by the pandemic: health equity, advocacy, and physician wellness.

Learn more at the AMA COVID-19 resource center.

Speakers

• Todd Askew, senior vice president, Advocacy, AMA
• Christine Sinsky, MD, vice president, Professional Satisfaction, AMA
• William McDade, MD, MPH, chief diversity and inclusion officer, ACGME

Unger: Hello, this is the American Medical Association's COVID-19 update. Today we have our final episode in a week-long series focused on residents and COVID-19 part of AMA's Resident Recognition week. We're addressing questions that are submitted by residents on three important issues that have been amplified by the pandemic: health equity, advocacy, and physician wellness.

To answer these questions, I'm joined by three health care leaders. Todd Askew, AMA senior vice president of advocacy in Washington, D.C. Dr. Christine Sinsky, AMA vice president of professional satisfaction in Madison, Wisconsin. And Dr. William McDade, chief diversity and inclusion officer at the Accreditation Council for Graduate Medical Education or ACGME in Chicago. I'm Todd Unger, AMA's chief experience officer in Chicago.

Health equity is a top concern for the nation. And one resident asks, while resident physicians may be more apt to recognize and have a desire to address health equity in our patients, they're often barriers to our ability to focus adequate time and energy on addressing these issues. How can resident physicians address these barriers? Dr. McDade can you start by answering that question?

Dr. McDade: Well, thank you very much, Todd. It's been really a very trying time for us with COVID. We've seen residents at the ends of their ropes in terms of their workload. We've seen people who are advocates who actually published various things in both the conference as well as in the major journals in medicine. Our residents are really leading the drive in this case to try to change the system in order to accommodate our patients in ways that I've never seen before.

We've seen residents who have been involved in hospital protests in support of Black Lives Matter, in support of equity and fairness in terms of the health care system. We also have seen that our residents have been victims to the same sorts of over-policing, the minority residents in particular that we see in the population in general. And so they've really come to the fore in advocacy for that particular issue after the murder of George Floyd.

So residents have a tremendous role to play. They are using their advocacy and despite the limited time they have, and the amount of stress that they're under because of COVID, in addition to their regular stress of just being a resident, they're taking on these leadership roles in ways that are quite admirable, to make change and continue their drive to press the sorts of change that patients and that medical education needs.

Unger: Well, Mr. Askew, let me ask this question from another resident relating to both advocacy and equity, how can protesting for, and being vocal about issues like Black Lives Matter, impact residents professionally?

Askew: Well, Todd, I think it's a good question. It's important to remember that when you're participating in advocacy, in many cases, it's important to be clear that you're not doing this on behalf of your institution or your particular program. You're speaking as an individual, your credibility comes in part from being a physician for being engaged with your patients and your community, but you are there as an individual exercising your constitutional rights.

That said, there's certainly a lot of programs that build advocacy into the experience, the residency experience, and a lot of institutions are actively engaged in advocacy programs. And that offers a clear signal where you're able to work in coordination with the program, with the program directors and your colleagues to participate in advocacy efforts in a meaningful way.

Unger: Dr. McDade anything to add to that?

Dr. McDade: I would say that when people think about what the role of the physician should be, I mean, you always have a responsibility to your patients and we have to make sure that residents understand that it's part of their professional development, their professional formation. And so the idea of social justice, the idea of trying to make sure that your patients are able to get the care they need is something that's built into medical education that we really have to reinforce.

I think that when institutions are leery of protest endorsement of things like Black Lives Matter, they're thinking about what's going to happen to the patients who feel alienated because of this and who may not seek care there because of that. And so there's a double-edged sword that's involved, but what I've found in my experience as a chief academic officer, when we had this conversation around LGBTQ issues, that when we embraced the idea that we should be more inclusive as an environment, as a system, as an institution, we actually brought more people into the hospital. And I think it made all patients feel that if you're concerned about the folks who are marginalized, then you're going to do a good job for me. It helps all boats rise. And I think people appreciate that.

Unger: The next question is about wellness, and one for you Dr. Sinsky. One that obviously has been an issue for physicians. And here's what one resident wrote in, "We have a problem. We all know the problem and we keep skirting the issue and finding bandaid solutions. What are some solutions that can address the root of the problem and achieve long lasting results?"

Dr. Sinsky: So, Todd, thanks so much for that question. And that resident is right on. I think we need to look at the root causes of burnout and address those. And one thing we know is the root cause of burnout is not a lack of resiliency among physicians, among residents or physicians. In fact, a study we published last week in JAMA Open, confirms that physicians are a highly resilient group, significantly more resilient than the general population. So when we think about fixes, we should think about fixing the workplace rather than fixing the worker.

And there's a lot we can do in terms of organization culture, making it standard best practice to regularly measure burnout among our residents and among our faculty and practicing physicians, track the cost of the burnout. We know that burnout costs $4.6 billion a year to the U.S. health care system. It's also very expensive to individual residencies and health care systems. And then we could address practice efficiency and workload and more effective teams. So those are some of the ways that we can do this.

And I wanted to add that I think residents and young physicians have a lot more power and influence than they may think because they can be part of the demand side for action, both when they choose their residency program, when they choose their first or their next practice. And on that score, we actually published STEPS Forward module last week on what to look for in your first or next practice.

Unger: Mr. Askew anything to add to that?

Askew: Sure, absolutely. I think another reason for burnout, I think people experience as it relates to advocacy is a lack of personal fulfillment, a lack of frustration. I think physicians by their nature are advocates. What they do day-to-day is advocate for the best interest of their patients, one patient at a time, in the clinical setting. But I think through exercising that advocacy muscle and it is a muscle, it does get stronger and more adept at being used, the more you use it, they can seek greater fulfillment, a sense of providing care and by advocating for large groups of individuals on specific issues, seatbelts, smoking, larger health care issues, coverage, access to care, for example, and larger societal issues that impact health care, not only equity, but other associated issues related to social determinants and others. There's a whole world of advocacy that physicians can engage in. And I think many that do, find a sense of personal fulfillment that is an outgrowth of what they do with their individual patients every day.

Unger: That's interesting because we did receive questions about how to make advocacy an important part of the residency experience. Dr. McDade, Dr. Sinsky, any other comments on that?

Dr. McDade: Well, let me just add to the wellness and the intersectionality with inequity or diversity. One of the things that marginalized or minoritized residents actually experience to a much greater degree than other people do in training is the idea that microaggressions or even macroaggressions impact them. And Lotte Dyrbye's work out of Mayo has suggested that microaggressions really contribute to the burnout and the depressive symptoms exhibited that lead to the unwellness of residents in training, medical students and training as well.

And suggested that these burdens of microaggressions really don't come from internal source of issues, but are really part of the environment that we have to try to fix in residency programs. And that's one of the things that the ACGME is focusing on right now is to figure out ways of mitigating some of the problems that occur that lead to the microaggressions, that lead to the burnout and the unwellness of residents who are subjected to them. I think it's an incredibly important thing to think about as we're trying to craft a wellbeing strategy, that we look at diversity and inclusiveness of the workplace as very important things.

Dr. Sinsky: I'd like to add on to what Dr. McDade has said. So Dr. Dyrbye, who you mentioned, is the author of another one of our STEPS Forward modules on wellbeing and medical students. And we also have one on wellbeing in residency. And within that, we have both structural things that an organization can do to promote wellbeing in our trainees, as well as success stories; case examples of what different organizations have done to improve the wellbeing of their residents.

Unger: Dr. Sinsky, are there any other ways that residents can feel empowered to raise awareness about wellness issues like that and perhaps even add it as a component in their curriculum?

Dr. Sinsky: Well, I think knowing what others have done is a good start because then you can create that same kind of change. So one example, at the University of North Carolina, the anesthesia residency program has a family day at the beginning of the academic year. And during that time, residents, family, and their support team, comes for a day and the children go off and learn what it's like in the OR for their parent, the family members and support people are able to ask questions and see what a day in the life of a resident is like so that they can be stronger supports for their resident through the upcoming year. So that's one of many examples.

Unger: Last question: many residents wrote in about "having limited powers of decision making" and yet described themselves as a “more woke generation” that wants to do more to achieve equity, have a voice increased diversity and training programs. One specific question asked about the resources to teach people about implicit bias. Dr. McDade, any advice to offer those residents?

Dr. McDade: Well, the idea of learning about implicit biases is essential because it really is the first step I think that people need to take in order to understand privilege. And I think because privilege by definition is something that you don't appreciate, it's really a very hard thing to come to grips with. A couple of things that I've suggested to people lately is Understanding Your Hidden Biases by Banaji and Greenwald. And the object of that is called a blind spot. It's to help people to identify what the implicit associations are that they make, that can be problematic in both assessment of patients and evaluation of resident performance, and in day-to-day life. These are the tasks and assumptions that we make about people that really could be misplaced and lead to wrong decision making. So that's one book.

Another book that I think is actually very helpful for people who aren't in the minority group, the majority population to get hold of is called "White Fragility." It's a book written by Robin diAngelo. And what it really helps you to do is to understand what your privileges in society and some of the things that you take for granted that help you to then understand the plights of those people who you're caring for, who you're working alongside and why inclusiveness is so important in order to think about our futures as a country.

Dr. Sinsky: I have one more thing to add there. I recently participated in a virtual reality experience that was meant to give non-minoritized individuals a little bit more of a walk in my shoes experience. And it was led by one of the physician leaders at Northwell in the New York City area. I found that really helpful use of technology to help raise awareness and remove some of the blinders that I certainly know I have.

Unger: What did you learn?

Dr. Sinsky: Well, I learned that I thought that I could understand what that experience was, but when I was sitting in the back of the bus, it was just kind of in a threatening 1950s kind of setup, I felt ill at ease. I felt like on high alert the whole time, as opposed to how I would ordinarily feel in transportation, which was sort of just going along.

Unger: Mr. Askew any final words of advice for residents?

Askew: Sure. I would just in terms of making sure that the residency program and experience includes these issues: your opinions matter. The program directors, they may not always agree, but they want to hear from you. They need to hear from you to inform their decisions about the opportunities that are going to be available to residents throughout the program. Make sure you're in communication and let them know if there are opportunities that you as a resident would like to have, or you feel should be part of their residency experience.

Unger: Well, thank you, Mr. Askew, Dr. McDade, Dr. Sinsky, we appreciate you being here today and sharing your perspective. That concludes our week-long series, Honoring Residents. We'll be back on Monday with another COVID-19 update. For updated resources on COVID-19 go to ama-assn.org/COVID-19. Thanks for joining us and take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.