Oncologist advocates for professional wellness as ‘workplace responsibility’
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Individual stressors that occur in day-to-day work life are “microtraumas” that eventually aggregate to significantly impact quality of life, according to Ishwaria M. Subbiah, MD, MS.
“We have seen a change in our day-to-day lives in recent years, and this is true for all individuals,” Subbiah, oncologist and associate professor in the department of palliative, rehabilitation and integrative medicine and the division of cancer medicine at The University of Texas MD Anderson Cancer Center, said during an interview with Healio.
“We know the value of a highly effective and well-cared-for team, in all industries and especially so in medicine,” she continued. “Historically, within health care, we have left individuals to take care of themselves because professional wellness was truly thought of as a personal responsibility that falls on that individual alone. However, professional wellness is equally a workplace responsibility.”
We are now in a time of increased awareness to the system-level and organizational factors that negatively impact the very people who carry out the patient care mission of the organization, Subbiah said.
Where it all began
It was Subbiah’s own experience in clinical medicine that brought her formally into the field of professional wellness.
“Clinician well-being has always been of interest and importance to me,” she said. “I’m a third-generation physician and second-generation oncologist. For me, caring for others is less of a job and more of my way of life. During the past decade, I could see how the workplace experience for clinicians was evolving, marked by less professional satisfaction along with higher turnover rates and burnout. For many clinicians, a lifetime of direct clinical service seemed no longer to be a realistic plan.”
This prompted Subbiah to expand “clinician well-being” from an area of interest to a central pillar of her professional work.
“This change in our workplace experience well preceded the COVID-19 pandemic, which primarily amplified, accelerated but not necessarily created what was already happening in medicine,” Subbiah said. “The approach to tackle the well-being of the oncology workforce will take the same systematic data-driven approach that informs our patient-level cancer care. We have decades worth of findings from the organizational psychology literature that are overdue for their spotlight in medicine and oncology.”
Rite of passage
Subbiah highlighted the role and impact of microtraumas — interactions and events that cause injury that are externally imperceptible.
“If macrotrauma is an open femur fracture from a car accident, then microtrauma would be a stress injury that accumulates over time to ultimately manifest with impaired function and pain,” she said. “Those of us in medicine feel the weight from the workday but often may not be able to pinpoint to a major event.”
Reflecting on training in medicine through the years, Subbiah said that suffering has been historically thought of as a “rite of passage” in medicine.
“I cannot think of any other profession that needed to make a rule that its team members can only work 80 hours per week, which is exactly what we had to do in medicine for our resident physicians who were working upwards of 120 hours a week, regularly,” she said.
From the first moments of medical education, the culture of medicine is defined by the ability to survive without showing any externally perceptible signs that the journey is rough, Subbiah continued.
“Those unable to make it were thought to not have ‘the right stuff.’ In the most tragic of ironies, medicine did not value compassion and humanity toward oneself or peers,” she said. “When it comes to the individual, there has always been a ‘red line’ between health care workers and the support services that may benefit them. That ‘red line’ was drawn by the culture of medicine and by state- or hospital-level policies that keep this culture alive. That line is getting a bit blurrier now, in a very good way.”
Mental health stigma
The challenges in seeking mental health care for the medical community is still very present, according to Subbiah.
“We have various regulatory entities such as state medical boards, hospital credentialing committees and others that have historically asked intrusive questions about a person’s mental well-being, even if it doesn’t impact their ability to practice,” she said. “Suddenly, their mental health becomes tied to their employment, their livelihood. Today, state medical board questions strive to be more focused to only those diagnoses that may interfere with medical practice.”
Subbiah and colleagues are now working on a study examining the rates of anxiety and depression in the U.S. physician community.
“We are actively analyzing the latest data on the prevalence of depression and anxiety in medicine comparing subspecialties, including oncology as well as the general population,” she said. “Instead of waiting until a distressed clinician’s practice is impacted before intervening, we want professional wellness efforts to be much more proactive because a clinician doesn’t go from zero to burnout in few days. Their microtraumas likely accumulated over years until reaching a cusp.”
Subbiah said this is where peer supporters can provide safe spaces to discuss experiences with each other and give and receive feedback.
“Peers can support and guide one another before ever reaching their breaking point,” she said. “These conversations on structured peer support are relatively new for health care but are truly promising. Ultimately the goal is for more proactive care of one another, while addressing the system-level and organizational factors that are the actual drivers of burnout.”
Beyond personal resilience
Professional wellness efforts ultimately can only succeed if they look beyond personal resilience, according to Subbiah.
“Study after study has demonstrated that physicians and health care workers do not have ‘a resiliency deficit.’ When someone hears the term ‘wellness,’ they tend to think of concepts that are related to resilience and lifestyle habits such as diet, sleep, exercise and other such entities,” she said. “These are all components of personal wellness, but when it comes to professional wellness, personal resilience is not the only component. In fact, the data suggest personal resilience to be lower on the list when compared with organizational factors that impact the workplace experience and ultimately lead to burnout.”
Professional wellness is one that is crucial to the sustainability of our health care system, which the COVID-19 pandemic demonstrated, according to Subbiah.
“What we choose to do with this knowledge remains to be seen,” she said. “At the moment, the approach is that each hospital, each health system has their own wellness plan. However, the wide variability in such plans reflects the glaring absence of a widely accepted national benchmark or standardization when it comes to clinician well-being.”
Call for national standards
The development and implementation of a wellness strategy are rightfully left to each hospital and practice, but there needs to be national standards of clinician well-being that set robust, attainable, and measurable expectations across health care settings, according to Subbiah.
“With standards comes accountability and enforceability. Clinicians are often in situations where they and their patients make life-altering medical decisions,” she said. “As such, our health care professionals should have the same level of protection on a federal level as airline pilots do but that’s simply not there now. Advocacy on the national- and state-level for professional wellness and many other health-related topics is an underappreciated and underdeveloped dimension of medicine. We as clinicians truly must recognize the power of each of us as public policy advocates.”
Subbiah said there is no substitute for firm advocacy from frontline clinicians directly with policymakers at the national level.
“The pandemic has shown us how much we individually have to advocate for the needs that we see — whether it is in ourselves, our peers or the patients we take care of,” she said. “Commiserating with one another at a department meeting may be cathartic peer support, but real change comes from ‘shaking off’ this learned helplessness and raising our individual and collective voice, directly with our city, state, and national legislators. We still have miles to go before we sleep, but at least we are on our way.”
For more information:
Ishwaria M. Subbiah, MD, MS, can be reached at isubbiah@mdanderson.org or on Twitter @ishwariaMD.
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