Humanism and Resilience in Residency Training: A Guide to Physician Wellness [1st ed.] 9783030456269, 9783030456276

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Humanism and Resilience in Residency Training A Guide to Physician Wellness Ana Hategan Karen Saperson Sheila Harms Heather Waters Editors

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Humanism and Resilience in Residency Training

Ana Hategan Karen Saperson Sheila Harms • Heather Waters Editors

Humanism and Resilience in Residency Training A Guide to Physician Wellness

Editors Ana Hategan Department of Psychiatry and Behavioural Neurosciences Division of Geriatric Psychiatry, Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, St. Joseph’s Healthcare Hamilton Hamilton, ON Canada Sheila Harms McMaster Children’s Hospital, Department of Psychiatry and Behavioural Neurosciences McMaster University Hamilton, ON Canada

Karen Saperson Department of Psychiatry and Behavioural Neurosciences McMaster University Hamilton, ON Canada Heather Waters Faculty of Health Sciences McMaster University, Department of Family Medicine Hamilton, ON Canada

ISBN 978-3-030-45626-9    ISBN 978-3-030-45627-6 (eBook) https://doi.org/10.1007/978-3-030-45627-6 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

With profound gratitude to Wendy Mattingly, for dedication to advancing scholarship at McMaster University.

Foreword

Wellness has gained increasing attention as a focus for educators and clinicians alike. The Institute for Healthcare Improvement (IHI) has shifted its focus from the Triple Aim (enhancing patient experience, improving population health, and reducing costs) in 2007 to the quadruple aim in 2017, which newly incorporates the care team well-being [1, 2]. This important change marked a fundamental shift in viewing the sustainability of our care teams as crucial for ensuring the health of those we serve. This shift in thinking has led to a veritable explosion of interventions, ranging from workload modifications to scheduling solutions [3, 4]. Numerous systematic reviews have cited trials of randomized, non-randomized, quasi-experimental, and quality improvement studies that aim to address this situation. In addition, while the science may be important to conduct, so too are works like this book. Translating the science into usable works of scholarship can help highlight and make accessible the evidence-­ informed strategies for improving wellness in the current climate. Meanwhile, in the educational sector, there has been increased attention to ensuring patient safety through duty hour restrictions. In the wake of the tragic death of Libby Zion, North America was forever changed in terms of its emphasis on duty hours restrictions for the most junior members of our teams [5]. And yet, the evidence is mounting that perhaps with duty hours restrictions, the unintended consequences of increased handoffs and transitions in care may have resulted in a zero-sum improvement overall [6].

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When addressing physician wellness, one cannot look at the causal factors in isolation, but rather as gears in a system where real change would involve a collaborative approach. The issues of learners balancing service with education, independently managing large workloads, dealing with difficult patient encounters without debriefing, working long hours without breaks, and sleep deprivation all play into each other and are a result of the way the system is organized [7, 8]. This can result in trainee physicians working in toxic environments with minimal autonomy over their schedules. Rather than addressing the root cause, physicians are often tasked to become more resilient, which by itself is a useful learned skill; however, placing emphasis on the affected puts the onus of burnout prevention on the individual while the aforementioned systemic factors remain status quo. This is worsened by the fact that the hidden curriculum often chides learners for criticizing the system, because the culture wrongfully equates seeking wellness with laziness [9]. This book does an excellent job of addressing the individual factors, but goes further to face head on the fact that systemic change must be targeted at the institution rather than stopping at the individual. Furthermore, the culture itself must change, and this text beautifully describes how we must transition to an ideology of humanistic practice as a strong foundation for this movement. This will aid us in moving away from retroactive remedies for burnout toward creating a culture of safety and wellness ingrained into learners from their early training. This requires developing a culture of kindness and humanism, which allows for self-compassion and the collaborative confrontation of factors contributing to burnout. There are many books that talk about individualist strategies around fostering wellness and resilience, but this book is one that does an excellent job at acknowledging the world beyond and its impact on the individual. To us, the most helpful part of this compilation is that it goes beyond placing the burden of resolving

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burnout on the resident and discusses building a culture of humanistic practice in medicine to combat it. Laila Nasser Resident in Emergency Medicine, McMaster University Hamilton, ON, Canada Teresa Chan Department of Medicine Division of Emergency Medicine, McMaster University Hamilton, ON, Canada

References 1. Bodenheimer T, Sinsky C.  From triple to quadruple aim : care of the patient. Ann Fam Med. 2014;12(6):573–6. 2. IsHak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;1(2):236–42. 3. Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195–05. 4. Busireddy KR, Miller JA, Ellison K, Ren V, Qayyum R, Panda M. Efficacy of interventions to reduce resident physician brnout: a systematic review. J Grad Med Educ. 2017;9(3):294–01. 5. Rosenbaum L, Lamas D. Eyes wide open – eamining the data on duty-­ hour reform. N Engl J Med. 2019;380(10):969–70. 6. Bolster L, Rourke L.  The effect of restricting residents’ duty hours on patient safety, resident well-being, and resident education: an updated systematic review. J Grad Med Educ. 2015;7(3):349–63. 7. Raj KS. Well-being in residency: a systematic review. J Grad Med Educ. 2016;8(5):674–84. 8. Physician Health and Wellness in Canada: Connecting Behaviours and Occupational Stressors to Psychological Outcomes. 2019. https://www. cma.ca/sites/default/files/pdf/Media-Releases/NPHS_Report_ENG_ Final.pdf. Accessed 30 Nov 2019. 9. Gofton W, Regehr G. What we don’t know we are teaching: unveiling the hidden curriculum. Clin Orthop Relat Res. 2006;(449):20–7.

Preface

Physicians experience high rates of burnout resulting in diminished quality of life and quality of patient care [1, 2]. Burnout symptoms are especially common in the early stages of a physician’s career and are particularly prevalent among residents [1]. The culture of medicine has promoted a myth that physicians are either immune to stress or that they do not become ill, perpetuating ideologies of stigma for those in need of support. Physicians have traditionally neglected their own health in favor of their many professional and personal roles and obligations [3, 4]. Many physicians have trait characteristics such as being independent, competitive, and have a track record of being high achievers, which may lead to an ethos of believing that attention paid to their own needs is secondary and potentially a sign of weakness. However, recently there has been an attitudinal shift, and increasing attention is being paid to physician health and well-being. This is partly attributable to evidence linking patient outcomes to physician wellness, and also to the devastating statistics of physician suicide. Wellness and self-care are now considered core competencies by medical education accreditation bodies, with expectations for medical schools to formally teach these skills in the curriculum, and for physicians to demonstrate a commitment to their own health and sustainable practice [3, 5–7]. Therefore, the approach to supporting physicians’ physical and psychological health is shifting from a focus on treatment of established medical conditions to one of promoting well-being, improving self-care, and preventing illness.

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Thus, strategies to prevent and mitigate burnout are becoming essential during residency training. Physicians’ responses to the stresses of medical practice vary. Some are at increased risk of developing depressive and anxiety symptoms, substance use disorders, and even considering or attempting suicide. Others will find ways to thrive under the high stress and pressure, even actively welcoming the numerous challenges that are associated with postgraduate medical education. Although many will experience exhaustion and sleep disruption at high stress periods, they will simultaneously manifest resilience by employing strategies to manage and recover. The traits that reinforce these responses to the stress of medical practice are considered amenable to intervention and change. Four of the “Big Five” personality traits (agreeableness, extraversion, openness, and conscientiousness) have been associated with resilience, whereas the tendency to easily experience negative emotions (or “neuroticism”) has been negatively correlated [8]. The Humanism and Resilience in Residency Training: A Guide to Physician Wellness aims to help identify adaptive individual traits and positive formal initiatives in residency training programs, while challenging those that are less adaptive and supportive. Moreover, recent evidence shows that introducing humanism in medical curricula during residency can diminish the risk of trainee burnout [9]. Unfortunately, few residency programs have formal humanism curricula for teaching this critical aspect of medicine, despite being a central tenet of professionalism and a required competency for all physicians. Therefore, this book intends to address this need. Although focusing our attention on individual factors is important, investment in providing optimal training and work environments is an essential component for the promotion and support of physician well-being. Research has indicated that resilience generally depends more on the resources received than on one’s innate abilities or positive attitude [10]. The environment has an enormous effect on our collective capacity to thrive as physicians. In 2019, the World Health Organization included burnout as an occupational phenomenon in the 11th Revision of the International Classification of Diseases (ICD-11) [11]. No amount of

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personal development is sufficient to support health and success in our training and workplace if the system and its institutional leaders offer inadequate support and a maladaptive or dysfunctional structure. As long as services are underfunded and understaffed, facilities are suboptimally managed, and administrators are inexperienced or disengaged from the realities of practicing physicians, physicians will continue to burn out and struggle. When it comes to pursuing success and maintaining well-being, the environment matters just as much, if not more, than an individual’s thoughts, feelings, and behaviors, and this book addresses these issues. Seeking out relationships that nurture each other, opportunities to use our talents, and places where we experience support and personal reward will further our ability to find meaning and wellness in our work and lives. Therefore, residency programs that create and support a culture of both wellness and resilience are more likely to produce graduates who are well prepared for this era of sustainable medicine. Moreover, in this time of environmental crisis, we need to rapidly address necessary change in medical culture to meaningfully address its carbon footprint and impact on climate change. We need sustainable, cost effective models of healthcare that provide sufficient resources now, while thoughtfully planning ahead for adaptations to meet ever changing societal healthcare needs. The modern physician must learn to adapt and work in this complex and dynamic model. Therefore, physicians must develop and nurture resilience so that they may sustain their effectiveness in an environment that is rapidly changing. The contemporary healthcare industry confronts two trends: (i) an influx of new generations of physicians with changing career and life expectations compared to previous generations, and (ii) recognition of the perils of physician burnout. Thus, an increasing number of physicians are speaking up and pushing back against unreasonable work schedules and unsustainable job demands. Healthcare leaders need to recognize the signs of such systemic problems and be proactive in redesigning the physician’s work and environment such that physicians are provided with the required resources, tools, and autonomy to deliver optimal patient care, experience workplace satisfaction, and sustain well-being.

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Physicians are seeking strategies to promote their own well-­ being and achieve success in their careers. In our contemporary, dynamic, and fast-paced medical practice, there is a trend towards training for adaptive and resiliency skills. This volume offers an integrated approach to resilience and well-being during residency training including engaging mindfulness and meditation practice, cognitive behavioral strategies for stress awareness, and positive psychology strategies for perspective taking, finding meaning, and supporting personal change, as a few examples. Through this book, our goal is to encourage discussion and consideration of lifestyle modifications to improve physical and psychological health and well-being, including the identification of supportive and detrimental lifestyle factors influencing physicians’ responses to stress. We emphasize the importance of advocating for systemic change and redesigning systems to promote physician well-­ being in the sustainable medicine era. Although this resource is primarily designed for residents to help them adapt to challenges, enhance their ability to find meaning, promote resilience, and maintain a positive perspective on work-life integration, any busy healthcare professional interested in learning the fundamentals of personal wellness can greatly benefit from its perusal. Undergraduates will find this book a useful wellness resource for their clinical placements. Written and edited by residents and academic physicians, this book shares personal and clinical experiences supplemented with evidence-based information and contemporary guidelines. Key features include easy-to-reference, heavily illustrated, content-­ specific guidance on how to identify and manage wellness challenges that arise during medical training, written succinctly and with clinical relevance. Any similarity to real/actual cases in the case vignettes presented in the book is purely coincidental. The editors have built their careers on experiences as both physicians as well as educators, which has informed this wellness guide. This book provides a hands-on, real-world approach to learning that will keep readers engaged and expand their understanding of key factors that affect wellness, including strategic techniques for optimizing resilience and well-being. It is our hope

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that this book remains a well-used reference for physicians during residency training and throughout professional medical practice. Hamilton, ON, Canada   

Ana Hategan Karen Saperson Sheila Harms Heather Waters

References 1. CMA National Physician Health Survey: A National Snapshot. 2018. https://www.cma.ca/sites/default/files/2018-11/nph-survey-e.pdf. Accessed 5 Oct 2019. 2. The Physicians Foundation 2018 Survey of America’s Physicians: Practice Patterns and Perspectives. 2018. https://www.merritthawkins.com/ news-and-insights/thought-leadership/survey/2018-survey-of-americasphysicians-­practice-patterns-and-perspectives/. Accessed 5 Oct 2019. 3. CMPA. Physician health: Putting yourself first. 2015. https://www.cmpaacpm.ca/en/advice-publications/browse-articles/2015/physician-healthputting-yourself-first. Accessed 5 Oct 2019. 4. Wiskar K. Physician health: a review of lifestyle behaviors and preventive health care among physicians. BCMJ. 2012;54(8):419–23. 5. Accreditation Council for Graduate Medical Education. Summary of changes to ACGME common program requirements Section VI. https:// www.acgme.org/What-We-Do/Accreditation/Common-ProgramRequirements/Summary-of-Proposed-Changes-to-ACGME-CommonProgram-Requirements-Section-VI. Accessed 5 Oct 2019. 6. Canadian Residency Accreditation Consortium (CanRAC). General standards of accreditation for residency programs version 1.1 Last updated July 1, 2017. https://pg.postmd.utoronto.ca/wp-content/uploads/2018/06/ General-Standards-of-Accreditation-for-Residency-Programs.pdf. Accessed October 5, 2019. 7. College of Family Physicians of Canada. Standards of accreditation for residency programs in family medicine. July 2018, version 1.2. https:// www.cfpc.ca/uploadedFiles/_Shared_Elements/Documents/20180701_ RB_V1.2_ENG.pdf. Accessed 5 Oct 2019. 8. Oshio A, Taku K, Hirano M, Saeed G. Resilience and big five personality traits: a meta-analysis. Pers Individ Dif. 2018;127:54–60. 9. Dotters-Katz SK, Chuang A, Weil A, Howell JO. Developing a pilot curriculum to foster humanism among graduate medical trainees. J Educ Health Promot. 2018;7:2.

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10. Ungar M, Theron L, Liebenberg L, et al. Patterns of individual coping, engagement with social supports and use of formal services among a five-­ country sample of resilient youth. Glob Ment Health (Camb). 2015;2:e21. 11. World Health Organization (WHO). Burn-out an “occupational phenomenon”: international classification of diseases. May 28, 2019. https:// www.who.int/mental_health/evidence/burn-out/en/. Accessed 5 Oct 2019.

Contents

Part I The Foundation of Introducing Humanism in Medical Curriculum 1 Humanism and the Physician ��������������������������������������  3 Heather Waters, Christine Foster, Dilshan Pieris, Sarah Kinzie, and Joyce Zazulak 2 The Role of Self-Compassion in Health and Well-Being �������������������������������������������������������������� 49 Joanna Jarecki, Satyam Choudhuri, and Tara Riddell 3 Sustainable Humanistic Medicine in a World of Climate Change and Digital Transformation���������� 79 Ana Hategan, Sumit Chaudhari, and Jane Nassif 4 Physicians with Children: Nurturing Humanism and Returning Joy to Medicine����������������123 Caroline Giroux, Suzanne Shimoyama, and Danielle Alexander 5 Physician Experience: Impact of Discrimination on Physician Wellness����������������������������������������������������159 Sarah Candace Payne, Ashley Marie Clare Cerqueira, Julia Kulikowski, Ana Hategan, and Heather Waters 6 The Transition to Independent Practice: A Challenging Time Requiring Careful Balance��������191 Joseph Emerson Marinas, Sumit Chaudhari, Tricia Woo, James A. Bourgeois, and Ana Hategan xvii

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Part II The Foundation of Maintaining Physician Resilience 7 Stress Awareness and Management in Medical Settings��������������������������������������������������������219 Jelena P. King, Elena Ballantyne, and Heather E. McNeely 8 Causes of Chronic Stress and Impact on Physician Health������������������������������������������������������������������������������247 Amanda Ritsma and Lauren Forrest 9 Cognitive and Mindfulness Conceptualization�����������273 Jelena P. King, Elena Ballantyne, and Heather E. McNeely 10 Recognizing Compassion Fatigue, Vicarious Trauma, and Burnout����������������������������������297 Lauren Forrest, Mariam Abdurrahman, and Amanda Ritsma Part III Adaptive Strategies to Promote Physician Wellness 11 Healthy Lifestyle Behaviors: Physical Activity to Fuel your Mind and Body��������������������������333 Emma Gregory, Alexander Dufort, and Ana Hategan 12 Healthy Lifestyle Behaviors: The Optimal Nutrition to Combat Burnout ��������������������������������������371 Alexander Dufort, Emma Gregory, and Tricia Woo 13 Healthy Lifestyle Behaviors: Sleep to Remain Well Around the Clock��������������������������������������������������403 Ana Hategan and Tara Riddell 14 Healthy Habits: Positive Psychology, Journaling, Meditation, and Nature Therapy����������������������������������439 Tara Riddell, Jane Nassif, Ana Hategan, and Joanna Jarecki

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15 Kindness Begins with Yourself: Strategies to Engage Medical Trainees in Self-Compassion��������473 Tara Riddell and Joanna Jarecki 16 Steps Toward Building a Culture of Humanistic Teaching and Medical Practice������������������������������������527 Sheila Harms and Anita Acai 17 Pushing Back: Recognizing the Need to Advocate for Systemic Change in a Sustainable Medical Field������������������������������������������������������������������555 Karen Saperson and Bryce J. M. Bogie 18 Recommendations and Resources for Coping with Burnout������������������������������������������������������������������573 Mariam Abdurrahman and Heather Hrobsky Index����������������������������������������������������������������������������������������605

Contributors

Mariam  Abdurrahman, MD, MSc  Department of Psychiatry, St. Joseph’s Health Centre, Toronto, ON, Canada Anita Acai, MSc, PhD (candidate)  Department of Psychology, Neuroscience & Behaviour and Office of Education Science, Department of Surgery, Hamilton, ON, Canada Danielle Alexander, MD  Department of Psychiatry and Behavioral Sciences, University of California Davis Health System, Sacramento, CA, USA Elena Ballantyne, PsyD  Department of Psychology, St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada Bryce  J.  M.  Bogie, MSc Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada James A. Bourgeois, OD, MD  Department of Psychiatry, Baylor Scott & White Health and Texas A&M University, Temple, TX, USA Ashley Marie Clare Cerqueira, MD  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Sumit Chaudhari, MD  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada

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Contributors

Satyam  Choudhuri, BHSc Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada Alexander  Dufort, MD  Department of Psychiatry and ­Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, McMaster University, Hamilton, ON, Canada Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph’s Healthcare Hamilton, ­Hamilton, ON, Canada Lauren Forrest, MD  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Christine  Foster, MD  Faculty of Health Sciences, McMaster University, Department of Family Medicine, Hamilton, ON, Canada Caroline Giroux, MD  Department of Psychiatry and Behavioral Sciences, University of California Davis Health System, Sacramento, CA, USA Emma Gregory, MD  Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, McMaster University, Hamilton, ON, Canada Sheila  Harms, MD, PhD (candidate) McMaster Children’s Hospital, ­Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Ana  Hategan, MD, FRCPC Department of Psychiatry and Behavioural Neurosciences, Division of Geriatric Psychiatry, Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, St. Joseph’s Healthcare Hamilton, ­Hamilton, ON, Canada Department of Psychiatry and Behavioural Neurosciences, Division of Geriatric Psychiatry, Michael G. DeGroote School of Medicine, Faculty of Health Sci­ ences, McMaster University, ­Hamilton, ON, Canada

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Heather  Hrobsky, MA, MSW Department of Psychiatry, St. Joseph’s Health Centre, Toronto, ON, Canada Joanna Jarecki, MD  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, ­Canada Jelena P. King, PhD  Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada Sarah  Kinzie, MD Faculty of Health Sciences, McMaster University, Department of Family Medicine, Hamilton, ON, ­ ­Canada Julia  Kulikowski, MD  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ­ ON, Canada Joseph  Emerson  Marinas, MD Department of Psychiatry, ­University of Alberta Hospital, Edmonton, AB, Canada Heather  E.  McNeely, PhD Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada Jane  Nassif, MD, MBA Hamilton Health Sciences, HITS eHealth, Hamilton, ON, Canada Health Information Technology Services (HITS), Division of Hamilton Health Sciences, Hamilton, ON, Canada Sarah  Candace  Payne, MD Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Dilshan Pieris, MSc  Faculty of Medicine, University of Toronto, Department of Medicine, Toronto, ON, Canada Tara  Riddell, MD Michael G.  DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Department of Psychiatry and Behavioural Neurosciences, Hamilton, ON, Canada Amanda Ritsma, MD  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada

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Contributors

Karen  Saperson, MBChB, FRCPC  Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Suzanne  Shimoyama, MD Department of Psychiatry and Behavioral Sciences, University of California Davis Health System, Sacramento, CA, USA Heather  Waters, MD Faculty of Health Sciences, McMaster University, Department of Family Medicine, Hamilton, ON, ­ ­Canada Tricia Woo, MD  Division of Geriatric Medicine, Department of Medicine, St Peter’s Hospital, McMaster University, Hamilton, ON, USA Joyce Zazulak, MD  Faculty of Health Sciences, McMaster University, Department of Family Medicine, Hamilton, ON, Canada

Part I

The Foundation of Introducing Humanism in Medical Curriculum

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Humanism and the Physician Heather Waters, Christine Foster, Dilshan Pieris, Sarah Kinzie, and Joyce Zazulak

Understanding Humanism in Medicine What Is Humanism in Medicine? In the daily practice of medicine, physicians apply scientific principles with varying levels of evidence to enhance the health and wellness of fellow human beings, that being their patients. Physicians must wrestle with and ultimately reconcile the subjectivity of human relationships with the objective detachment of science in order to optimize the effectiveness of their work. The potential for tension between these two domains has been apparent since the earliest days of medicine: even ancient philosophers who lived in a world before modern science recognized the existential dangers of an imbalance between the two [1, 2]. The physi-

H. Waters (*) · C. Foster · S. Kinzie · J. Zazulak Faculty of Health Sciences, McMaster University, Department of Family Medicine, Hamilton, ON, Canada e-mail: [email protected]; [email protected]; [email protected] D. Pieris Faculty of Medicine, University of Toronto, Department of Medicine, Toronto, ON, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Hategan et al. (eds.), Humanism and Resilience in Residency Training, https://doi.org/10.1007/978-3-030-45627-6_1

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cian is often the singular embodiment of this tension, sometimes struggling in a tug of war between two professional identities, trying simultaneously to preserve their own humanity, connect meaningfully with patients, and keep pace in an increasingly complex scientific and technological world.

Did You Know?

Humanism in medicine has been defined as “the application of scientific knowledge and skills with respectful, compassionate care that is sensitive to the values, autonomy and cultural needs of individual patients and their families” [3]. Humanism is an approach to patient care that acknowledges both the importance of scientific knowledge of the patient’s disease process and biographical knowledge of the patient’s social environment, values, and goals [4]. Biographical knowledge requires getting to know one’s patient as a person, unique in their identity, context, illness experience, and determination of meaning. Humanism is rooted in the core values of empathy, compassion, relationship-based care, and professionalism [5]. A humanistic approach recognizes that physicians use the “lived-­ body” and the “lived-world” as foundations for understanding the human condition and thus, the patient experience [6]. A physician must have a scientific understanding of the “biological body” as well as a humanistic understanding of the embodied nature of each patient’s illness experience [7]. A humanistic grounding allows the physician to understand the impact of illness on patients’ lives, “not just as a secondary effect of the biological disease, but as a primary phenomenon” [8]. While humanism has long been recognized as a core philosophical value of medicine, it was only recently articulated as a core clinical competence for residents and practicing physicians, likely as a response to numerous challenges and flaws in contemporary medical practice [9]. Physicians and patients must both contend with powerful dehumanizing forces that comprise the daily realities of medicine. These include an increasing depen-

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dence on technology, a diminishing amount of time spent directly with patients, growing financial pressures, and intensifying bureaucracy in medicine. Yet, the more enduring inspiration for the campaign to restore humanism is recognition of its role as a countervailing force acting alongside science that enables physicians to address patients’ needs for wellness, healing, and alleviation of suffering.

Did You Know?

The terms “health” and “wellness,” although often used interchangeably, are distinct concepts. As per the World Health Organization, health is an objective “state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity” [10]. Wellness is an active, dynamic, and holistic process that is subjectively perceived and self-­ directed; it relates to decisions of intentional healthy living and optimizing potential [11]. There is an important distinction between “disease” and “illness”; disease is a biomedical abnormality that is physiological or psychological in nature; illness is experiential, the lived human response to disease (also referred to as “illness experience”). There is a difference between “curing” and “healing”; curing is the elimination of all evidence of disease, while healing involves the promotion of wholeness and wellness. Even when curing is not possible, physicians have the ability to promote healing through a humanistic approach to practice.

Limitations of the Biomedical Model Rapid progression of scientific knowledge has created and sustained the biomedical model of disease, which has become the dominant paradigm in medical culture, education, and healthcare policy [12]. This model of disease emerged in the 1950s alongside swift developments in medical science, including the dis-

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covery of specific disease processes and disease-causing agents. Biomedicine “assumes disease to be fully accounted for by deviations from the norm of measurable biological variables” [6]. In other words, the biomedical model posits that any given disease can be aptly described by its underlying biological, chemical, and physical mechanisms. Knowledge of the parts is sufficient to explain the whole. There are three main problems with the biomedical model of disease that humanism seeks to redress. The first is that biomedicine is reductive. Molecules, transmitters, and receptors are seen to represent the most valid level of knowledge, presumed to be the best way to understand and explain disease. Within this framework of understanding, there is no weight given to the psychological, social, and behavioral dimensions of illness; as such, this approach fails to view human disease as primarily a human experience [13]. For example, understanding the physiology of vasodilation in flushing, the pathways leading to catecholamine release in tachycardia, or the receptors responsible for increasing sweat gland activity in diaphoresis, is meaningless unless one understands the underlying human causes: embarrassment, anxiety, and nervousness. Second, the biomedical model of disease is “exclusionistic”; in other words, symptoms and processes that are not understood by current biological explanatory models are excluded from the field of medicine [14]. The result is that “patients with vague complaints and non-localizable lesions are relegated by biomedical reductionism to a netherworld of hypochondriacs and malcontents” [15]. Through this method, biomedicine has a way of filtering patient complaints into only those problems that can be medically recognized and addressed based on current knowledge. This is discouraging for patients and undoubtedly inspires the caricature of the out-of-touch doctor, as well as the recently trending twitter hashtag “#doctorsaredickheads.” When the extent of a doctor’s tools to treat disease were entirely contained within a small black bag, the simple value of the supportive, empathic presence was perhaps more apparent. Finally, biomedicine is incapable of recognizing the limits of science’s applicability to humans. In recent years, scientific

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and technological discoveries have even obscured the boundary between life and death. Through mechanical ventilators, extracorporeal membrane oxygenation (ECMO) machines, and pacemakers, humanity has been forced to accept that neither brain activity nor the ability to oxygenate and circulate blood are sufficient descriptors of human life. A thousand other smaller scale interventions have given us the ability to prolong life to a point that may no longer be considered meaningful. Biomedicine alone cannot distinguish a life worth living; it can sometimes answer the question of “what,” but it can never answer the question of “why.” Instead, a patient’s values, goals and spirituality, their very concept of a meaningful life, and how much they are willing to suffer to achieve and preserve it, are the most relevant factors. (For further details, see Chap. 16.) Certainly, the application of scientific models to human health has provided a window to more fully understand disease. As physicians, we can use the explanatory power of the physical sciences to understand some aspects of human function and disease, right down to the most basic anatomic and molecular parts. These parts appropriately become targets for interventions and treatments. We cannot, however, abstract meaning about the human experience from information about the biological parts. If we fail to acknowledge the limits of science, we risk inflicting suffering on the whole person through treatment of the parts [16, 17]. This is the gap that humanism seeks to fill. Refer to Fig. 1.1 for a representation of the dual importance of the biomedical and humanistic paradigms for effective medical practice.

Case Study I Aisha, a medical student, hears a patient desperately calling for water one afternoon on the medicine ward. “Water! Water!” She notices that the rest of the members of the healthcare team are busy performing other tasks. The patient is old, frail, and bed bound. The loud pleading continues.

H. Waters et al.

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Fig. 1.1  Humanism and the biomedical model in medical practice

Although the patient is unknown to Aisha and not being cared for by her team, she feels compassion and is unable to walk by his room without helping. She finds the kitchen and fills a Styrofoam cup with the appropriate ratio of ice and water and delivers it to his bedside. The patient is grateful and settles, and Aisha feels an immediate swell of satisfaction. Although her medical knowledge is limited at this point, she is delighted to have made some small difference to a patient’s hospital experience. Aisha leaves the room without noticing the sign above the patient’s bed reading “FLUID RESTRICTION