Pursuing Wellness in Neurosurgery: Resiliency

To the Editor: For all of us in medicine, we understand that being a physician is more than just a "job." It is a noble profession wherein the most vulnerable of people—sick patients—entrust us to take care of them. This is especially true for the field of neurosurgery; it is a calling that is simultaneously one of the most demanding and rewarding. Training to become a neurosurgeon is no easy task; it is a tough road to travel. It is the commitment to the patient that keeps us going through the hardships and makes us most proud. Ultimately, we are rewarded with the privilege of being in a position to greatly impact the lives of a great many people. As such, the years of education, long hours of training, and self-sacrifice are well worth it for all of us. As stewards of good health and wellbeing, physicians should also be role models to their patients and the general public. However, the demands placed on a neurosurgeon can make achieving a balance challenging and could lead to burnout, which threatens not just the provider but also the patient. Burnout, a term used to describe feelings of emotional exhaustion, low self-accomplishment, and depersonalization associated with the work environment, is a crucial marker for physician wellbeing and has also been clearly linked to suboptimal patient outcomes. On-call duties, emergencies, and increasing administrative and bureaucratic burdens all threaten a work-life balance. Add to the mix the research and teaching responsibilities of academic neurosurgeons with the demands of starting a family and it is often times one's health that suffers. Bad habits cultivated during residency training, a period of extreme work-life imbalance perhaps unmatched by any other field or profession, may easily be promulgated into one's career. Thus, it is critical that physical and mental fitness be promoted during residency training. Wellness in residency training lays the groundwork for wellness for one's entire career. While residency is a herculean test of one's mettle, difficult and stressful situations in both our professional and personal lives will inevitably present themselves for the rest of our lives. Neurosurgery residency at a busy tertiary care center can be brutal, though the challenges have changed over the years. Taking care of critically ill patients around the clock can be both physically and emotionally draining. Gone are the days of the giants who worked endless hours and never left the hospital; residents now find themselves in a heavily scrutinized and compartmentalized work structure (leaning towards shift work), with exponentially higher administrative burdens, litigation exposure, and an antiphysician culture prevalent within hospital administration that devalues the contribution of the physician. Thus, while residents in the duty hour reform era face vastly different challenges than their predecessors, burnout and depression are still major concerns. In my training program, we uncovered alarmingly high rates of physiological and psychological abnormalities among our young resident physicians, conditions that are detrimental to teamwork, learning, professionalism, and patient care. We invest a tremendous amount of time and resources to train a neurosurgeon, so why would we not also invest in their wellbeing so that they may go on to lead longer and more productive careers? The small investment during residency training will be returned many times over in the way of improved patient care and contributions to our field. So, what must be done? And what is the right path? The honest answer is that it is unknown, as we are venturing into uncharted waters, especially for neurosurgery. The first step is that we must reject the notion that a program that is mindful of the wellbeing of their residents will necessarily produce a "weaker," coddled, and more entitled neurosurgeon. In fact, I would argue the opposite—we can produce tougher graduates. A wellness program should not aim to shield residents from the hardships of training to become a neurosurgeon, but rather strive to strengthen the backbone of the resident so that they may respond favorably under stress and flourish. Stress during residency is good. It is the driving fuel that promotes personal and professional growth. As my chairman during my training, Dr Benzel, explained, you cannot train for a marathon without exposing yourself to boluses of titrated, increasing doses of stress. It simply cannot be done. While exposure to appropriately supervised stress and pressure to perform at a high level must remain an integral component of neurosurgical training, we as educators can focus on building the resiliency of our residents so that they respond favorably undersuch pressures both during training and beyond in their own careers. The main character trait that is uniformly present in residents that thrive during their training is "grit," which is the major ingredient of resiliency. One must be prepared to take fire from all directions and continue marching forward. It is this resiliency that determines whether one will wilt or stand tall and seize the moment during moments of stress. As such, a "wellness initiative" must be aimed at building resiliency in our residents. It is this resiliency that will be carried onward into a successful career. Educators must drive and champion this effort; physical and mental fitness have been shown to optimize learning, so why should learning in residency be an exception? I call to all program directors and chairmen to look closely at their programs and determine what will be most effective for their residents, as one size does not fit all and each will likely require a tailored approach. I also encourage faculty participation. We have implemented a successful wellness initiative at our institution that has already undergone several iterations of change since it was begun 2 years ago. Our wellness program (La Sierra) has yielded improvements in teamwork, camaraderie, psychological makeup, sleep quality, and fitness among its participants. Academic productivity, learning, and patient care are more difficult to track. We will be sharing both our successes and pitfalls in a series of publications that will be compiled into a series (Pursuing Wellness in Neurosurgery). I welcome contributions and insights from other centers so that we may all learn from each other in this endeavor. I thank Dr Oyesiku for allowing the journal Neurosurgery to serve as the forum for this important discussion. Our residents, faculty, families, and patients will undoubtedly all benefit from the ensuing discussion and thought that this novel series will promote.