Depression, compassion fatigue, burnout, and a high rate of suicide have become primary concerns in the veterinary profession. Although there have been differing viewpoints on the prevalence of these conditions,1 there is no dispute that veterinarians are often exposed to potentially destabilizing stressors that take an emotional toll. Medical students, residents, and physicians in clinical practice experience similar stressors,2 and in response, the medical profession has published a vast literature on the problem and developed some effective programs for students and doctors.3–5 Given the similarities between the veterinary and human medical professions, it seems likely that similar programs would be helpful for veterinarians.
Veterinarians and Physicians
Many of the stresses that veterinarians and physicians face are similar, although there are some notable differences. Both professions demand long work hours and high levels of responsibility, and trainees in both professions often graduate with large amounts of student debt that cause substantial financial pressure after graduation. Practitioners in both disciplines often experience exhaustion and overexposure to death and the grieving of individuals and families, and both are routinely in the position of making life-and-death decisions and implementing care plans that may be associated with high risks of morbidity and death. In addition, both professions select for highly capable, bright students who tend toward perfectionism and self-reliance, making it harder for them to reach out for help. Further, the cultures of human and veterinary medicine both view seeking support as a sign of weakness.6–9 Medical and veterinary students are typically intelligent and capable of focusing intently and hold themselves to high performance standards. Although these qualities come with obvious benefits in a demanding profession, they also bring vulnerability to depression, compassion fatigue, and burnout.
But, veterinarians face some unique moral dilemmas. The most critical is the frequency with which veterinarians are forced by external circumstances to make clinical decisions that may not be in the best interests of a patient. For example, legal or financial obstacles may prevent a veterinarian from providing care rather than euthanizing a patient, even when clear alternatives for providing care exist. Such situations force veterinarians to compromise their core professional values, which can corrode their sense of integrity. Faced with recurring feelings of regret, veterinarians are at high risk of avoiding their pain by numbing their feelings, sometimes with the help of substances.
For many veterinarians, moral dilemmas are a weekly occurrence. In 1 study,10 50% of the veterinarians surveyed reported dealing with 2 to 3 ethical dilemmas/wk, and 34% reported dealing with 3 to 5/wk, with all of these dilemmas rated as “stressful.” In my own work with veterinary interns, I have found that, over time, an accumulation of moral stress is detrimental to their sense of being a “good” doctor, regardless of the external circumstances. Writing about moral stress, Elizabeth Strand, DSW, noted that it occurs when one is aware of the ethical principles at stake “but external factors prevent you from doing (something). People who work for organizations that have ‘moral climates’ where they can discuss their moral dilemmas and benefit from other's social support seem to have better outcomes.”6
Caring for terminally ill patients and grief-stricken families can be overwhelmingly stressful. Physicians, of course, share this experience. Nevertheless, veterinarians are exposed to approximately 5 times as many deaths as are physicians.11 The distress implied by this statistic is compelling and should not be overlooked. Repeated exposure to death, even when death is considered humane and the best alternative, is likely to take an emotional toll and can trigger memories of one's personal history of loss. The veterinary interns I work with routinely talk about the gravity of their life-and-death responsibilities and the emotional weight of recommending euthanasia, especially when there is medical uncertainty. In addition to feeling overwhelmed and burdened by the pet owner's grief, they feel personally burdened and saddened by the death of each animal.
Professional Development Programs for Physicians
Recently, researchers have shifted from looking at the causes of burnout to understanding and promoting physician wellness.3 As a result, the literature now includes publications describing methods of building resilience by improving connections between colleagues and strengthening the community of physicians as a whole.12 One recurring approach for improving physician well-being is the use of professional development groups.5,13,14
Professional development groups that focus on well-being for physicians have been found to reduce isolation, stress, and burnout.4,5 When these programs occur early in training, they have the capacity to induct students into a culture of mutual support and reduce the stigma of seeking professional help down the road, should it be needed. Although these programs vary in content, their format usually involves meeting in groups. A supportive group offers members many benefits, including the opportunity to speak openly, reflect on experiences, notice feelings, learn together, and be mutually supportive. My observation is that both veterinary and medical trainees feel relieved to talk to their colleagues in training because they find it hard to communicate their painful experiences to people outside the profession.2,15
Human medicine has developed a variety of ways of supporting physicians in training and practice. Although the groups vary in size and in the discipline of their members, their shared goals are to help clinicians understand and reflect on their vulnerabilities, values, and biases and recognize when they need help; consider a variety of alternatives for handling difficult clinical situations; profit from the experiences and support of colleagues; and enhance compassion for patients and themselves, especially during challenging clinical interactions.
Professional development courses for medical students
At Harvard Medical School, first- through third-year medical students are required to attend a yearlong course entitled “The Developing Physician: Lifelong Integration of Personal and Professional Growth with Sensitive, Compassionate Care.” The students meet at regularly scheduled intervals (monthly or every other month depending on the year) in groups of 7 to 14, with meetings facilitated by 2 faculty members from different medical specialties. Although the students are free to discuss all aspects of their clinical work, the discussion often focuses on their experiences and feelings during clinical and professional interactions. The meetings are semistructured, and often start with group leaders offering prompts to help students openly discuss various positive and negative issues they may have encountered.
Medical students often report difficulty acclimatizing to and learning about a hospital's culture, which includes medical knowledge and procedures as well as norms for interpersonal and political interactions. To address this, the course is designed to encourage medical students to stop, process what they are experiencing, and reflect on how they are responding. In short, the course aims for students to become aware of their thoughts and emotional reactions as they develop into professionals. Eugene Beresin, MD, a cocreator of the course, describes “small group tutorials… [as the] heart and soul of The Developing Physician.”16 He goes on to say that “tutorials are necessary to provide a ‘safe space’ to share personal experiences with classmates and tutors” and they “help to facilitate on-going well-being, maintain compassion and empathy, diminish stress and prevent burnout.”16 Therefore, learning to self-reflect and process clinical experiences with peers protects against burnout and promotes resilience in medical trainees. I believe the same is true for veterinarians in training.
Clinical teams and training groups in the Cambridge Health Alliance Department of Psychiatry
The Cambridge Health Alliance is a municipal hospital and teaching affiliate of Harvard Medical School with a mission of providing exemplary care to underserved and disenfranchised populations. This can include working with some very difficult patients. Owing to the intensity of the work, the Department of Psychiatry created interdisciplinary teams that include trainees and staff from the fields of psychiatry, psychology, social work, and nursing, along with a team leader from one of these disciplines. These teams aim to mitigate the stress of working with a complex, high-trauma population while providing expert clinical supervision and emotional support to trainees. On average, 15 people sit on a team, which meets for 90 minutes every week throughout the academic year. During team meetings, members have the opportunity to review patients who are diagnostically complex, emotionally taxing, high risk, or making little progress. The trainee presents the case briefly, staff and trainees consult, and a treatment plan is devised with the expectation of follow-up the next week. The mantra of these training teams is “never worry alone,” and the team's process demonstrates that consultation provides better care while at the same time providing valuable support for team members.
In addition to these weekly team meetings, psychiatry residents and psychology interns at teaching hospitals around Boston, including at the Cambridge Health Alliance, are required to attend year-round, weekly group meetings that aim to provide a safe, confidential place where trainees can be internally curious and discuss work concerns. Although the group process prioritizes professional development, it includes the option of discussing personal issues that impact trainees in their work as therapists. The goal of these group meetings is to help mental health providers anticipate common problems and avoid being reactive with patients. To this end, in addition to guiding trainees to reflect on what is most difficult for them, meetings aim to help them feel comfortable in reaching out for support and consultation.
Balint groups
Michael Balint, a British psychoanalyst, developed a group program currently in use for palliative care postdoctoral fellows at the Massachusetts General Hospital and the Dana Farber Cancer Institute. Similar Balint groups are active in many medical and psychiatric residency training programs across the United States and abroad. In the 1950s, Michael Balint recognized that general practitioners were struggling with difficult patient encounters and launched a psychoanalytically based group program for physicians aimed at improving the doctor-patient relationship.17 Balint believed that processing doctor-patient interactions in detail in the presence of a group of colleagues was the best way to understand challenging interactions. The Balint group model has a reputation for helping doctors increase “their competence in patient encounters and enable[s] them to endure in their job and find joy and challenge in their relationships with their patients.”17
Balint groups, however, require a commitment of at least 1 to 3 years from physicians. Allegedly, the longest-lived group met for 15 years. Groups have 4 to 10 members and use a formal structure for each meeting, such that one physician presents a detailed case, focusing on what she or he said and felt during an interaction with a patient and describing what was difficult for her or him without interruption from the group. The other group participants then talk about how they felt listening to the story and ask the speaker questions about the encounter, but not about the medical problem itself. This process gives physicians a deeper understanding of what is difficult for them and how their feelings might have affected the interaction, which generally results in participants having more compassion for themselves and their patients. Finally, this model allows all group members to create and rehearse alternative responses to this type of clinical interaction. Balint groups, with their process of self-reflection and focus on understanding the doctor-patient interaction, are one of the bedrocks of the current groups for physician wellness.
Schwartz Rounds
The Schwartz Rounds program, another highly regarded professional development program for medical professionals, was developed explicitly to enhance compassion within the doctor-patient relationship. When Kenneth Schwartz, an attorney in his 40s, developed terminal lung cancer, he wanted to create a program that would highlight the acts of compassion he experienced during his treatment and that had a positive impact on him. Even though his doctors could not offer him a cure, he thought their compassionate and caring interactions with him were profound and should be integrated into all patient care.
The Schwartz Rounds program aims to create a safe, supportive environment in which clinicians can “share their experiences, dilemmas, joys, concerns, and fears (both for their patients and for themselves).”18 Similar to medical grand rounds meetings, the Schwartz Rounds meetings are interdisciplinary and open to the entire hospital staff. Thus, there is no upper limit to the number of participants.
For each meeting, several members of a clinical team present their personal experiences of working with a challenging patient, after preparing with a trained Schwartz Rounds facilitator in advance. They focus on the psychological, social, and emotional aspects of caring for the patient as well as the limitations of the hospital environment. After the presentation, the facilitator invites the audience to share their thoughts and impressions, while steering the focus away from medical solutions. Schwartz Rounds are held in more than 440 health-care organizations today,19 and participants report that the opportunity to reflect and process common provider-patient dynamics with a group of peers fosters compassion and helps develop a stronger, more supportive work environment.20
A Pilot Group for Veterinary Interns: The Intern Forum
For the past few years, I have been researching and observing various professional development programs for physicians with an eye to the needs of veterinarians. Taking pieces from various programs, I designed a professional development program, called the Intern Forum, and began offering it 3 years ago to veterinary interns at the Angell Animal Medical Center in Boston. The Intern Forum grew out of the relationships I developed with clinicians at Angell during the care of my own pet. During monthly pain management appointments extending over several years, I learned about the challenging aspects of pet owner–veterinarian interactions and wondered whether my training in mental health and mental health administration might be useful to the staff at Angell.
After meeting with various groups from the hospital staff 5 years ago, I concluded that veterinarians and physicians have enough challenges in common to make my experience in a hospital-based psychiatry department useful. On the basis of consultations with members of the Angell staff, veterinary interns were chosen as the pilot group, and I was given permission to begin working with them. After meeting monthly with interns at Angell for 3 years, I requested permission from the Tufts University Cummings School of Veterinary Medicine to add another intern cohort with the aim of understanding which challenges, if any, were unique to interns at Angell and which might be generalized among veterinary intern groups.
Having worked with this second group of veterinary interns for nearly a year, it has become clear that hospital-based internships in general are extremely challenging, and it seems likely that veterinary interns across the country who are receiving similar training would have similar experiences and express similar feelings. The pressures of learning medicine, either human or veterinary, can be overwhelming. The high levels of responsibility and steep learning curve, combined with the lack of sleep, make medicine one of the most difficult professional training experiences.
The Intern Forum includes the entire intern class, which is approximately 15 people. One-hour meetings are held on a monthly basis, and all meetings are confidential. No confidences that are discussed during these meetings are reported to hospital administrators or senior staff, and group members agree not to discuss the content of meetings with anyone outside the group. Typically, at the beginning of each meeting, I review some details from the previous meeting and then invite the group to have an open discussion. I rarely have to suggest a topic, because the participants almost always have events in mind they wish to discuss. Often someone begins by expressing regret about a clinical “mistake” or concerns about possibly having mishandled an interaction with a disgruntled pet owner. I let the intern complete her or his story, which is sometimes accompanied by tears, before allowing other interns to respond. Without exception, they are quick to reassure the speaker that they have had similar experiences. And their comforting words illustrate the ways in which they have tried to cope.
As each year of the program progressed, interns moved away from talking about their anxieties over medical decision-making and interactions with difficult pet owners in favor of focusing on difficult interactions with faculty members, residents, and hospital staff. And, in my experience, as interns worried about where to apply and how to complete their residency applications around the time of the Christmas holidays, their stress levels peaked. Each year, a few of them questioned whether they wanted to go on to a residency because of repeated moral dilemmas and the seemingly endless nature of the schedule. After this period was over, the group typically turned to discussions of their personal experience of the internship, which invariably included a sense of exhaustion, shared anger about the stressful nature of the training year, feelings of being undervalued, and the toll the internship had taken on their personal lives. By the spring, the interns were counting the hours and days of emergency room shifts that remained before graduation. At the same time, they expressed a deep appreciation for the confidence and sense of mastery they had gained and for the tremendous amount of medicine they had learned.
At the end of the year, I ask the interns to share a list of concrete improvements to the internship program (eg, an alternative call schedule) that I can bring to the internship director. This final step has proven beneficial both for the interns, who made important suggestions and felt empowered by doing so, and for the internship director, who was able to use these suggestions to make improvements for future intern classes.
One of my goals with the Intern Forum has been to understand the developmental arc of the internship year. Because I am now familiar with the typical concerns of veterinary interns, I can anticipate and focus on those areas where group meetings can have the greatest potential impacts. During the middle and again at the end of the intern year, I administer short questionnaires asking participants about their experience with the group. The questions are open-ended and qualitative and ask participants to provide constructive feedback and recommendations for improvement. To date, the feedback has been positive, with all responders citing the benefits of being in the group and recommending that the group be offered to the next incoming class.
Conclusions
The professional life of veterinarians, like physicians, is inherently stressful and often isolating, which contributes to depression, burnout, and job dissatisfaction. Authors who have examined physician and veterinarian well-being recommend finding ways to promote self-reflection and to create strong positive bonds between coworkers. Given what already exists for physicians, there is no need to reinvent the wheel for veterinarians. Adapting what we know is a logical next step. Providing developmentally informed, safe, confidential professional development groups for trainees, and possibly also for staff and faculty, is one good way to meet this need. Workplaces that foster emotional support and cultivate compassion, especially early in professionals' careers, not only provide an antidote to burnout, but also promote resilience. Tolerating emotional pain, accepting death, embracing grief, and grappling with moral doubt are daily concerns for those who choose the helping professions. In my experience with psychiatric and veterinary trainees, meeting in groups with a trained facilitator provides much-needed support for the individuals who take up this challenge.
In light of the positive reception veterinary interns have given the Intern Forum, I believe residents and newly graduated veterinarians who are transitioning into clinical practice would also benefit from professional development groups. I recommend offering a group during every year of veterinary training. Furthermore, because veterinarians continue to face various challenges throughout their careers, it would be interesting to extend the group model to serve the needs of more senior professionals.
Acknowledgments
The author declared that there were no conflicts of interest.
The author thanks Joseph Powers, PhD, for his support of the Intern Forum along with his exceptional clinical supervision and Eugene Beresin, MD, for providing important content contributions in the area of professional development for medical students and physicians.
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