Pharmacy Residents’ Mental Wellness: Why and How to Prioritize Resilience in Residency

Kala Rorabaugh, PharmD BCPPS
Pharmacy Clinical Specialist, Pediatric Hematology/Oncology
WVU Medicine J. W. Ruby Memorial Hospital
Morgantown, WV

Aaron Stewart, PharmD CTTS
Postgraduate Year-2 Oncology Pharmacy Resident
WVU Medicine J. W. Ruby Memorial Hospital
Morgantown, WV

Spencer Yingling, PharmD
Postgraduate Year-2 Oncology Pharmacy Resident
WVU Medicine J. W. Ruby Memorial Hospital
Morgantown, WV

In recent years, discussions about the overall wellness of healthcare providers and the effect that it may have on patient care have dominated national professional organizations.¹ Although burnout among healthcare providers, including pharmacists, is not a new phenomenon, minimal guidance on promoting wellness has been given to new pharmacists to help them prevent burnout throughout a career.

The term burnout was coined in 1974 by H. J. Freudenberger to describe the effects of long-term exhaustive stress associated with one’s occupation.² The characteristics include visible exhaustion and fatigue, sleeplessness, frustration, paranoia about one’s colleagues, and inflexibility. In 2019, the World Health Organization (WHO) announced that burnout would be updated in the International Classification of Diseases (ICD-11) in 2022 to a syndrome “characterized by feelings of energy depletion or exhaustion, increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job, and reduced professional efficacy.”³ Similar to Freudenberger, WHO recognizes the correlation between prolonged occupational stress and burnout.

Le and Young evaluated the stress experienced by pharmacy residents using a questionnaire that included the 10-item Perceived Stress Score (PSS10) and the Multiple Affect Adjective Checklist–Revised (MAACL-R).⁴ The PSS10 is a validated tool used to evaluate perceived stress on a scale of 0 to 40, where higher scores correlate with higher perceived stress levels. The MAACL-R is a licensed test used to evaluate the “affect of individuals; specifically depression, anxiety, hostility, and dysphoria.” The PSS10 results showed a mean ±SD perceived stress level of 19 ± 5.90 and a statistically significant correlation between elevated PSS10 scores and a work week longer than 60 hours. According to the MAACL-R results, working more than 60 hours per week was also statistically significantly correlated with depression, hostility, and dysphoria. Elevated PSS10 scores were correlated with statistical significance in relation to anxiety, depression, hostility, and dysphoria.

The increased stress on pharmacy residents can have serious adverse effects on both residents and patients. In the United States, depression affects about 7% of the general population but affects 30% of medical residents.^5,6 Although the data on pharmacy residents do not yet exist, given their strenuous training, it is likely that they also have an increased incidence of depression. In 2004, the aggregate suicide rate ratio among male and female physicians compared to the general population was 1.41 (95% confidence interval [CI], 1.21–1.65) and 2.27 (95% CI, 1.90–2.73), respectively.⁷ Reports of medical resident suicides are regrettably easy to find, and in 2011, a pharmacy resident in South Carolina took her own life.⁸ Despite the obvious negative impact on the individual resident, patients are also potentially at risk. Le and Young evaluated the relationship between pharmacy residents’ stress and medication errors.⁹ Residents were asked to respond to the PSS10 and self-report medication errors. Perceived stress scores were positively correlated with self-reported medication errors (p < .001) among all residents surveyed.

At West Virginia University (WVU) Medicine, a Pharmacy Residency Wellness Program was designed to educate residents about wellness, provide them with the tools to help combat burnout, and remove the stigma associated with mental illness. The program began as a small session hosted by two preceptors, in which the preceptors provided anecdotes about their own experiences as well as tools they used to cope with stress. The program was expanded after residents gave positive feedback.

The first formal session was an introduction to the wellness program that included the reasons for implementing the program (outlined above), along with important information about WVU Medicine’s Employee Assistance Program, mental health resources in the community, and stories of preceptors’ personal experiences, all of which helped to remove the stigma associated with mental illness.

The director of the SupportingYOU Second Victim program at WVU Medicine Children’s Hospital spoke with the residents and preceptors about that program. WVU Health Sciences Building Wellness Center staff provided presentations by a neuroscientist, a clinical therapist, and a yoga instructor, who educated residents and preceptors on mindfulness and meditation, covering the scientific evidence for practicing meditation and instruction on yoga poses; a meditation session was also included. The clinical therapist discussed different types of mental health care, mental illness stereotyping, and the physiological responses to stress. Three preceptors collaborated to create an activity to help residents name their values and target their actions to match those values, both at work and at home. Members from the pediatric supportive care team discussed death and dying with the residents and preceptors. Future sessions will cover exercise, faith, sleep hygiene, financial health, and career transitions. We are incredibly lucky to have the support from our leadership and department to develop and maintain a wellness program.

Wellness Tips from the Pharmacy Residency Mentorship and Wellness Coordinator

Know what tools are available and reach out. Seek out employee assistance programs or local mental health offices. Do not be afraid to set up a baseline appointment with a therapist; an advantage is that after you become an established patient, it will be easier for you to schedule future appointments. The National Suicide Prevention Lifeline number is 1.800.273.8255, and the Crisis Text Line can be contacted by texting CONNECT to 741741.⁵

Develop coping skills. Maintain work-life balance, and do not be afraid to set boundaries where necessary. Maintain social connections by reaching out to friends and family members or by building new relationships. Learn positive coping skills from mentors.

Manage your time well. Managing your time can help reduce stress. Knowing first what your weaknesses are and then addressing what may hold you back can help propel you forward. Make a priority list instead of a to-do list. Break those priorities into bite-size pieces. For example: “Review 5 patient charts” does not seem as daunting as “Conduct research.”¹⁰ Avoid social media: not only does it derail productivity, but in 2014, Vogel and colleagues found a negative correlation between time spent on Facebook and self-esteem, especially when one is viewing people whose lives seem better than that of the study subject.¹¹

Advocate for mental health care. Be an advocate for mental health care within your health system.

Wellness Tips from Oncology Residents

The idea that high stress levels are expected and should be tolerated throughout residency exists throughout the healthcare community. The implementation of the wellness program at our institution has helped correct that erroneous idea. Our key takeaways are these:

Don’t wait for mental health concerns to arise before seeking help. Feeling stressed and inadequate are common experiences for residents and are no less important than the residency program itself. Early recognition of these concerns is important and can help residents obtain early assistance to learn strategies for addressing them.

Set reasonable expectations. Residents may struggle with how they are perceived by their preceptors. The associated stress may accumulate throughout the year, resulting in lack of confidence, feelings of unease, and burnout. The wellness program at our institution gave residents and preceptors the opportunity to unite and address these topics upfront, set the standard for expectations and progression throughout the residency year, and alleviate the burden of troublesome worries and concerns.

Find meaningful downtime. Finding meaningful downtime activities between rotations and work shifts should be a goal for all residents. Meaningful downtime may differ from resident to resident, but that time should be spent doing an activity that appeals to and provides benefit to the resident. Though free time during residency is limited, the time available should be used wisely. Our Pharmacy Resident Wellness Program offers suggestions for activity sessions and actively encourages residents to acknowledge and act upon their need for meaningful downtime.

Be proud of and grateful for your own achievements. It is very easy for residents to focus on the negative aspects of life, but doing so creates a poor psychological environment. Our Pharmacy Resident Wellness Program provides us with tools to help us see ourselves positively and recognize the effort we display daily.

References

1. Bridgeman PJ, Bridgeman MB, Barone J. Burnout syndrome among healthcare professionals. Am J Health Syst Pharm. 2018;75:147-152.
2. Freudenberger HJ. Staff burn-out. J Soc Issues. 1974;50(1):159-165.
3. Chatterjee R, Wroth C. WHO redefines burnout as a ‘syndrome’ linked to chronic stress at work. National Public Radio, Morning Edition, May 28, 2019. Accessed October 17, 2019. Available at https://www.npr.org/sections/health-shots/2019/05/28/727637944/who-redefines-burnout-as-a-syndrome-linked-to-chronic-stress-at-work.
4. Le HM, Young SD. Evaluation of stress experienced by pharmacy residents. Am J Health Syst Pharm. 2017;74:599-604.
5. Mayberry KM, Miller LN. Incidence of self-reported depression among pharmacy residents in Tennessee. Am J Pharm Educ. 2017;81(8):5960.
6. Williams E, Martin SL, Fabrikant A, Wang A, Pojasek M. Rates of depressive symptoms among pharmacy residents. Am J Health Syst Pharm. 2018;75(5):292-297.
7. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161(12):2295-2302.
8. Bowers P. Bridge jumper identified as Tosin Oyelowo. Charleston City Paper. December 19, 2011. Accessed October 17, 2019. Available at https://www.charlestoncitypaper.com/charleston/bridge-jumper-identified-as-tosin-oyelowo/Content?oid=3662179.
9. Le HM, Young SD. Exploring the relationship between environmental stressors, pharmacy residents’ stress and medication errors. J Psychol Cognition. 2017;2(3):192-197.
10. Flaxington BD. Developing time management skills: how to become more organized and find more time in a day. Psychology Today. July 27, 2015. Accessed October 17, 2019. Available at https://www.psychologytoday.com/us/blog/understand-other-people/201507/developing-time-management-skills.
11. Vogel EA, Rose JP, Roberts L, Eckles K. Social comparison, social media, and self-esteem. Am Psych Assoc. 2014;3(4):206-222.