MAY 2019

Compassionate care in Pediatrics

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The situation

Access to high quality healthcare is a key human right recognized by the European Union, its Institutions and the citizens of Europe. Any high quality, high performing healthcare system relies on the effectiveness and wellbeing of its healthcare professionals. In addition, innovation and interdisciplinary collaboration are essential to meet the needs of the children and families that need our care.

Resource constraints, changing patient needs, increasing demands and system’s complexity are irreversibly changing our professional work. However, in the process of trying to respond to complex challenges in healthcare there is a risk of unintentionally damaging the health and wellbeing of the healthcare professionals we ask to care for the health and wellbeing of others. For example, regulatory and inspection regimes that have been put in place are in danger of creating cultures of blame and fear rather than cultures of compassion, learning, innovation and collaboration. In addition, systems issues, such as diminished physician and trainee sense of control, electronic health record burdens, and disengagement of healthcare professionals from workplace governance, all may negatively affect wellbeing.

How may this affect paediatric (and other) trainees in Europe?

In addition to the factors described above, residents and fellows in many specialties work long hours and transition during their training from totally supervised work to greater autonomy and more independent practice. They have responsibility for patient care with limited influence over care decisions, schedules or work environment. There may be a lack of recognition for work done, insufficient social support in the working place, unfair treatment, lack of civility, respect or positive value to trainees, and witnessing of unprofessional behaviour in others. Paediatric trainees may be at particular risk of decreased wellbeing. Character traits especially valued in paediatricians like compassion, altruism, and perfectionism also predispose to burnout, and some specialties may therefore be at particular risk. Burnout may also be viewed as a consequence of the  ‘hidden curriculum’, where trainees observe and mirror the maladaptive behaviours of their trainers. As trainees may start a family during residency, some struggle with work-life balance, as reported by a recent survey by the American Academy of Pediatrics (AAP). Women seem to be more affected than men.

The General Medical Council (GMC) conducts yearly surveys into training across all specialities and in 2018 reported that whilst around 80% of trainees in the United Kingdom (UK) described the quality of their posts as excellent/good, 23.8% of trainees and 21.2% of trainers feel burnt out to a high or very high degree by their work . A similar survey done by the Dutch Junior Doctors showed that in 2018 around 30% of trainees rated the quality of their training as excellent/good, and work-life balance was disturbed in such a way that around 20% of trainees experience symptoms of burn out by their work . This may be due in part because European Regulations regarding working hours  are not consistently adhered to and most female residents are not replaced while on pregnancy leave. Within paediatrics, a 2017 national survey done by the Junior Section of the Dutch Paediatric Society, showed that more than 50% of trainees sometimes experienced symptoms of burn out by their work whereas 10% did frequently. More than 50% of trainees felt their work-life balance was good, either always (2.2%) or most of the time (53,8%); almost 40% felt their work-life balance was acceptable but they would like to see it improved. Trainees in some paediatric subspecialty areas may be more at risk for burnout than in other areas. For example, in the United States, while the prevalence of burnout during paediatric training mirrors rates described in other medical specialties (30%–50%), higher rates are seen in specific paediatric subspecialties such as haematology/oncology, neonatal and paediatric intensive care, and paediatric surgery.

The cost of burnout is well recognised. Burnout can be evaluated using standardised tools such as the Maslach Burnout Inventory. A 2017 study found that burnout doubled the likelihood of being involved in patient safety incidents, of showing suboptimal professional behaviours, or of low patient reported satisfaction. In addition, trainees may decide to end their paediatric training due to issues like burnout, unfavourable work-life balance and unsafe culture.

Current Good Practices

In The Netherlands, several paediatric training programmes have started to implement a Challenge and Support Programme. This programme enables paediatric trainees to regularly discuss challenges and opportunities for personal and professional growth, as well as work-life balance and career paths with a certified coach, an approach that is very common in sectors other than health. This programme is in part reimbursed by their paediatric department. It is now being implemented in other specialty training programmes as well and promoted by the Dutch Junior Doctors. The AAP developed their curriculum Resilience in the Face of Grief and Loss in response to the growing data on the emotional toll of medical training and practice. Whilst the initial focus was on addressing grief and loss during a medical career, the working group further expanded this to address all aspects of health, wellness, resilience and burnout prevention. This learner centred curriculum based on adult learning principles addresses the knowledge, skills and attitudes needed for residents to develop and maintain strategies to increase cultural and personal wellness and resilience. As well as residents, the curriculum is relevant to the whole journey through a medical career, from students to senior doctors. Many training centres in the UK  now have Trainee Support Services offering support with personal illness, issues with personal factors such as stress and family issues, and environmental factors in the workplace (HEENE).

As the difficulties trainees experience may be rooted in workplace and learning culture, a systems-based approach may be needed to improve working and training conditions rather than focusing on individual personal factors alone. Several national medical specialist societies in Europe have embraced the concept of Compassionate and Inclusive Leadership. Compassionate leadership enhances the intrinsic motivation of healthcare staff and reinforces their fundamental altruism.  It helps promote a culture of learning, innovation and collaboration. This concept has already been embraced in the National Health Service in the UK and is currently being explored in the Netherlands. For example, in Birmingham Women and Children’s Hospital in the United Kingdom, gaps in rotations meant that trainees were working in unacceptable conditions and that their learning (and potentially patient care) was suffering. The organisation responded by bringing together trainees, consultants, other clinicians, the finance department, and the HR department, in order to understand the issues involved.  All involved committed to making the hospital the best organisation in the UK for trainees to work in. Weekly meetings became the medium for innovation. Thirty four rotations were redesigned and clinical staff led the initiative to create new roles to support the work. As poor learning environments such as disorganised rotations and inadequate supervision are associated with learner burnout, this hospital is now an exemplar for others across the UK in terms of their work with and integration of trainees.

In complex systems like healthcare, there is always error. Unfortunately, in medical departments with a hierarchical structure, the culture is frequently to blame the individual for the error rather than to try to understand the various processes in the system that lead to it.  This culture of Blame and Shame can lead to considerable emotional fallout in the individual healthcare professional and stands in the way of Just Culture that is needed to improve patient care. Humans are fallible and that human errors are likely to occur in the best organizations. Errors are the end result of a series of failures in the system and therefore errors are therefore consequences and not the causes. The Dutch Health and Youth Care Inspectorate have therefore decided to work from a Healthy Sense of Trust in healthcare professionals. This means the Inspectorate assumes that care providers are always prepared to learn, improve and innovate and its quality and safety inspections are based on a thorough evaluation of “good governance” (i.e., whether the working culture is open, safe and just and thus enables learning and improvements) in addition to the evaluation of which system improvements are proposed.

 Our Recommendations

Globally, burnout remains a significant problem for the medical workforce, and whilst significant strategies have been implemented to address this, the problem still remains. The negative impact of burnout upon trainees, patients and families is well documented. As burnout has been clearly linked to patient safety concerns and suboptimal patient care, we should start viewing doctors’ wellbeing as integral to professionalism. and as central to patient care. Young EAP and EAP therefore urge all programs and departments across Europe to meet the challenge presented by burnout, by addressing personal and environmental factors in their workplaces.

  • All residency programs should cultivate a supportive culture, as outlined in the European Junior Doctors’ (EJD) Statement on Wellbeing, Stress and Burnout and the EJD Statement on Protection and Rights during Pregnancy and Parenthood. In short this means that:
    • Access to supervision should be ensured;
    • Junior Doctors resting periods should be respected, protecting physicians’ health and quality of care;
    • The common culture of hierarchical health systems – where communication between supervisors and trainees can increase the feeling of being in a hostile environment – should be changed;
    • Specific programmes are needed to detect and address stress related problems and mental health issues in doctors at an early stage. Confidentiality must be assured so that individuals do not fear to seek help.
    • Mechanisms such as periodic evaluations with tutors or workshops on developing communication skills or coping with emotions, must be implemented, and
    • Working conditions should promote a healthy balance between career and family life.
  • The Paediatric Training Curriculum should invest in both clinical skill and the personal-social, leadership, and teamwork skills, which are necessary to achieve success in complex and high performing healthcare systems. Crew Resource Management could serve as an example as it teaches skills for dealing with complexity, including team based training in situational awareness, decision making, communication, and problem solving. Preferably, regular intervision and coaching sessions should be available to all trainees.
  • National (pediatric) societies may consider to explore the concept of “Compassionate and Inclusive Leadership” and promote “Just Culture”.
  • The European Union of Medical Specialists may consider including EACME requirements for programs to educate trainees and faculty physicians about fatigue and burnout, following the example of the American Accreditation Council for Graduate Medical Education.

About the authors

Lenneke Schrier is the European Junior Doctor Representative to the European Academy of Paediatrics and Chair of Young EAP. She currently works as a paediatrician/clinical fellow in Paediatric Oncology at the Prinses Máxima Centre in Utrecht, The Netherlands.

Sian Copley is a 4th year resident from the UK working in the North East of England. Sian  represents UK paediatric trainees within Young EAP, and paediatric trainees/Young EAP within the EAP Advocacy Group.

Robert Ross Russell is the chair of the European Board of Paediatrics and a member of the Executive Committee of the European Academy of Paediatrics. He is a Consultant Paediatrician at Cambridge University Hospitals Foundation Trust in the UK.

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