R Bogerd

Chapter 1 introduces physician flourishing, operationalized as feelings of professional fulfillment and being able to deliver compassionate care, as the topic of this thesis. In this chapter, I describe how both elements are under pressure today and I zoom in on physicians’ perfectionism/ self-criticism and deprioritizing self-care as two of the dominant cultural challenges to physician flourishing. Logically following from this, I introduce ‘cultures of wellness’ as the theoretical lens used to study the topic of this thesis. Cultures of wellness can be defined as “a set of normative values, attitudes, and behaviors that promote self-care, personal and professional growth, and compassion for colleagues, patients and self”. In general, cultures of wellness have been found to be robust determinants of physicians’ professional fulfillment and their ability to deliver compassionate patient care. There are, however, still many gaps in our knowledge with regards to physician flourishing in the context of cultures of wellness. There is a need for more understanding on how elements of cultures of wellness may affect physicians’ flourishing, both for faculty and for residents. Additionally, there is not much research on elements of cultures of wellness and physician flourishing in the Dutch healthcare setting. Therefore, the overarching research question of this thesis is:

What role do elements of cultures of wellness play in Dutch physicians’ professional fulfillment and compassionate care practices?

By answering the research question, this thesis aims to offer starting points for fostering cultures of wellness in medicine and (post-graduate) medical education to contribute to a professionally fulfilled, sustainable, and high-performing medical workforce.

To help close the gap in research on professional fulfillment and its determinants among Dutch physicians, Chapter 2 provides a holistic perspective on Dutch physicians’ well-being and specifically their levels of professional fulfillment. In a representative sample of 374 registered cardiologists using a web-based survey, we investigated how Dutch physicians experience their positive (professional fulfillment) and negative (work exhaustion and interpersonal disengagement) work-related well-being and what cultural and other aspects determine these experiences. We used frequencies to depict scores on the three well-being indicators and performed three multiple regression analyses to elucidate their determinants. We found that Dutch cardiologists experienced relatively high levels of professional fulfillment, for which satisfying and meaningful patient interactions were the greatest predictor. In addition, Dutch cardiologists’ levels of professional fulfillment were positively affected by a good person job-fit and high levels of personal resilience, as well as a sense of autonomy and involvement in overall managerial decision-making. Experienced workload, work-home interference and (negative) team atmosphere were related to the negative well-being dimensions. The findings of this chapter show that it is critical to invest in physicians’ resources of energy. Promoting the well-being of cardiologists seems most effective by boosting, for example, their professional autonomy and ensuring satisfying physician-patient interactions.

While investing in energy-providing resources may be an effective strategy to promote physicians’ flourishing, our introductory chapter shows that it is equally crucial to be aware of cultural challenges to physician flourishing within the profession. In striving to deliver high quality patient care physicians often develop perfectionistic mindsets, a self-critical attitude and low self-tolerance. Both perfectionism and self-criticism have been associated with burnout in physicians. A kinder attitude towards the self, i.e. self-kindness, has been found to buffer against stress and burnout.

Self-kindness refers to being gentle, supportive and understanding towards the self, instead of being harsh and self-critical. While ample evidence shows that self-kindness is associated with reduced burnout in physicians, up till now research on the relationship between self-kindness and professional fulfillment remained largely underexplored.

Chapter 3 therefore explored to what extent a kinder attitude towards the self, i.e. self-kindness, was associated with physicians’ professional fulfillment and whether this relationship was mediated by personal resilience and work-home interference (the two mediators were selected based on relevant literature). Using the same sample as used in chapter 2, we performed a parallel mediation analysis with Hayes’ SPSS macro PROCESS v3.5. The findings in this chapter show that Dutch cardiologists reported moderate levels of self-kindness, and that self-kind cardiologists experienced higher levels of professional fulfillment, which was partly explained by the fact that they were more resilient and better able to manage their work-life balance. We speculated that resilient physicians may find more time and space to enjoy positive feelings and opportunities at work, important indicators of professional fulfillment. Additionally, our findings show that self-kindness may be associated with self-care skills, as it seems that better self-care skills could indeed result in more effectively reducing work’s negative impact on physicians’ personal spheres- thereby improving their feelings of professional fulfillment. Research has shown that self-kindness is a trainable skill, which may be developed through exercises included in evidence-based self-compassion training programs. Physicians and healthcare organizations responsible for the well-being of the medical workforce may include such programs in their well-being enhancing strategies. More so, the results of this study seem to suggest that physicians operating in demanding work environments with a focus on efficiency, productivity and competitiveness may comfortably be more self-kind instead of being harsh and judgmental towards themselves. Doing so will likely benefit their own well-being and thereby ultimately optimize the quality of patient care.

Self-kindness is frequently mentioned as a contributing factor or even prerequisite for the ability to be kind or compassionate towards others. As being compassionate towards patients is crucial for high quality care, being more kind towards themselves may not only benefit physicians but also their patients. Despite the fact that compassion is a crucial element of high quality patient care, caring for patients with compassion is not self-evident. Some faculty show more compassion than others. Research suggests that there are individual attributes, experiences and characteristics that can be associated with the variation in clinicians’ expressions of compassionate behavior towards patients. Gender may be such a characteristic. Given that role modelling is crucial for instilling compassion skills in future doctors, some faculty fail to role model compassion in practice and that it is largely a matter of chance which role models residents encounter during their training, more insight into the effect of faculty gender on the relationship is needed.

In chapter 4, we therefore analyzed 12416 resident evaluations of 2399 faculty members across 22 Dutch hospitals. Using descriptive statistics, we investigated to what extent residents observe faculty showing compassionate behavior towards patients and families during their training. Additionally, we built and tested a multivariate general linear model to explore the relation between faculty’s observed compassionate behavior and them being seen as role models. Our findings in this chapter showed that supervisors’ showing compassion towards patients in practice is indeed observed by residents, and that role modelling may therefore be an effective strategy in teaching residents how to become compassionate caregivers. The element of showing compassion in post-graduate medical educational cultures may therefore stimulate future physicians’ flourishing in terms of becoming compassionate caregivers. Female faculty slightly but significantly outperformed their male peers on both role modelling and compassionate behavior scores.

However, when male faculty showed compassion, this positively reflected on their role model status more than when female faculty demonstrated compassion. In showing this, chapter 4 contributes to the growing understanding that the medical profession is not gender-neutral. On the whole, this chapter shows that compassion is being seen and appreciated by residents and could therefore increase knowledge among faculty about the impact of their behaviors towards patients and families. Variation in staff groups, e.g. with regards to gender, may be a practical and potentially beneficial strategy for transferring a range of compassion skills to future doctors. In addition, future research could be aimed at revealing and understanding differences in expressing compassionate behavior between (female and male) faculty in a qualitative way. These insights can be used to inform teacher training courses as well as courses on compassion in the (post-graduate) medical curriculum.

The previous chapters quantitatively looked at a variety of elements of cultures of wellness in relation to physician flourishing: collegiality and team atmosphere, psychological safety, self-kindness and a healthy work-life balance. A major and largely overlooked element of cultures of wellness in the literature was perceived appreciation. It was unclear how appreciation at work manifested in the eyes of residents, as well as how it would impact their levels of professional fulfillment and compassionate care practices. Because residents are in the unique position of being both fully part of the health care team and still in training, their experiences may differ from those of faculty. Hence, and in light of the pressing workforce and retention challenges that residency programs face, an in-depth exploration of how appreciation at work manifests in the eyes of residents is needed as well as how the underlying mechanisms between appreciation and professional fulfillment and performance work for them.

Continuing within the field of post-graduate medical education, chapter 5, based on open-ended interviews with 12 residents from different specialties, training years, regions in the Netherlands, and genders, explored how appreciation at work manifests for residents and how it impacts their flourishing. Findings revealed that feeling appreciated, being seen and heard as a unique person, was crucial for residents’ professional fulfillment and compassionate care practices. Residents narrated their experiences with appreciation at work coming from three narratives, namely as learner, physician or colleague and employee. The dominant narrative was dependent on personal preferences and characteristics, year of education, medical specialty, previous experiences, and other contextual factors. In general, residents mentioned that the experience of feeling valued was more intense when they were appreciated for something they highly valued themselves and when appreciation was expressed at an unexpected moment. Appreciation, residents said, relieved their stress levels, made them more confident and prouder of themselves, enhanced their motivation and commitment and stimulated the feeling of being able to contribute to patients’ (quality of) lives – all positively reflecting on their feelings of fulfillment and the ability to provide compassionate care.

All in all, this thesis explored whether and how elements of cultures of wellness impact Dutch physicians’ flourishing – or, more specifically, their professional fulfillment and compassionate care practices. Chapter 6 provides an answer to this question by arguing that cultures of wellness play a role in physicians’ flourishing via three overlapping themes. Elements of cultures of wellness may help physicians to find ‘Meaning in work’ and support them and their organizations to restore and foster ‘Kindness in the workplace’. On a more systemic level, we conclude that placing ‘Human connections at the core of practice’ will most likely support physician flourishing and contribute to ensuring sustainable healthcare systems capable of delivering high-quality patient care.

In summary, our exploration of (elements of) cultures of wellness suggests that it may be timely to reimagine and reinforce the relational model in healthcare. In order to do so, I have argued for three potentially helpful strategies: 1) (Stimulate physicians and other healthcare workers to) invest in interpersonal relationships with both patients and colleagues, 2) Explicitly start conversations around professionals’ core values and 3) Incorporate leadership strategies that are aimed at normalizing (self-)kindness in medical practice and post-graduate medical education. I hope that the insights of this thesis continue to find their way into practice and that the members of the profession feel the courage and find the tools to indeed collectively foster a culture that promotes meaning and kindness. After all, it doesn’t cost us anything to be kind.