Assessing the Impact of Physician Pain on Motivation to Provide Longitudinal Osteopathic Manipulative Therapy to Patients and Its Correlation to Opioid Prescribing

Physician wellness has become a recent high priority in the medical community. This focus on wellbeing has stemmed from a culture of notoriously high-stress work, long hours, and an increase in publicized physician suicides.8 Many physicians report an increased work burden due to general physician shortages, thus resulting in burn-out. These stressors and associated burn-out are resulting in physicians making the decision to leave the workforce early.9 Mental health initiatives such as Balint groups and peer coaching have been implemented as an effort to combat these concerns.10, 11 As described in greater detail below, very few publications have focused specifically on the physical health considerations of physician wellness.

The Accreditation Council for Graduate Medical Education (ACGME) asks about resident and faculty wellness in their annual programmatic surveys.12 The mechanisms for fulfilling wellness requirements are left to each program to select. This lack of specificity provides programs latitude to meet their own needs, but also doesn't mandate evidence-based approaches. Even the ACGME faculty survey contains questions regarding wellness. ACGME has made the AWARE suite of mobile apps available to residents. The AWARE software is comprised of videos and tools to help residents identify and address burnout or unmitigated stress.13 The Clinical Learning Environment Review (CLER) Pathway to Excellence through the ACGME emphasizes an entire section dedicated to well-being. The well-being pathway in CLER 2.0 calls out "physical and emotional well-being" directly.14 Unfortunately, there are no clear definitions or examples of how a residency program may appropriately meet the required endpoints. The opened-ended nature of this document allows graduate medical education programs to innovate, and address needs specific to each residency program. The well-being section goes on to require programs to demonstrate systems-based approaches in ". . .preventing, eliminating, or mitigating impediments to the well-being of residents, fellows and faculty members".14 The subsections of this pathway requirement only list examples of mental health concerns that could impact residents. There is no direct mention of physical well-being in the document itself.

The primary goal of wellness is to improve the physician's ability to cope with challenging working conditions. To this end, most of the residency programs are focused on mental health.11 Residency programs are working with residents to explore solutions that are most meaningful. The coping strategies developed by residents in training will carry with them into the rest of their careers.15 However, the physical aspects of wellness are noted to be vague and ill-defined. Physicians do report feeling hypocritical when they are encouraging their patients engage in healthy activities, such as exercise, yet are unable to make time for it themselves.16

The inclusion of both mental and physical wellness is imperative according to the Osteopathic principles. Osteopathic approaches to medicine support care for the whole individual. The person's mind, body and soul are understood to be integrated and balanced in a well person.17 It is documented that exercise is known to reduce stress and improve general well-being.18 However, there have been no articles identified that investigated physical health as an independent variable in physician burnout. Delivering osteopathic manipulative treatment as a physician has the potential of creating musculoskeletal discomfort. Physicians have reported soreness and conflicted motivation when scheduling OMT appointments. They want to help their patients and seek to maintain their own well-being simultaneously. Additionally, patients with a larger body habitus may require more exertion to treat. This places physicians in a conflicting mental state, as delivering care could compromise their own sense of comfort and wellness if they offer appropriate patient-centered care.

The role of physician pain in the decision to provide OMT as a modality for patient care necessitates more research. Despite noting that numerous anecdotal reports are made to the faculty of our program each year, we were unable to find published literature specifically addressing this aspect of physician wellness. Numerous publications have addressed physical well-being and patient outcomes.19 For instance, physical pain is a known impediment to regular exercise and lifestyle changes.20 Pain has also been studied extensively for its interference in job performance.21 Due to the physical requirements associated with OMT, physicians who offer OMT services are at a greater risk of soreness. This treatment modality could interfere with the range, scope and frequency of pain management options that are provided to their patient panels. Informal reports have described group sessions where a resident cohort would voluntarily meet outside of traditional work hours to practice OMT on each other as a mechanism to manage individual pain. While valuable as a learning tool, these sessions could be construed as additional patient encounters. It is plausible that these sessions are contributing to physical wear and tear as the residents tend to each other's needs. Additionally, when considering the gatherings as additional patient care encounters, they have the potential to erode work life balance if they feel obligated to treat their peers. Without using social time to get treatment, the physicians wouldn't otherwise have access to care themselves. In this sense, failing to allow for individual treatment could result in canceling patient appointments secondary to physician pain or discomfort. Physicians in these scenarios are continuing to provide treatments on days that would normally be reserved for recuperation.