Climbing the Second Mountain: Introducing a Novel Resident Wellness Program
Our program similarly involves a reward system to encourage resident participation and progress toward their Second Mountain, but it differs in that it emphasizes the need to spend time outside of the hospital as a key component of the program.
Nicholas A. Rossi, MD; Wasyl Szeremeta, MD, MBA; and Harold S. Pine, MD
"The main source of illness in this world is the doctor’s own illness,” wrote Samuel Shem in his 1978 classic, House of God.1 Perhaps the ultimate example of “the doctor’s own illness,” burnout has been increasingly recognized as a severe detriment to the well-being, medical judgment, and overall happiness of physicians and resident trainees.2-5 As a specialty, otolaryngology is not immune to the effects of physician burnout. In a 2010 questionnaire-based study by Contag et al., a staggering 75% of microvascular free flap head and neck surgeons were found to be experiencing moderate-to-high levels of burnout.3 In another 2008 study by Golub et al., moderate-to-high burnout was observed in 70% of otolaryngology academic faculty members.4 A more recent 2020 study by Reed et al. found a 50% burnout rate among otolaryngology residents. These astounding figures are a cause for alarm in our community as we aim to minimize these ill effects on our fellow faculty members and trainees.
There are two ways to change the system, in Samuel Shem’s own words, “Firstly, on an individual level, by learning how to stay human in the system; secondly, on a collective level, by taking action.”1 At a time before burnout was widely recognized as an issue among physicians, Samuel Shem eloquently identified it and emphasized the possibility of changing the system as a potential remedy. However, many physicians find the system to be hesitant to structural change. Here at the University of Texas Medical Branch (UTMB) Department of Otolaryngology, we have decided to act on both the individual and the collective levels with the introduction of a novel resident wellness program: the Second Mountain. During residency training, learning foundational information and sharpening surgical skills are the obvious “first mountain” for residents. In the Second Mountain program, residents are encouraged to choose an activity or goal outside of medicine that they actively work to pursue during their time in residency. With time and perseverance, we believe that the implementation of the Second Mountain program will provide an outlet for residents to de-stress, develop a well-rounded character, and ultimately become better physicians.
Several exciting resident wellness initiatives have preceded ours within the otolaryngology community. At the University of Colorado, a unique resident-run education system was created for both patients and nurses centered around topics pertinent to patient care.6 The system is designed with incentives for residents who participate in more of these sessions. The University of Michigan has taken steps to increase the personalization of patient-physician interactions as well as implemented a regular schedule of focus groups for residents to receive peer support. We are pleased to see our otolaryngology colleagues across the country putting a priority on wellness. Our program similarly involves a reward system to encourage resident participation and progress toward their Second Mountain, but it differs in that it emphasizes the need to spend time outside of the hospital as a key component of the program.
Resident response has been overwhelmingly positive, and some examples of the goals Second Mountain residents have chosen include learning how to surf, volunteering for animal rescue organizations, and advancing to a higher belt level in Brazilian Jiu Jitsu. The department assists the resident financially to participate in the program, making it easier for the resident to work toward their individual goal. Progress toward the Second Mountain is regularly tracked by a faculty mentor, many of whom have Second Mountain goals of their own. When milestones along the way are achieved, the resident is rewarded with custom-designed Second Mountain patches (Figure 1).
The core of the Second Mountain program was inspired from the ideas of retired Navy SEAL Commander Mark Divine in his book Unbeatable Mind,7 in which he describes five figurative “mountains” one must climb to maximize one’s potential: physical, mental, emotional, intuitional, and Kokoro, or “spirit.” Participants in the Second Mountain program may choose a goal within the realm of any of these five mountains. The physical mountain is the most straightforward to pursue and the most popular so far among participants. Examples of physical mountains include reaching a higher rock-climbing proficiency, losing weight, or training for a triathlon. The mental mountain involves stepping outside the realm of otolaryngology by doing something mentally stimulating such as learning a new language or reading nonmedical literature. The emotional mountain can be pursued in ways such as prayer, meditation, poetry, volunteering, or creative writing. Traversing the intuitional mountain is more difficult, and developing a refined sense of intuition takes experience and mentorship. Finally, the Kokoro mountain brings the ideas of all five mountains together. Japanese for “heart” or “spirit,” the Kokoro mountain emphasizes the teamwork mentality and purpose-driven action. It can only be mastered in union with the other four mountains. By integrating all five mountains we can be “physically strong, mentally sharp, emotionally and morally mature, intuitively aware, and spiritually grounded.”
Although the Second Mountain program was originally designed for residents within the Department of Otolaryngology, higher aspirations remain. The program has been officially opened to otolaryngology faculty as well as the Department of Audiology and Speech Language Pathology. Our ultimate vision is to share the Second Mountain program among all departments in our hospital so that eventually every department has a Second Mountain program of its own. We also hope other otolaryngology residency programs around the country will adopt Second Mountain programs. Even Samuel Shem said about hobbies, “You should have at least one.”1
With the introduction of our resident wellness program, we strive to fight resident burnout on both the individual and collective levels, as Shem himself advocated. Only with actionable changes can we effectively mitigate burnout, improve resident education, and, most importantly, maximize patient care.
1. Shem S. The House of God. 1st ed: Richard Marek Publishers; 1978.
2. Reed L, Mamidala M, Stocks R, Sheyn A. Factors Correlating to Burnout among Otolaryngology Residents. Ann Otol Rhinol Laryngol. Jun 2020;129(6):599-604. doi:10.1177/0003489420903329
3. Contag SP, Golub JS, Teknos TN, et al. Professional burnout among microvascular and reconstructive free-flap head and neck surgeons in the United States. Arch Otolaryngol Head Neck Surg. Oct 2010;136(10):950-6. doi:10.1001/archoto.2010.175
4. Golub JS, Johns MM, Weiss PS, Ramesh AK, Ossoff RH. Burnout in academic faculty of otolaryngology-head and neck surgery. Laryngoscope. Nov 2008;118(11):1951-6. doi:10.1097/MLG.0b013e31818226e9
5. McIntire JB, Lee DD, Ohlstein JF, Williams Iii E. Career Satisfaction, Commitment, and Burnout Among American Facial Plastic Surgeons. Facial Plast Surg Aesthet Med. Apr 2020; doi:10.1089/fpsam.2020.0086
6. Ambrose EC, Devare J, Truesdale CM, et al. Two Novel Approaches to Improve Otolaryngology Resident Wellness: The ACGME Back to Bedside Initiative. Otolaryngol Head Neck Surg. Jun 2018;158(6):979-980. doi:10.1177/0194599818758272
7. Divine M. Unbeatable Mind. 2nd ed. CreateSpace Independent Publishing Platform; 2014.