Giving Friendship Proper Emphasis in Academic Medicine

I breathed a song into the air, It fell to earth, I knew not where; … And the song, from beginning to end, I found again in the heart of a friend. —Henry Wadsworth Longfellow, “The Arrow and the Song”1 We have all had one of those days when nothing seems to go right. Maybe you meet with a patient whose condition continues to worsen and you do not know how to help. Later you are teaching a class, but the students look like they would rather be somewhere else. Then you open your email queue and read some negative feedback about a manuscript you submitted for publication. As you make your way home at the end of the day, you feel alone, discouraged, inadequate. You need a friend. Happily, the field of academic medicine is replete with friends and friendship. Collegiality and connection have been identified as important to the decision to enter and remain in academic medicine.2,3 Experiences of friendship can strengthen the sense of belonging and meaning for members of the health professions and for those who work throughout academic medicine.4,5 Our journal has received many submissions over the years suggesting the salutary role of friendship in diverse aspects of academic medicine.6–21 In a recent qualitative study6 of pediatric residents and attending physicians, for instance, friendships were found to facilitate supervisory relationships and trust in clinical training. Another qualitative study7 of faculty highlighted how relationships of friendship among cofacilitators engaged in professional development activities can enable efficient and effective teaching. Interviews with novice researchers also identified the support of friends as an important factor supporting accountability and productivity in academic writing.8 The growth of peer mentoring programs in academic medicine is providing another opportunity for friendship formation among colleagues.9 And having friends may protect against feelings of shame,10 a very real problem for individuals in academic medicine and the health professions communities.11 As our field turns attention increasingly to aspects of work environments that promote wellness, it is clear that friendship can play a valuable role in fostering resilience and personal well-being. Recent studies suggest that these relationships may be especially protective for nonmajority populations. For instance, in an online survey12 conducted in Ontario, Canada, Black physicians and trainees reported seeking support from family and friends to cope with negative experiences of racism and discrimination. Resident physicians who were international medical graduates identified friendships as the most important factor supporting their wellness.13 Female nurses and residents similarly reported the beneficial effects of friendship in the workplace, in a previous study14 at one U.S. teaching hospital. Early work has shown that adult friendships can strengthen and help sustain healthy habits,22,23 can reduce stress,24 and can serve as informal care networks in times of need.25 Furthermore, having close relationships may be protective against the negative effects of many common life events such as job loss or illness.23,26,27 Loneliness, arguably our most recent pandemic, is associated with increased risk of premature mortality.28 Heart disease and myocardial infarction may specifically be associated with loneliness, while close relationships may offer protective effects.29,30 Having relationships with friends influences mental health as well. In a study31 of 51 young adults in same-sex close-friend dyads, for example, negative friendship features were found to be associated with higher levels of clinical symptoms, but positive friendship features were tied to better self-esteem. In another study32 of young adults, those who identified fewer close relationships and were socially isolated were more likely to engage in risky behaviors. Researchers have argued that the beneficial effects of other factors typically associated with long-term well-being—e.g., community engagement, religious affiliation—may be due to their effects on friendship networks.33 In academic medicine, friendships may also play a role in preventing burnout and encouraging work–life balance.2,4 In light of such observations, it is clearly time to reflect on friendship and to give it proper emphasis, not only with respect to our personal lives but in relation to our work lives. There is clear evidence that workplace friendships reduce stress, improve teamwork, and contribute to systemic improvements in workplace culture.34 Unfortunately, overemphasis on long hours spent in isolating tasks or on overly simplistic measures of productivity can hamper development of the close personal relationships that may be necessary for professional longevity and work satisfaction. In fact, workplace friendships not only are consistent with quality work, but they can also enhance the sense of well-being and health experienced by employees.35 We also need to question the aspects of training and work that interfere with the development of personal relationships.15 A recent publication36 suggests that mitigating the negative impact of work on physicians’ personal relationships might even have potential to improve the quality of patient experience and reduce malpractice risk.30 In addition, the immediate and long-term effects of isolation associated with the recent pandemic require careful consideration,37 particularly for those whose work postpandemic has remained remote, e.g., in telehealth or geographically distributed administrative and supervisory activities. New strategies will be needed as our field continues to evolve; for instance, Hejri et al16 offer some intriguing ideas in this issue about how social network analysis could be used to better understand the social dimensions of teaching and colleague relationships in academic medicine. Friendship in the workplace admittedly can introduce complicated dynamics. Overlapping relationships, such as friendships between coworkers or even friendship in the context of direct or indirect supervisory relationships, inherently raise ethical tensions.38 Attention to professional and personal boundary keeping is necessary so that friendship and professionalism can coexist in academic medical settings as they do in other workplaces.17,18 Furthermore, while friendship can contribute to a welcoming milieu in the workplace, in-groups, cliques, and exclusive “clubs” can, unfortunately, make individuals feel excluded. Fostering belonging can, paradoxically, bring greater attention to issues of nonbelonging. Such issues are important to acknowledge as our field reflects on the role of personal relationships in creating cultures of inclusion for all. Importantly, when leaders acknowledge the reality of workplace friendships and the potential benefits, ethical conflicts and issues of belonging can be effectively addressed.35 Taken together, it is apparent that our field has several opportunities and challenges in considering the role of friendship in our work. As we move forward, we can consider how leaders can better support a sense of personal connection and shape a broader culture of belonging in the workplace, encouraging friendships and at the same time ensuring that individuals do not feel excluded. We can clarify and study best practices for navigating friendship interactions among coworkers at work, not at work, and in novel environments, such as on social media platforms.19 We can think with others from both academic and nonacademic settings about how team members who are also friends might anticipate and work through difficult collaborative issues, such as assigning credit for shared work, assigning authorship, shifting roles with different power dynamics on team projects, and related topics. And we should reflect on how clinical supervisors and teachers can nurture their learners, creating supportive relationships while also maintaining appropriate professional boundaries, a spirit beautifully reflected in the first-place medical student essay20 by Frederico Erhart featured in this issue of the journal. It is possible to actively cultivate more friendships, and most people would likely benefit from doing so. Despite busy schedules and time pressure, there is real value in making time to check in with colleagues about aspects of life outside work. Maintaining an open attitude to possible new friendships at work and looking for common ground during interactions with colleagues may make work more meaningful and pleasant. Also, looking for opportunities to share credit for equal work can reinforce trust and fairness in the work culture, as will openly acknowledging team dynamics, hierarchical relationships, and necessary boundaries and expectations.21 For academic leaders, modeling friendly and appropriate personal connections with colleagues can be a powerful way to create a milieu of mutualism and respect. Establishing occasions for unstructured interaction and socializing among employees who might not work directly together can contribute to a culture of collegiality. Finally, deliberately advancing projects that promote collaboration among colleagues can enhance cooperation. By working together, we can enjoy more of the tremendous gift that is friendship at work. Grace W. Gengoux, PhD, BCBA-D Stanford University School of MedicineLaura Weiss Roberts, MD, MA Editor-in-chief, Academic Medicine

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