Fostering Student, Resident, and Faculty Wellness to Produce Healthy Doctors and a Healthy Population

Professional identity formation: linking meaning to well-being

Trainee distress and burnout continue to be serious concerns for educational programs in medicine, prompting the implementation of numerous interventions. Although an expansive body of literature suggests that the experience of meaning at work is critical to professional wellbeing, relatively little attention has been paid to how this might be leveraged in the educational milieu. We propose that professional identity formation (PIF), the process by which trainees come to not only attain competence, but additionally to "think, act and feel" like physicians, affords us a unique opportunity to ground trainees in the meaningfulness of their work. Using the widely accepted tri-partite model of meaning, we outline how this process can contribute to wellbeing. We suggest strategies to optimize the influence of PIF on wellbeing, offering curricular suggestions, as well as ideas regarding the respective roles of communities of practice, teachers, and formative educational experiences. Collectively, these encourage trainees to act as intentional agents in the making of their novel professional selves, anchoring them to the meaningfulness of their work, and supporting their short and long-term wellbeing.

Resident Training Experiences Providing Spanish-Language Concordant Care: Implications for Growing Health Equity Efforts Within Graduate Medical Education

Training experiences where residents provide Spanish-language concordant care (SLCC) have not been widely described despite their increasing need and prevalence in graduate medical education. In this qualitative study, we enrolled nonnative Spanish-speaking residents (n = 21) within SLCC training clinics from 3 geographically unique programs. Participants completed semistructured interviews focused on their overall SLCC training experience. Major themes identified included (1) high levels of satisfaction in their SLCC experience, (2) concern about ongoing language barriers, (3) demonstration of high levels of cultural humility in caring for patients with limited English proficiency, and (4) identification of several valuable programmatic and clinical resources. Based on these findings, we conclude that SLCC training experiences are of significant value to trainees in becoming pediatricians able to promote health equity. Themes identified could help inform how graduate medical education programs utilize SLCC to grow health-equity based efforts to deliver more effective and compassionate care to our linguistically diverse populations.

Creating joy in the workplace

Creating a joyful workplace is not the same as dealing with issues of stress, fatigue, burn-out, and resilience. It requires a proactive approach to augment feelings of worth, appreciation, and well-being in the members of the team. The sense that one is pursuing worthwhile, valuable activities requires a wholesale commitment to the mission, vision and values of the organization. These tenets are often created through an organic consensus of collegial workmates and then put to action by a leadership team. Reassessing the goals and virtues of the organization at appropriate intervals leads to ongoing loyalty and commitment to the team and a positive attitude. Well-being is addressed through the creation of a bright and cheerful physical and psychosocial workplace that offers programs that encourage mindfulness, humor, playfulness, and fitful lifestyle choices. The sense that one's work is appreciated and valued stems from an attitude of gratitude on behalf of all levels of the organization including management and peers where such encouragement flourishes. Those expressions of appreciation may be in the form of celebrations in the workplace and/or compensation and benefits that appropriately value the contributions of the employee. The organization's executive team should be dedicated to crafting an environment that leads to delighted, healthy employees.

Seeking Help in the "Perfect Storm": Why Residents and Faculty Access an On-Site Wellness Program

Background

In the face of significant distress among physicians, access to counseling is critical.

Objective

An on-site wellness program for physicians-in-training and faculty was assessed by examining (a) were participants representative of those eligible for services and (b) demographic and trainee vs. faculty differences in burnout, distress, suicide risk, and presenting concerns of participants who utilized services.

Methods

From 2013–2018, 73% (N = 468; 316 residents/fellows, 152 faculty) of individuals seeking services also consented to research. At intake, participants completed a distress measure (ACORN) and two items from the Maslach Burnout Inventory (MBI), and clinicians categorized presenting concerns and suicide risk. Using Chi-square analyses, participants’ characteristics were compared to physicians eligible for treatment. The association between demographics, faculty vs. trainee status, specialty, and distress, burnout, suicide risk, and presenting concerns was evaluated with ANOVAs and logistic regressions.

Results

Women, trainees, and primary care physicians were more likely to access services. On the ACORN, 63% were in the clinical range (M =1.7, SD =0.6). On the MBI, 36% scored in the clinical range. Clinicians rated 9% of participants with suicide risk. Neither gender, racial/ethnic minority status, nor specialty were associated with distress, burnout or suicide risk. Trainees reported greater distress than faculty (F (1,447) = 8.42, P = .004, ηp2 = .018). Participants reported multiple presenting concerns (M = 3.0, SD = 1.18) with faculty more commonly endorsing work-related issues. Trainees more commonly reported new or worsening psychological symptoms, performance and family concerns.

Conclusions

Two physician groups which often report higher levels of burnout and distress when surveyed, women physicians and residents/fellows, were the most likely to get professional help in an on-site wellness program. Physician wellness programs need to be prepared to address work and personal stressors and different levels of distress and risk.

Targeting Causes of Burnout in Residency: An Innovative Approach Used at Hennepin Healthcare

PROBLEM

Rates of burnout are high in physicians in the United States. While others have reported on the success of burnout-reduction strategies on practicing physicians and residents, few strategies have approached the problem longitudinally in residents.

APPROACH

From 2014 to 2019, the authors used a previously developed survey to assess factors related to resident burnout, including sleep, personal time, professional fulfillment, effects on relationships, program recognition, and peer support. At Hennepin Healthcare, a safety-net hospital in Minneapolis, Minnesota, the authors created a reproducible process for collecting data from internal medicine residents annually, and for using evidence-based conceptual frameworks to develop a continuous improvement method to address worklife across training years. Interventions included jeopardy coverage for essential life events, a newsletter celebrating resident achievements, removal of after-hours consult pager call, an extra day off for senior residents on the wards, and care packages distributed to night teams.

OUTCOMES

Annually from 2014 to 2019, 40/66 (60.6%) to 62/73 residents (84.9%) completed the survey (average response rate was 72.1% over 6 years). Survey results were shared with residents in multiple formats, and feedback was requested, demonstrating that burnout reduction is a priority for program leadership. High professional fulfillment scores were documented every year. Self-reported rates of burnout were between 25% and 35%. Significant improvements were seen in perception of empathy, sleep impairment, and peer support.

NEXT STEPS

The authors developed a plan for minimizing burnout, which includes the following evidence-based domains: workload, control, balance in effort and reward, work-life balance, fairness, values, support, gender equity, moral distress, and moral injury. Additional interventions include protected time for didactics, trauma-informed care training, and addressing workplace racism. The authors aspire to achieve an integrated culture of well-being for residents and faculty; foster an efficient, effective, and fair learning environment; and reduce-and ultimately eliminate-burnout.

Death Cafés for prevention of burnout in intensive care unit employees: study protocol for a randomized controlled trial (STOPTHEBURN)

BACKGROUND

Burnout is an occupational syndrome that leads to mental health problems, job turnover, and patient safety events. Those caring for critically ill patients are especially susceptible due to high patient mortality, long hours, and regular encounters with trauma and ethical issues. Interventions to prevent burnout in this population are needed. Preliminary studies suggest debriefing sessions may reduce burnout. This study aims to assess whether participation in regular debriefing can prevent burnout in intensive care unit (ICU) clinicians.

METHODS

A randomized controlled trial will be conducted in two large academic medical centers. Two hundred ICU clinicians will be recruited with target enrollment of 100 physicians and 100 non-physicians (nurses, pharmacists, therapists). Participants must have worked in the ICU for the equivalent of at least 1 full time work week in the preceding 4 weeks. Enrolled subjects will be randomized to virtually attend biweekly debriefing sessions facilitated by a psychotherapist for 3 months or to a control arm without sessions. Our debriefs are modeled after Death Cafés, which are informal discussions focusing on death, dying, loss, grief, and illness. These sessions allow for reflection on distressing events and offer community and collaboration among hospital employees outside of work. The primary outcome is clinician burnout as measured by the Maslach Burnout Inventory (MBI) Score. Secondary outcomes include depression and anxiety, as measured by the Patient Health Questionnaire 8 (PHQ-8) and Generalized Anxiety Disorder 7-item scale (GAD-7), respectively. Questionnaires will be administered prior to the intervention, at 1 month, at 3 months, and at 6 months after enrollment. These values will be compared between groups temporally. Qualitative feedback will also be collected and analyzed.

DISCUSSION

With ICU clinician burnout rates exceeding 50%, Death Café debriefing sessions may prove to be an effective tool to avert this debilitating syndrome. With COVID-19 limiting social interactions and overloading ICUs worldwide, the virtual administration of the Death Café for ICU clinicians provides an innovative strategy to potentially mitigate burnout in this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04347811 . Registered on 15 April 2020.

An Interactive Lifestyle Medicine Curriculum for Third-Year Medical Students to Promote Student and Patient Wellness

INTRODUCTION

Although lifestyle intervention and behavior modification are effective in the prevention and treatment of chronic disease, few medical schools provide specific training in stress management, nutrition, or physical activity. While the prevalence of chronic disease rises, medical students and physicians lack sufficient knowledge and skills to promote their patients' as well as their own wellness across these domains.

METHODS

We developed three hour-long workshops delivered to third-year medical students. We employed interactive lectures, small-group discussions, and reflective activities to teach the pillars of lifestyle medicine. These sessions focused on knowledge and skills to advance lifestyle counseling and behavior modification interventions with patients and to promote student wellness. We assessed student satisfaction with each session as well as self-perceived knowledge, skills, and attitudes toward lifestyle medicine and behavior change before and after the curriculum.

RESULTS

Over 2 years, 183 students participated in the workshop series. The sessions received high ratings, with a mean of 4.2 on a 5-point Likert scale. Participating in the curriculum significantly enhanced students' understanding of the connection between lifestyle factors and the health of patients and improved their confidence about counseling for behavioral change.

DISCUSSION

Lifestyle medicine provides an evidence-based framework for teaching students about the impact of lifestyle modification on chronic disease. While receiving knowledge and skills to advance patient care in the domains of stress management, nutrition, and physical activity, students who completed this curriculum also had the opportunity to reflect on their own health promotion, which could mitigate professional burnout.

Wellness and Work: Mixed Messages in Residency Training

Resident physicians are at higher risk for depression, anxiety, and burnout when compared with same-age peers, resulting in substantive personal and professional consequences. Training programs across the country have acknowledged the gravity of this situation and many have implemented programs and curricula that address wellness and resilience, yet the benefits of such initiatives are still largely unknown. While the development of wellness programming is well intentioned, it is often incongruent with the residency training environment. The mixed messaging that occurs when wellness programs are implemented in environments that do not support self-care may unintentionally cause resident distress. Indeed, outside of the time dedicated to wellness curricula, residents are often rewarded for self-sacrifice. In this commentary, we describe how the complexities of the medical system and culture contribute to mixed messaging and we explore the potential impact on residents. We offer recommendations to strengthen wellness programs through efforts to promote structural change in the training environment.

Resident and Faculty Perspectives on Prevention of Resident Burnout: A Focus Group Study

CONTEXT

The high prevalence and negative implications of resident physicians' burnout is well documented, yet few effective interventions have been identified.

OBJECTIVE

To document resident and faculty perspectives on resident burnout, including perceived contributing factors and their recommended strategies for attention and prevention.

DESIGN

We conducted 14 focus groups with core faculty and residents in 5 specialties at a large integrated health care system in Southern California. Training programs sampled included family medicine, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry. Discussions were recorded, transcribed, and analyzed using a matrix-based approach to identify common themes.

MAIN OUTCOME MEASURES

Resident and faculty perspectives regarding causes of burnout, preventive factors, and potential intervention strategies.

RESULTS

Five themes captured the range of factors participants identified as contributing or protective factors for resident burnout: 1) having or lacking a sense of meaning at work; 2) fatigue and exhaustion; 3) cultural norms in medicine; 4) the steep learning curve from medical school to residency; and 5) social relationships at and outside work. Recommended intervention strategies targeted individuals, residents' social networks, and the learning and work environment.

CONCLUSION

We engaged residents and core faculty across specialties in the identification of factors contributing to burnout and possible targets for interventions. Our results highlight potential focus areas for future burnout interventions and point to the importance of interventions targeted at the social environments in which residents' work and learn.

Adapting Maslow's Hierarchy of Needs as a Framework for Resident Wellness

ISSUE

Burnout in graduate medical education is pervasive and has a deleterious impact on career satisfaction, personal well-being, and patient outcomes. Interventions in residency programs have often addressed isolated contributors to burnout; however, a more comprehensive framework for conceptualizing wellness is needed.

EVIDENCE

In this article the authors propose Maslow's hierarchy of human needs (physiologic, safety, love/belonging, esteem, and self-actualization) as a potential framework for addressing wellness initiatives. There are numerous contributors to burnout among physician-trainees, and programs to combat burnout must be equally multifaceted. A holistic approach, considering both the trainees personal and professional needs, is recommended. Maslow's Needs can be adapted to create such a framework in graduate medical education. The authors review current evidence to support this model.

IMPLICATIONS

This work surveys current interventions to mitigate burnout and organizes them into a scaffold that can be used by residency programs interested in a complete framework to supporting wellness.

Well-Being among Emergency Medicine Resident Physicians: Results from the ABEM Longitudinal Study of Emergency Medicine Residents

BACKGROUND

The Longitudinal Study of Emergency Medicine Residents (LSEMR) conducted by the American Board of Emergency Medicine queries a randomized cohort of emergency medicine (EM) residents. It is designed to identify residents' perceptions of their training, sources of stress, well-being level, and career choice satisfaction over time.

OBJECTIVES

This study utilizes LSEMR to identify resident well-being levels, career satisfaction, factors producing stress, and whether a specific cohort is more stressed than the overall respondent group.

METHODS

Data from five longitudinal cohorts were analyzed using descriptive statistics to assess stressors, career satisfaction, and self-reported resident well-being. Participants' answers were reported on a 5-point Likert scale.

RESULTS

There were 766 residents who completed the survey in five cohorts. Respondents were 30 years old (median 29), male (66%), and predominantly White (79%). The most frequently encountered problems included "time devoted to documentation and bureaucratic issues," "knowing enough," and "crowding in the emergency department." In contrast, the least frequently reported problems included "gender discrimination," "EMS support," "minority discrimination," and "other residents." Respondents thought being an EM resident was fun and would select EM again. Less than 20% indicated they had seriously considered transferring to another EM program. Resident reports of health concerns changed over time, with fewer residents reporting they were exceptionally healthy in 2016.

CONCLUSIONS

Residents are, overall, happy with their career choice. However, concern was expressed regarding continued well-being in training. Sources of stress in training are identified. Strategies should be developed to decrease identified stressors and increase well-being among EM residents.

New common program requirements for the resident physician workforce and the omission of strategic napping: A missed opportunity

OBJECTIVES

Napping has known benefits for fatigue mitigation and improved alertness. However the Accreditation Council for Graduate Medical Education (ACGME) New Common Program Requirements recently removed the 16 h work limit for PGY1 residents and removed any suggestions of napping.

METHODS

We utilized a cross-sectional study design to administer a 44-item questionnaire in June 2016 to 858 residents and fellows at one large urban academic medical center. We assessed: 1) resident physician sentiment of work environment supportiveness for napping at work; and 2) agreement with 2011 ACGME guidelines on workweek hour limitations and strategic napping recommendations.

RESULTS

While 89% of residents reported access to an on-call room at work, only 20% felt their work environment supported a culture of napping while at work. Over 76% expressed agreement with the 2011 ACGME work-hour restrictions.

CONCLUSIONS

Strategies to support napping and well-being within the resident physician workforce and organizational setting are warranted.