Thriving, Not Surviving, in Residency: JGME-ALiEM Hot Topics in Medical Education Journal Club

jgme aliem residency wellness journal clubThis year’s JGME-ALiEM Hot Topics in Medical Education journal club features the systematic review on residency wellness recently published in the Journal of Graduate Medical Education (JGME).  This week, share your thoughts about this timely topic and paper on the blog, on Twitter (follow #JGMEscholar) and during a live Google Hangout with author Kristin Raj, MD (@KristinRajMD), Christopher Doty, MD (@PoppasPearls), and Jonathan Sherbino, MD (@Sherbino). Ultimately, a curated summary of our discussions will be published in the JGME. Some of your best tweets and blog comments will be featured.

Background on Wellness

Residency can be difficult, daunting and arduous. It is a time when you are sometimes forced to prioritize between clinical and academic responsibilities and adequate sleep, exercise, or quality time with your family. The increased workload, stress on personal relationships, and predilection for self-neglect during training create the perfect storm for the degeneration of a resident’s sense of health and well-being. Burnout in physicians has broad implications for the field of Emergency Medicine (EM). Studies indicate that physician burnout influences the quality care, impacts patient safety and satisfaction, and leads to early physician retirement.1,2

EM was ranked highly in rates of burnout among physicians and one study even has EM ranked highest. Rates of depression amongst physicians in training is approximately 22-35%.3 This is startling when compared to the rates of depression in the general population, which is approximately 17%.4 What is even more tragic is that due to a multitude of factors, nearly 400 physicians commit suicide every year in the U.S.5 This is roughly equivalent to losing an entire medical school (all four years) annually!

To tackle this immense and tragic issue, some residency programs have started to develop and expand formal wellness programs at their institution. One of the earliest programs in the U.S. came from Stanford. Their wellness program was developed in 2010 after the death of one of their residents.6 The AMA Steps Forward program has published a comprehensive module called “Physician wellness: preventing resident and fellow burnout” that lays out key steps to start a wellness program at your institution.

The conversation around wellness initially focused on the endpoint of burnout, such as how to recognize, treat, and prevent it. Recently there has been a call for a shift from a focus on burnout to a focus on preventative strategies and the promotion of wellness right from the start in training.7,8 There has been an urge to teach individuals the skills needed for resilience and positivity. There has also been a call challenging executive leadership and institutions to tackle the systems-based problems that contribute to physician burnout and disruption in wellness.1

Featured JGME Paper

Raj KS. Well-Being in Residency: A Systematic Review. J Grad Med Educ. 2016 Dec;8(5):674-684. doi: 10.4300/JGME-D-15-00764.1. PMID: 28018531. [Open access PDF]

ABSTRACT

Article Focus

Raj reviews the literature on resident well-being to identify factors associated with wellness. In addition, this paper aims to identify interventions that may promote wellness and suggests a framework for future research.

Overall, this systematic review identified numerous studies that showed that resident well-being was lower than that of the general population. Furthermore, residents suffered from higher rates of emotional exhaustion, work-life balance challenges, and depersonalization than their faculty counterparts.

The paper identified numerous POSITIVE factors that improved well being including:

  • Autonomy
  • Competence
  • Social relatedness
  • Accomplishment of goals
  • Opportunities for learning
  • Positive feedback
  • Positive colleague relationships
  • Engagement in spiritual practices
  • Increasing physical activity
  • Exposure to nature

The paper also identified factors with a NEGATIVE impact on resident well-being and included:

  • Sleep deprivation
  • Strained relationships with family and significant others
  • Drug and alcohol use

Finally, as residency programs develop wellness initiatives, this review suggests that utilization rates may be suboptimal for the following reasons:

  • Stigmatization of mental health within residency education and clinical medicine
  • Resident concern about helpfulness of initiatives
  • Resident time constraints

Watch the Google Hangout video or the podcast version

Hot Topics Questions

Post your answer to any question below or discuss via Twitter using #JGMEscholar.

Q1 – This systematic review identified factors (e.g. basic physical needs, social relationships, autonomy, development of competence) that correlate with wellness. What does the construct – “wellness” – mean?

Q2 – Only a single investigator was part of this study? Why? Does this threaten the reliability of the articles selected and the abstraction of relevant data?

Q3 – What can we do to decrease the stigma associated with participating in mental wellness programs or seeking mental health resources?

Q4 – Do you have a wellness program in your residency program? If yes, what does it include? How does it work? What are the benefits?If no, what type of program would you like to see implemented? Why?


Previous JGME-ALiEM Hot Topics journal clubs


Disclaimer: We reserve the right to use any and all tweets to #JGMEscholar and comments below in a curated, commentary for the Journal of Graduate Medical Education Your comments will be attributed. Many thanks in advance for your thoughts and contributions.

1.
Shanafelt T, Noseworthy J. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):129-146. [PubMed]
2.
Lu D, Dresden S, McCloskey C, Branzetti J, Gisondi M. Impact of Burnout on Self-Reported Patient Care Among Emergency Physicians. WestJEM. 2015;16(7):996-1001. doi: 10.5811/westjem.2015.9.27945
3.
Shanafelt T, Hasan O, Dyrbye L, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613. [PubMed]
4.
Daskivich TJ, Jardine DA, Tseng J, et al. Promotion of Wellness and Mental Health Awareness Among Physicians in Training: Perspective of a National, Multispecialty Panel of Residents and Fellows. Journal of Graduate Medical Education. 2015;7(1):143-147. doi: 10.4300/jgme-07-01-42
5.
Sargent DA. Preventing Physician Suicide. JAMA. 1977;237(2):143. doi: 10.1001/jama.1977.03270290043024
6.
Salles A, Liebert CA, Greco RS. Promoting Balance in the Lives of Resident Physicians. JAMA Surg. 2015;150(7):607. doi: 10.1001/jamasurg.2015.0257
7.
Schmitz G, Heron S, Kuhn G, et al. Strategies for coping with stress in emergency medicine: Early education is vital. J Emerg Trauma Shock. 2012;5(1):64. doi: 10.4103/0974-2700.93117
8.
Eckleberry-Hunt J, Van Dyke A, Lick D, Tucciarone J. Changing the Conversation From Burnout to Wellness: Physician Well-being in Residency Training Programs. Journal of Graduate Medical Education. 2009;1(2):225-230. doi: 10.4300/jgme-d-09-00026.1
Nicole Battaglioli, MD

Nicole Battaglioli, MD

Champion, 2016-17 ALiEM Chief Resident Incubator
Chief Operating Officer, 2016-17 ALiEM Wellness Think Tank
Clinical Associate
Mayo Clinic Health System;
Arlene Chung, MD

Arlene Chung, MD

Chief Strategy Officer,
2016-17 ALiEM Wellness Think Tank
Assistant Professor of Emergency Medicine
Assistant Program Director
Mount Sinai Emergency Medicine Residency
Editor, AKOSMED (EM wellness blog)
Michelle Lin, MD
ALiEM Editor-in-Chief
Academy Endowed Chair of EM Education
Professor of Clinical Emergency Medicine
University of California, San Francisco
Michelle Lin, MD
Michelle Lin, MD

Latest posts by Michelle Lin, MD (see all)

Jonathan Sherbino, MD, MEd
Associate Professor, McMaster University
Clinician Educator,
Royal College of Physicians & Surgeons of Canada
  • Christopher Doty

    Q4: After a devastating loss in our program little over a year ago we instituted a multimodal wellness program that is run out of the residency office and funded by the department. It has included dedicated time during our weekly conference and other times for various wellness activities. These have included: free sessions with licensed massage therapists, a workshop on self massage and myofascial release, guided meditation, breathing exercises, a nutrition lecture, and talks on stress management. Several more are planned. We also have started “random acts of kindness” in conference including coffee, donuts, and snacks. We also serve these randomly in the clinical area as well. Everything is tagged with our #WildcatWellness stickers promote recognition and branding. How much impact the snacks have, but I do believe we are making headway with the mini lecture series in conference. Conference time is a hot commodity, and I believe it speaks volumes to dedicate some of this time regularly to wellness topics. We also have vocational events vocational events as a department after journal clubs in order to promote bonding among the residents and between the residents and faculty. This is all made possible because of major buy-in from the departmental and program leadership. Clearly, the loss of one of our residents has motivated these changes.

    • I’ve adopted mindfulness in my personal practice and we’ve introduced this to our residency program at our annual retreat. What does the guided meditation practice look like? Also, how frequently are these interventions occurring? I worry that our “annual” retreat has little sustained impact.

      • Christopher Doty

        We allocate a minimum of 15 minutes during conference once a month for an “intervention”. These include the lectures, discussions, meditation, massage, etc. The snacks are about once per month and are on a different week than the intervention.

    • Nadim Lalani

      Q4: At U of C we are embarking on a 2-year curriculum entitled “Advanced Performance in Medicine”(c). It seeks to address the need to navigate goal-setting and achievement of CBME, the call for innovative approaches to wellness in residency programs as well as leadership and soft skills training that is absent in most programs. It combines group coaching with 1:1 coaching with EM physicians trained in professional coaching method. This forum is too short to give you the entire lit search and proposal, but we’re borrowing from the business world and sports psychology. In short coaching is partnering with a professional to have a series of goal-oriented conversations in order to achieve personal and professional success. We have innovated a structured approach of 12 coaching topics called “The 12 Conversations of Healers”(c). Each topic is introduced and discussed at half day. We share stories and coach each other around themes such as self-talk, values, beliefs, brand, mission and purpose. A cadre of physician mentors are being trained in coaching method to have 1:1 conversations around these very same topics with residents once a month for the year. We believe that we can use coaching to enable better emotional intelligence, soft skills and career path alignment, promote a culture of wellness, promote resilience and achievement and develop leadership skills amongst our residents.

  • Christopher Doty

    Q3: The stigma of seeking mental health resources is huge in medicine. We have a culture of medicine that defeats our ability to care for ourselves. We do not want to be seen as the weak link in the chain. We therefore do not share with our colleagues and partners about the everyday stresses that we all face. This atomizes us and causes separation from each other so that we are not able to connect on a deeper level in order to share our feelings and thus realize that feelings of doubt or depression or stress are not only common in medicine, but are ubiquitous. This separation keeps us from capitalizing on the connectivity in our social networks and prevents us from building resiliency through a “shared burden”. Instead, not only do we feel the full force of our own burden, we worry about burdening others if we let on that we are suffering, this added stress further our burden as we worry about pulling our wait.I believe we must share our feelings of doubt and stress and depression with each other. Thereby capitalizing on our social networks to build resiliency and normalizing the conversation around these feelings as part of our job. Essentially, they are an occupational hazard that we are not allowing ourselves to be protected from or even admit that the hazard is there. If we normalized this conversation, the stigma of mental health resources would be gone and people would begin to realize that even having these feelings makes you normal, Not an outlier. I apologize for the long post.

    • Nadim Lalani

      I think that Christopher has it on it …absolutely 100% agree with sharing. In my experience residents generally put attendings on a pedestal – some very same attendings who portray “having their stuff together”and being all-knowing. Nobody does! How about honesty and openness? Admitting when we’re not our best selves, the circumstances surrounding that and how to bring ourselves and each other up. yes! to sharing, being human and normalising that we are all flawed human beings in medicine. It all starts from the top with well respected attendings sharing about humanness on shift and during academic days.

  • Nadim Lalani

    Q1: to me wellness is more than physical health [which I feel should also be pencilled into half days and curricula – because it is such an important part of thriving in medicine]. It is also more than mental health [love Christophers innovation below] . It includes a spiritual dimension of meaning and purpose such that a resident who is well is healthy, happy, engaged in their lives outside and inside of med and being the very best authentic version of themselves.

    • Loice Swisher

      I agree that the sense of purpose is critical for wellness. For me it is the most important. When I find myself faltering, I tend to read Dr. Naomi Remen’s writings to help recenter.

      “Meaning is a human need. It strengthens us, not by numbing our pain or distracting us from our problems, or even by comforting us. It heals us by reminding us of our integrity, who we are, and what we stand for. It offers us a place from which to meet the challenges of life. Part of our responsibility as professionals is to fight for our sense of meaning — against fatigue and numbness, overwork, and unreasonable expectations — to find ways to strengthen it in ourselves and in each other.”
      http://www.onbeing.org/program/listening-generously/feature/recapturing-soul-medicine/849

  • Loice Swisher

    I believe that to decrease the stigma associated with mental health issues we need to decrease the fear of what may happen if these are disclosed. I believe many feel that there is a significant risk being open will make things worse. To be seen as ‘the weak link’ is just the tip of the iceberg. There is worry that one might be taken off work not knowing what that would mean for the paycheck or job prospects in the future. Perhaps worse is being involuntarily placed in a psych hospital. And for me the worst would be to be sent away to navigate the search for help on one’s own- to feel further isolation and destroying the feeling of belonging.

    To encourage those at-risk or in need, we need to openly address those fears as real. To overcome stigma we need 1) role-models, 2) easy access to assured confidential service and 3) process transparency.

    Role- models: Being able to see what others have gone through and how their choices affected them is powerful. Personally, the sole thing that brought me into EM wellness and resilience was Chris Doty’s letter a year regarding the loss of his resident. It showed me how to have courage. I might be able to survive my fear. However to share my journey into suicidal thoughts, I needed more. I needed a doc who traveled that same path before. I called the only one I could find- Jay Lynch (https://news.aamc.org/medical-education/article/reducing-stigma-suicide-rates/)

    Easy Access/Confidential Services: Those that haven’t used these services before tend to be more at a loss on how to find the right/best option. Traditionally aged residents in particularly may have never had to seek their own healthcare providers or navigate the insurance situation before. When one has no energy from depression or doesn’t care because of suicidality, having to figure this out can be too much.

    Process Transparency- Having a high degree of confidence on what will happen might increase seeking of mental health help. It is one thing to know EAPs exist but it is quite another to know what would happen if one called up and said that they were depressed or suicidal. What happens when call? How long does it take to get help? What happens after the limited number of sessions?

    • Christopher Doty

      Agree with Loice (as usual) on this. There is some literature to show that those that are already depressed are least likely to seek help or disclose. We now have found a disease and developed a culture that together completely isolate physicians with depression and burnout. Those most at risk are most isolated and the least likely to seek help. PMID: 20841531

  • Loice Swisher

    Q1- Wellness is difficult to define but easy to feel. For me it is much more than physical health. It is the sense of feeling lovable and capable- feeling secure- feeling that life has meaning. I suspect an honest global self assessment has a reasonable degree of accuracy. The problem is that when the assessment is low that chances are the individual and others don’t know how to address this. Could be one doesn’t know why one feels that way or that they don’t know what to do about it. Scripts and specifics can help individualize a response.

    The first two areas specific I would want to assess are ‘thwarted belongingness” and “perceived burdensomeness”- basically feeling isolated and a failure. In Joiner’s theory of suicide these are the 2 components needed to develop a desire for suicide. However, just avoiding killing oneself doesn’t make one well. Neither does not being burnt out, adequate sleep or able to run a marathon.

    Perhaps a series of likert scale questions on specifics might be able to guide one on where there is a weak link. My thoughts are Do you have: Hope? Joy? Wonder? Energy? Sense of purpose/meaning? Sense of belonging? Sense of competence/value?

  • Shahina Braganza

    Q1 – This systematic review identified factors (e.g. basic physical needs, social relationships, autonomy, development of competence) that correlate with wellness. What does the construct – “wellness” – mean?

    Wellness is probably equivalent to Resilience – which I guess is ‘Wellness that is robust enough to withstand adversity’.

    5 pillars of Resilience have been described:

    Self Awareness – really knowing yourself – the way you think, feel and respond to situations. This allows you to be aware of how others respond to you, and allows you to modify your behaviours toward positive interactions.

    Self Care – the physiology of course (nutrition, sleep, exercise); the importance of having a good General Practitioner (family doctor); taking time off when you need to and – in my view – having an indulgence: something a little extravagant that reliably recharges you ☺

    Positive relationships – on the work and on the home fronts. These relationships should be mutually beneficial, and you need to build them up before you really need them.

    A reflective practice (for example, but not limited to, Mindfulness) – pausing to reflect, and perhaps even to be grateful. Focusing your attention to the present moment is not only useful for understanding and modulating your emotions; it encourages a drive for improvement in personal and professional performance. Furthermore, attention training is great for working in a busy, chaotic ER environment.

    Purpose – a sense of being a part of, and contributing, to something bigger than oneself. How lucky are we that this is an inherent part of what we do at work everyday! But one’s sense of purpose must extend beyond their professional identity – each one of us has to work out what the big picture is for us, and to then find our place in it.

    In the podcast, Arlene Chung alluded to the “Work-Life” construct – should we be taking a global approach to Resident Wellness (and then where is the boundary/privacy)?

    This is likely an individual thing, and the supervisor/mentor needs to use judgement and discretion. But I agree fully that it is important to look at the total picture. Certainly for me, my biggest struggle is with the Work-Life construct itself (and feeling inadequate on both fronts at times). Reconciling the big overlap between the two is helping me to resolve the sense of conflict.

    Q2 – Only a single investigator was part of this study? Why? Does this threaten the reliability of the articles selected and the abstraction of relevant data?

    I’ll leave this to the critical appraisal experts. But from me – thank you for doing this Kristen. I have a pile of papers I haven’t got around to reading – you have summarised them for me!

    I was curious about the concept of Competence, and I wonder if this is the same as one’s self-perception of competence? I further wonder whether there might be a gender difference for the latter. Just curious.

    Q3 – What can we do to decrease the stigma associated with participating in mental wellness programs or seeking mental health resources?

    Firstly, we need to be/get well ourselves! Our residents can’t be what they can’t see.

    Secondly, as stated in the podcast by Christopher Doty, senior doctors must get involved and lead this. We set the standard for normalising the conversation (and the experience) by sharing our own vulnerability and our own struggles. This gives permission for others to struggle, validates their experiences, and gives them hope that it will be okay in the end.

    When I experienced mild burnout as a 2nd year Registrar (Resident), my department director responded immediately – “I’ve been there; don’t act on anything just yet; let’s meet up and talk”. This did three things:

    1. It validated my experience – I knew that he understood what I could not articulate.

    2. It helped me to see that if it could happen to someone as formidable and capable as him, it was okay for it to happen to me.

    3. It helped me to see that one could experience struggle and still go on to have a functional career (and life!).

    Thirdly, making it a component of Residency Program accreditation gives it the attention and gravitas it deserves – congratulations to the Canadian College on this initiative.

    Q4 – Do you have a wellness program in your residency program?

    Our program is in evolution…

    One focus is on group Mindfulness practice – and we are presenting a Learning Lab at Stanford Medicine X – ED 2017 – in late April: OneED Mindfulness Project: Getting started and maintaining momentum in your healthcare workplace.

    However, the specific practice itself is secondary to the statement that it makes: that our ER cares about Wellness in its staff, and is willing to put some effort into achieving it.

  • Danica K

    This topic is so important, yet it often feels as if we “play” pretend it’s important without actually believing it is. There is also a huge variability between institutions and specialty cultures.
    I wonder if anyone finds the study results surprising? It seems fairly obvious and consistent to me (from my experiences anyway) that trainees have higher rates of burnout than faculty. Work hours are (generally) longer, studying still needs to be done somehow, there’s constant eccentricities between what our supervisors do for management, and (to be cliche), the suture is nearly always cut too long or too short.
    All of these wellness initiatives are important but what strikes me most is the need to change medical culture and expectations. It doesn’t mean we shouldn’t strive for excellence, but as one very wise person once told me, “No amount of therapy or mindfulness will help if you’re in a war zone.”

  • MJ Brown

    UTEM Nashville is in its 2nd year and providing for a dedicated approach to Resident health wellness resiliency is a program goal outlined by our Program director Mark Reiter. We appreciated having you speak last year at our conference. This helped in many ways. Last week for the EM wellness week we had a grand rounds presentation on Mindfulness for EM residents and many of our hospital medical staff. We have an experienced Program coordinator Kim Palmiter with contacts in the GME community; she is an excellent resource and able toassist in the study and implementation of our Wellness/Residency program. She also has experience with the devastation of resident death thru suicide.
    We have developed peer support, monthly wellness gatherings for residents, significant others, and interested faculty, journal club monthly and at our April journal clubwill review the article presented in this discussion. We have quarterly team building events- these have varied themes and educational intent(e.g. Working with local ems on extrication techniques, visit to the state Capitol to meet with a physician legislator from our hospital, service days, creative days recently a Nashville songwriter joined us and led 14 people in a songwriting experience-it all began with a D ). In our inaugural year we had an overnite retreat and have a committee planning for our 2nd retreat this June. With our quarterly programs we have given books for optional reading and discussion: let your life speak-Palmer; my stroke of insight-Taylor;kitchen table wisdom-Remen; how doctors think-Groopman
    We have had conference lectures on self care, financial wellbeing, critical incidents.
    We have 3 faculty, one 2nd year resident, one spouse and our program coordinator make up our ‘wellness committee’.
    We have applied for a culture of compassion grant to assist/ augment with the costs of this program; will study the effect of creating a culture of compassion for resident self care, wellness and resiliency.