Resident WellnessTSVETI MARKOVA, MD, FAAFPASSOCIATE DEAN GME & DIOPROFESSOR AND CHAIR, DFMPHSWAYNE STATE UNIVERSITY SCHOOL OF MEDICINE

Agenda

Background and Framing Questions The ACGME’s requirements Table Top Discussion Institutional Approach & Measuring Wellness Local and National Efforts ResourcesQuestions and Answers

Burnout and Satisfaction with Life-Work Balance Among US Physicians (N=7,288)

Burnout by Specialty Satisfaction with Life-Work Balance

Shanafelt, TD, et.al. Mayo Clin Proc. 2015;90(12):1600‐1613 with TJN Modifications

T. Nasca2017

Burnout in Training

Highly prevalent among medical students, residents and physicians– In residents, studies show burnout rates of 41‐90%

In residency, levels rise quickly within the first few months of residency

ACGME work hour changes do not appear to have improved sleep, burnout, depression symptoms or errors

Resident distress (e.g. burnout and depression) associated with medical errors and poorer patient care

West, CP et al, JAMA 2006; Desai et al, JAMA 2013; Sen S, JAMA Intern Med 2013

Depression During InternshipSpecialty (N=740)Specialty (N=740)

• Internal medicine 358 (48.5)

• General surgery 98 (13.3)

• OB/gynecology 42 (5.7)

• Pediatrics 94 (12.7)

• Psychiatry 63 (8.5)

• Emergency medicine 47 (6.3)

• Medicine/pediatrics 19 (2.6)

• Family medicine 19 (2.6)

Percentage with “Depression” (PHQ >10)Percentage with “Depression” (PHQ >10)

Sen et al, Arch Gen Psych 2010

Mean PHQ-9 increased from 2.4 to 6.4

80 hours working 24 hours awake Change Little time for family/significant others Loneliness and social isolation Work overload Overwhelming responsibility Exposure to pain, suffering, death, dying Continual high stakes assessment “I can never read enough!”

Environment

What has the GME community done to address resident wellness?

The ACGME has revised the Common Program Requirements (section VI) and the institutional requirements with an emphasis on wellness Residency education must occur in an environment

that emphasizes “commitment to the well-being of the students, residents, faculty members and all members of the health care team.”

What are these requirements? Are they achievable?

Programs, in partnership with their Sponsoring Institutions, have the same responsibility to address well-being as to evaluate other aspects of competence. This responsibility must include:

• Efforts to enhance the meaning that each resident finds in the experience of being a physician, including protecting time with patients, minimizing non-physician obligations, providing administrative support, promoting progressive autonomy and flexibility, and enhancing professional relationships; (Core)(VI.C.1.a)

• Attention to scheduling, work intensity, and work compression that impacts well-being (Core)(VI.C.1.b)

Well-Being: ACGME Program and Sponsoring InstitutionResponsibilities

Policies and programs that encourage optimal resident and faculty member well-being (Core) (VI.C.1.d)

• Well-being includes having time away from work to engage with family and friends, as well as to attend to personal needs and to one’s own health, including adequate rest, healthy diet, and regular exercise.

Cont

Residents must be given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours. (Core) (VI.C.1.d).(1))

• The intent is to ensure that residents have the opportunity to access medical and dental care, including mental health care, at times that are appropriate to their individual circumstances. Residents must be provided with time away from the program as needed to access care, including appointments scheduled during their working hours.

Cont

The program, in partnership with the SI, must encourage residents and faculty members to alert the program director or other designated personnel or programs when they are concerned that another resident, fellow, or faculty member may be displaying signs of burnout, depression, substance abuse, suicidal ideation, or potential for violence (Core) (VI.C.1.e).(1))

• Reluctance to seek help for burnout, depression, substance abuse and/or suicidal ideation, due to stigma associated with these conditions

• Essential that residents and faculty members are able to report concerns, so that program director or other designated personnel can assess

• Designated personnel should be familiar with institution’s impaired physician policy and follow institution’s policies for reporting

Cont

Provide access to appropriate tools for self-screening (Core)(VI.C.1.e).(2) Provide access to confidential, affordable mental health assessment, counseling, and treatment, including access to urgent and emergent care 24 hours a day, seven days a week (Core) (VI.C.1.e).(3))• Immediate access at all times to a mental health professional

• In-person, telemedicine, or telephonic means are acceptable

• Care in the emergency department may be necessary, but not as primary means to meet requirement

• “Affordable” intended to ensure that financial cost not be a barrier to obtaining care

Cont

Programs must encourage residents to use fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning• Programs are expected to adopt fatigue mitigation processes and

ensure there are no negative consequences or stigma for using fatigue mitigation strategies

• Emphasis on the importance of adequate rest before and after clinical responsibilities

Fatigue Mitigation

Physician Wellness

“We must move beyond the pathological focus upon physician burnout and begin a conversation about what makes a physician well.”

Eckelberry-Hunt, van Dyke, Lick, & Tucciarone; Journal of Graduate Medical Education, 2009: 1(2), 225-230.

Patient Care and Physician Well-Being

Clinicians who care for themselves provide better care for others

They are less likely to make errors or leave the profession Habits of practice to promote well-being and resilience

need to be cultivated across the continuum A healthy learning environment will lead to improved

health care for all, both providers and patients

Table Top Discussion #1

Wellness is a complex construct

Systematic Approach to Wellness Acknowledge issue Assess:

Outline metric Choose validated instrument Compare with benchmarks Review and analyze

Intervene Monitor regularly Promote health (exercise, nutrition, mindfulness, fatigue mitigation) Peer support (social events, common space) Institutional culture (policies, mission, “just culture”, efficient work flow) Support services (mental health, EAP) Professional development (time management, leadership, teamwork)

Measurement ToolsConstruct Scales

Depression Zung Self-Rating Depression Scale

Beck Depression Inventory

Burnout Abbreviated MaslachBurnout Inventory

Mini Z

WorkplaceSatisfaction

Minnesota Satisfaction Questionnaire

Life Satisfaction Generalized Self-Efficacy Scale

Satisfaction with Life Scale

Coping Ways of Coping Scale

Optimism Personal Optimism Scale

Life Orientation Test (Revised)

Wellness Physician Well-Being Index

Resident Wellness Scale

Example of Measuring an Intervention

Exercise activity Global measure: Wellness? Burnout?

Which tool

Frequency

Data gathering methodology

Specific measures: Participant #

Steps, # flights

Correlation with the global measure?

Qualitative assessment: small groups, individual interviews, etc.

Complex Concept

Complex Measurement System

Complex Analysis

Design and Implement Interventions: Institutional, Program, Individual levels

Wellness advisory committee (Resident Council) Identify “Resident Wellness Champions” Resident-driven mini-interventions

Peer mentorship program

Communication project: Facebook, blog, twitter, Google hang outs

“Residents as Teachers” Certificate program (culminating edu. project to improve environment; professional empowerment)

Community service initiatives

Social events, wellness activities

Resources for self-care and fitness Institutional Resources: EAP, 24/7/365

National Level Collaboration

ACGME Task Force Coalition for Physician Accountability AAMC focus area Collaboration for Healing and Renewal in

Medicine (CHARM) Special Societies Annual symposiums National Academy of Medicine (NAM)

Action Collaborative on Clinician Well-being National Academy of Medicine

First Meeting, January 6, 2017 Chair: Victor Dzau, MD Co-Chairs: Thomas Nasca, MD and Darrell Kirch, MD More than 30 organizations and institutions Vivek Murthy, US Surgeon General Discussion of opportunities through NAM Benchmarks and how to define success 3 meetings/year for two years February, 2018 Webinar https://nam.edu/initiatives/clinician-resilience-and-well-being/

“Care of the PatientRequires

Care of the Provider.”Bodenheimer and Sinsky

Ann Fam Med 2014

Our Journey: The “4th Aim”

Ultimate Goals Transition from individual to

program to institutional level

Test impact of learning environment interventions

Foster and assess culture of wellness

Centralize multi-institutional data to analyze normative response patterns, large scale trends across programs, regions and time

ResourcesPersonal strategies:

Mind tools: https://www.mindtools.com Focus on time and stress management, leadership and personal effectiveness skills

Mini-Z: https://www.stepsforward.org/modules/physician-burnout-survey Part of AMA’s STEPS Forward program

Franklin Covey: http://www.franklincovey.com/resources/ tools on stress assessment, self‐scoring 7‐habits profile on current level of self‐effectiveness,

and 360° assessments for self‐awareness

American Foundation for Suicide Prevention: https://suicidepreventionlifeline.org/ Interactive screening program with resources and 24/7 lifeline

ResourcesInstitutional interventions:

STEPS Forward Wellness program, AMA: https://www.stepsforward.org/modules/improving‐physician‐resilience AMA STEPS Forward wellness program is an interactive practice transformation series offering

innovative strategies that will allow physicians and their staff to thrive in the evolving health care environment

ACGME: http://www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being/Resources To promote a culture of physician well-being and provide support in the case of burnout,

depression, or suicide.

AAMC: https://www.aamc.org/initiatives/462288/articlesbooks.html Books, recourses and initiatives on well-being in academic medicine

Canadian Physicians Health Institute: http://php.oma.org/CPHI.html

Acknowledgements

R. Brent Stansfield, PhD Tim Brigham, MDiv, PhD Steve Angus, MD

Questions?