#MedEd: Wellness

So today we wanted to spend some time talking about wellness. Yes, it’s practically a four-letter word in medicine these days. However, we want to share a systems approach to thinking about improving wellness and well-being for those of you who are students, residents, or young faculty who may be approaching this problem at your own institutions. Especially with COVID-19, we are all feeling the stress and anxiety of the unknown. It is particularly important to reach out if you are someone going through this to get help, or alternatively, if you are in a position of leadership to reach out to your residents/trainees to discuss mental health. 

We’re supposed to be social distancing now, and traditional visits may not be occurring right now, but here are some ways to have these conversations/therapy sessions virtually (not sponsored by anything, just experience/anecdotes have suggested these are helpful): 

• Betterhelp.com - virtual chat and online face-to-face sessions approximately $40-$70/week.

• Talkspace.com - same thing, can get $100 off with 1004U, about $25/week with just text, and can cost more if you want face-to-face sessions.

• Headspace - meditation app, offering premium versions free for healthcare employees with verification using your NPI number.

• Be sure to look with your employees to see if your employee assistance programs cover online mental health services! 

So let’s ask some questions: 

What is burn out?

The term “burnout” was first coined in the 1970s by psychologist Herbert Freudenberger, it is defined as emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment due to work-related stress. We know that physicians and residents can feel this particularly deeply. And there’s a lot of reasons for that: we work super long hours. We see stressful things. We have to numb ourselves to these stressful things, and we still are expected to be learning and studying throughout all of this. It’s really hard to achieve work-life balance in the environment where we spend most of our time.

Some studies have quoted that burnout is as high as 47-70% among surgical residents. This high prevalence is problematic, as it leads to a number of downstream consequences, including poor healthcare outcomes for our patients and ourselves.

So how do we stop burn out, and not just promote wellness, but, as SMFM has put it, THRIVE? 

In recognizing the problem, it’s important to acknowledge the beast that is the institution of medicine helped to create this. It’s in recognizing that, and as we all become empowered, to lead change in medicine in the future.

As we all know, ACGME has now placed work-hour limitations starting 7/2003, with change to the 80-hour work week. The literature suggests that because of this, resident burnout has decreased, and resident satisfaction and well-being has increased after the implementation of work-hour limitations. Prevalence of burnout decreased from 74 → 58% in one of these studies; while perhaps somewhat meaningful, is still an over 50% rate of burnout! But this is encouraging in that systematic/institutional changes are the things that can lead to a bigger difference in resident wellness.

In NEJM Catalyst, Bohman and colleagues proposed a really nice framework for approaching systems-levels issues with wellness: practice efficiency, a culture of wellness, and personal resilience:

View fullsize

(C) NEJM Catalyst

Culture of Wellness

Cultural change is derived from the institution and the policies it promotes. Besides work hour issues, what else is essential in a culture that promotes well-being? One study in JGME surveyed residents and fellows and suggested that in particular these things were important:

• Effective mentorship with formalization of mentorship systems. W

  • Wellness activities within these mentorship systems.

• Awareness and de-stigmatization of mental health issues.

  • Robust systems to prevent and respond to these issues.

  • A residency culture that supports and prioritizes this.

Efficiency of Practice

Efficiency can be defined as achieving productivity with minimal wasted efforts. This gives you more time to focus on other areas in your life that will make you happy, and provide time to develop personal resilience (the last cog in this wheel). We want to help patients, not computers.

Within institutions, EMR hangups and interoperability along with systems and communications problems, can be addressed and provide efficient approaches to minimize extra work. Additionally, some of the development of efficiency is personal: there is an element of this that comes with experience, whether that is with patient care or with computer usage!

Personal Resilience

This is a more challenging feature to define, and looks different for everyone, but it boils down to the ability to recover quickly from difficulties. Perhaps you define this as “toughness,” “grit,” or “resilience.” Dr. Angela Duckworth has an excellent book called “Grit: The Power of Passion and Perseverance,” and you can hear a preview through an NPR podcast here.

This is where taking care of yourself comes in; perhaps this is why people promote yoga, meditation, etc. - maybe that’s the thing for you that makes it so that you can persevere. It also suggests why pizza and ice cream parties may not be effective. They are one-time “breaks” but may be helpful for some people to develop their personal resilience. That time might be better spent with family, or getting healthcare or personal errands done, or just being able to be yourself.

 Some Examples of Institutional Major Changes

Harvard South Shore psychiatry residency identified areas of improvement in wellness and made concrete changes, which they published in 2019:

• One thing they wanted to change was “on call” experience, and thus made an “on-call patient task force” to improve workflow while on call.

• Also made a “food action team” to provide healthy food while on call (culture of wellness).

• Increased social activities outside of work - collaborated with HSS leadership to find funding to promote resident participation in sports leagues (culture of wellness) .

• Also emphasized importance of preventative care (provided residents with psychotherapists, nutritionists, dentists, and PCPs).

At Columbia OBGYN, we discussed changes to culture with Dr. Dena Goffman at SMFM:

• Changed hours for certain physicians (ie. working 12-8 pm to allow parents to take children to school, etc.).

• This cultural change and unique approach to work hours (the 8-5 isn’t for everyone!) helps to promote a culture of wellness.

AMA’s Steps Forward Campaign

A lot of this is using technology to help instead of hurt us. As one example featured in this campaign, changes in call management included creating a “one touch team” to resolved 50% or more of incoming calls with “one touch” instead of being bounced around from person-to-person; hiring of NPs to help with ‘in-basket management’ and coverage for out-of-office physicians; and dedication to decompress clinic schedules and provide administrative time to work on clerical work.

Things We’ve Done at Brown OB/GYN:

• Sharing of dotphrases to promote efficiency and consistency of documentation.

• We’ve compiled a list of therapists that accept our employer-sponsored insurance, and who have after-hours times available.

• We have a “no questions asked” policy with respect to sick leave - or maybe better phrased, “only loving questions asked.”  

  1. If you’re sick, we will dedicate someone will cover you.

  2. If you need to go to a medical appointment, someone will cover you.  

  3. Not made to feel guilty for missing days.

• Efficiency of call schedule - we constantly scrutinize the schedule to minimize people in house who don’t have to be there.

• Mentorship - we have robust mentorship systems for individuals, classes, and specialty interests, with built in social time for these various mentorship opportunities.

Go forth and be well!

#MedEd: Applying into Gynecologic Oncology

Today we welcome one of our colleagues, Dr. Deanna Glassman, current PGY-4 at Women and Infants / Brown University, but heading off to Houston, TX this summer to become a new fellow in gynecologic oncology at MD Anderson Cancer Center!

She shares with us her own story of applying into GynOnc and the essential facts of this field.

#MedEd: Applying into REI

Nick and Fei and joined by Dr. Andrey Dolinko, who will be a reproductive endocrinology and infertility fellow at the University of Pennsylvania next year. He talks to us about what to expect in residency and his tips for success in matching in REI. 

#MedEd: How to Give Feedback

We’re starting into a new miniseries at CREOGs Over Coffee that will be devoted to topics specific to medical education! To help us kick this off, we’ve invited Dr. Dayna Burrell, assistant professor and OB/GYN residency program director at Brown / Women and Infants, as well familiar voice Liz Kettyle, CNM, clinical instructor at Brown / Women and Infants. Now well into a new academic year, the dreaded topic on the front of everyone’s minds is delivering feedback. The word ‘feedback’ itself probably conjures up a lot of negative emotion, and Dr. Burrell and Liz are here to help change the spin on that and set you up to both receive and give feedback effectively.

For the website today, we’ll devote space to their seven tips for effective feedback:

1. Define the time: Plan in advance. Set expectations that feedback will happen on a regular basis - after each procedure, after each delivery, on a weekly basis - whatever makes the most sense for that learning environment. When people know what to expect, and time is defined, both the person giving feedback and the person receiving it will be less anxious, and it will be more likely to have an impact.
   

2. Create a positive learning environment: Setting the stage for a positive learning environment can really optimize your ability to give and the learner’s ability to receive the feedback that’s coming.  If possible, try to find a private space away from the direct clinical area. Try to pay attention to the learner’s needs -- has he been in the OR all day? Would it help to get water, coffee, a sandwich before the feedback session?  Pay attention to the small talk you’ve had with him. Do you remember any relevant details in his world? How’s that patient from yesterday doing? Is your baby sleeping through the night yet? Are you getting settled into your new place? You are demonstrating that you care about the learner as a person. You are providing feedback because you care! You are invested in his development and really want him to be successful! 
   

3. Define that this is feedback happening now: When Dayna started as an APD, she was given the advice to start defining the feedback, by starting each meeting with, “This is your feedback session.” At her program, this immediately improved the perception of the quantity and quality of feedback given. It seems silly, but meetings with someone who is senior to you can be stressful and anxiety provoking and the messaging can be lost in that stress. Take the time, acknowledge the purpose of the meeting in a relaxed manner and move forward. 
   

4. Allow the learner to self assess: Having the learner tell you about what she thinks went well and what could be improved upon lends tremendous insight that can make your ability to deliver feedback much more impactful.  If your views align, it can be mutually rewarding, thereby strengthening your relationship. You can validate her observations which in turn strengthens her confidence. If there is a discrepancy, a deeper dive will be required to understand how, where and why you perceive the performance differently and this may guide how you decide to approach your delivery.  
   

5. The feedback sandwich, or your food analogy of choice:

   1. The traditional sandwich: positive - area for improvement - positive. A great place to start when you are giving feedback- it is very concrete. 

      • So what is the content? Start with a positive, and roll into an area for improvement- remember you aren’t trying to criticize, you are aiming to provide specific information to reinforce or change a behavior. And you can’t change someone’s personality! Focus on behaviors that you can impact. End with a positive, or a goal to accomplish. 

      • The sandwich is getting a bad wrap per the literature of being overused, and students complaining about it being predictable. So spice it up. Add condiments, maybe some dill pickles, maybe some pesto!

   • The sushi roll: the sushi rice on the outside represents the background/the positive, the tougher nori represents the area for improvement, the spicy tuna on the inside represents the end goals, the part of the bite that makes it all come together

   • The sundae: the ice cream represents that background/the positive- comes in many flavors! The toppings represent areas for improvement- also many varieties- some small and concise(sprinkles), some more wide spread (hot fudge). The whipped cream and cherry are the bonuses on top- the plans, the goals. 
     

6. Engage in a dialogue: Now we need to close the loop and ask about barriers she perceives with respect to accomplishing the identified objectives. Listening openly to her perspectives on how her learning and performance can be optimized is crucial. Be prepared, the dialogue may include feedback on your institution and teaching style. 
   

7. Set Goals: This is it. Arguably the most important part of the whole feedback session. Set goals to improve! How do you meet those goals, what tools do you need for success, how do you measure success. As the person giving feedback- make sure you follow up. Recognize when someone is meeting those goals, or acknowledge their effort to get there, for the sake of positive reinforcement.