#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:
(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.”
If you’re sick, we will dedicate someone will cover you.
If you need to go to a medical appointment, someone will cover you.
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!