Promoting Wellness in Graduate Medical Education

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In 2015, Mata estimated that 29 percent (range: 20.9–43.2%) of physicians-in-training had depression or depressive symptoms, and that those symptoms increased in time over the course of their training. It has been reported that four hundred physicians commit suicide each year at a rate that is twice that of the general population. We have a problem when the profession that extols caring for others is burning out its caregivers.

Eckleberry-Hunt and colleagues noted that the conversation should turn from just defining burnout to promoting well-being in residency training program. Drs. Dzau, Kirch, and Nasca provided a perspective in the NEJM in 2018 entitled, “To Care Is Human — Collectively Confronting the Clinician-Burnout Crisis,” in which they commented that clinicians are human, and delivering the best care takes a personal toll on them. They postulate that burnout may be associated with increased rates of medical errors, malpractice suits, and health care-associated infections and noted that “we have an urgent, shared professional responsibility to respond and develop solutions.” The National Academy of Medicine, the Association of American Medical Colleges, and the Accreditation Council for Graduate Medical Education (ACGME) have issued a Call to Action in the form of a National Action Collaborative on Clinician Well-Being and Resilience. Key action steps include increasing visibility of clinician stress and burnout, improving health care organizations’ baseline understanding of the challenges to clinician well-being, identifying evidence-based solutions, and monitoring the effectiveness of implementation of these solutions. A web-based resource center on Clinician Well-Being Knowledge Hub was developed on the National Academy of Medicine website.

The ACGME has implemented new guidance in the common program requirements. Section VI.C addresses well-being and indicates that the program and the sponsoring institution share the responsibility to address physician well-being. They add that well-being should be addressed similarly to other core competencies in residency education, such as professionalism. Residency programs are encouraged to identify residents experiencing burnout, depression, and substance abuse, but moreover, to be proactive at creating systems that encourage wellness and eliminate stigma for reporting concerns and providing intervention.

Several specific requirements for residency programs are outlined in the ACGME guidelines. These include protecting time for residents with patients, minimizing non-physician obligations by providing adequate administrative support; promoting progressive autonomy and flexibility, enhancing professional relationships with colleagues; providing attention to scheduling, work intensity, and work compression that impacts resident well-being; and, evaluating workplace safety data and addressing the safety of residents and faculty members. Residents must be given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours. All program faculty and residents must be educated about identifying symptoms of burnout, depression, and substance abuse and providing assistance to those who experience these symptoms. The program director of other professional should be alerted to faculty or residents experiencing symptoms without fear of stigma. Access to confidential, affordable mental health services must be available at a reasonable cost. Supporting women physicians during pregnancy, breastfeeding and return to work, as well as supporting all residents with appropriate parental leave is an important component of enhancing resident wellness.

The Florida State University College of Medicine has responded to the epidemic of physician burn-out and high risk of suicide by creating a Wellness Committee, with representation from faculty, students, and staff. A separate subcommittee of the Graduate Medical Education Committee to address wellness has also been formed to share best practices and to study the effectiveness of interventions. Within the GME subcommittee, a survey of program practices was undertaken. Some of the current interventions to promote wellness in an active manner include instruction on meditation and mindfulness, reflective journaling on maintaining work-life balance, team building events, such as social and sports events, and free or reduced gym membership. One of the activities rated most highly by residents include a series of structured sessions with clinical psychologists to address work-life balance, dealing with stress, and building resilience. These sessions are designed to enhance the resident tool box to deal with stressors, to promote work-life balance, and to facilitate resources for more intensive intervention when needed. In addition, the psychologists provide a confidential space for residents to bring forward concerns regarding the program.

The wellness curriculum should be foundational to the program, and not just seen as an add-on or afterthought. The culture of wellness needs to extend beyond the residency program to incorporate the entire training institution, which is an integral component of the clinical learning environment. Getting administrative buy-in and linking the residency wellness programs to those of the institution are important. Promoting resident wellness and resiliency is critical for the pipeline of healthy physicians equipped with the emotional, mental and physical health needed to care for their patients in the future.

Joan Younger Meek, MD, MS, FAAP, FABM is the associate dean for graduate medical education and a professor of clinical sciences at Florida State University College of Medicine.

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