HEALTHY LIVING
Fostering a Culture of Well-being in Residency Programs By Faraz Yousefian, DO, Sujitha Yadlapati, MD and Eduardo Rodriguez, MD
B
urnout is defined as a combination of emotional exhaustion, low sense of accomplishment and depersonalization. This remains an ongoing concern in residency programs.1 Residency requires long work hours filled with intense scrutiny of one's clinical performance, which is coupled at times with reduced exposure to experiences outside the workplace. Continuous exposure to workplace stressors places trainees at risk of emotional exhaustion, depression and suicidal ideation. While the percentage of physicians reporting burnout differs among different specialties, nearly half of all physicians report burnout with higher rates seen in residents than medical students or early-career physicians.2 ACGME (Accreditation Council for Graduate Medical Education), in response to this, has revised program requirements for residencies to include initiatives for resident wellness. In 2018, ACGME began measuring resident well-being with a national well-being survey. The first step to establishing steps for intervention is to assess burnout. This can serve as a starting point for residencies to identify specific circumstances and establish a framework of interventions. Many standardized assessment tools and surveys ranging from freely available resources to those available at cost have been established. ACGME has endorsed Maslach Burnout Inventory (MBI-HSS), Mayo Clinic Well-Being Index, Patient Health Questionnaire-9 and professional quality of life scale as assessments at the program-level and individual resident level.1 Assessment of burnout should be conducted periodically for each resident or the program as a whole. While each of these tools can be used, extra caution should be taken while assessing residents who are at risk. Trainees at risk of suicidal ideation are challenging to identify, and reliance on assessment tools alone should be avoided.1 In terms of interventions, a residency learning environment can be a tool for reducing burnout if systematic interventions focused on promoting well-being, specifically self-care, mindfulness and meditation, are established. Reduced work hours have also been shown to improve well-being.3 Practical strategies for strengthening resident well-being require organizational change. Systems can be implemented at individual resident, program and institutional levels to create a cultural shift. Although no standardized plan is established across residency programs, institutional (top-down) and resident (bottom-up) are critical. On reviewing plans published in literature by various residency programs, resident-proposed wellness activities can include policy changes for adequate time off or breaks between rotations such as ICU
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SAN ANTONIO MEDICINE • January 2022
and CCU, or other equally intensive rotations in surgical fields. Initiating incentives to encourage resident physical fitness, such as offering yoga sessions, allowing residents access to hospital gyms or discounts to fitness classes, can promote physical fitness. Establishing an annual wellness retreat or events for all residents can encourage team building and camaraderie.4 Addressing sleep disorders and sleep deprivation by structuring days off can be helpful. In addition, psychological health also plays an important role. Alcohol dependence, abuse of sedative medications and overeating are related to higher rates of depression among residents.1 Residents often delay seeking mental health or medical treatment due to lack of time, concern for confidentiality and cost. Encouraging and allotting time off for doctor’s visits is crucial to address this. Building a solid support system of colleagues and friends has also been shown to lower burnout.1 Mentoring from peers and faculty may also help provide support and lower burnout. The path to wellness begins with an empathetic, judgment-free discussion of a resident’s health and well-being with a faculty member, program director or advisor. Trust and confidentiality are crucial elements offered by faculty to ensure residents feel supported in their effort to seek help when experiencing burnout. Interventions such as speaking with a professional therapist, examining the basis of burnout, developing better relationships with colleagues and reshaping one’s mindset can all be effective strategies.1 While individual interventions can benefit, studies show that institutional and organizational changes are necessary to shift significantly. Organizational interventions can include forming committees composed of residents and faculty who meet regularly to develop strategies to improve the clinical environment and ensure adequate time off.4 Workplace interventions such as EHR (electronic health record) optimization and delegating administrative tasks to nonclinical staff can improve overall wellness. Resident schedules are a vital component of this discussion as well. ACGME duty hour changes over the last decade came into place to combat burnout.1 Protected time off and openness of a program to work with a resident to ensure they can have days off to attend health care appointments and personal commitments outside the workplace can be beneficial. Residency programs should recognize that allowing residents to have more control over their schedules leads to overall improving wellness. In conclusion, wellness should become a culture rather than a benchmark in residency training. Continual efforts to work on this
