Well-being or the lack thereof: how do we support it?

For the last several years, there has been an increasing focus at the national level on physician burnout and its effect on our healthcare system. (1) A recent survey (2) of a community graduate medical education program in Wichita KS adds to the worry.  The authors surveyed all of the residents and core faculty in thirteen programs that are associated with the KUSOM in Wichita. The response rate was about 50 percent (281/439) with higher response from the faculty (55%) than the residents (47%55%) than the residents (47%).  The surveyed used the Abbreviated version of the Maslach Burnout Inventory (MBI-9).  The authors found that 32 percent of the residents and faculty had emotional exhaustion and 31 percent depersonalization.  Overall, 94/281 (43%) were considered burned out, with 51 percent of the residents meeting burnout criteria. There were three themes that emerged as activities that promote wellness among physicians: promotion of healthy and mindfulness activities; enhanced program leadership; and administration, program, and system modification to make the practice of medicine better for physicians.

Another survey of family medicine residents and faculty in Texas explored burnout. (3) Participants included 295 family medicine residents and faculty members across eleven FM programs within the Residency Research Network of Texas. The residents and faculty completed several measures that assessed resilience, burnout, flexibility, and stress. The primary outcome variables were burnout (depersonalization, emotional exhaustion, and personal achievement) and resilience. Depersonalization accounted for 27.1% of the variance (P<.001), with a moderate effect size (f²=.371). Risk factors included younger age, non-Hispanic white ethnicity, and lower resilience predicted. Resilience was the only variable that predicted depersonalization among program faculty while younger age and non-Hispanic white ethnicity along with resilience were significant predictors of depersonalization among residents. Emotional exhaustion accounted for 39% of the variance in the model (F [11,286] = 16.609, P<.001). Resiliency was significantly associated with younger age and greater psychological flexibility. Younger age, identifying as an ethnic minority, and psychological flexibility predicted resiliency among faculty, but there were no statistically significant predictors of resilience among the resident physicians.

And finally, a survey from the Association of Family Medicine Residency Directors (AFMRD) Physician Wellness Task Force (4) was done to help programs create a “culture of wellness.”  Of the 16 elements presented, 14 were rated as essential by at least 80% of the program directors. The five areas that were ranked as the most important after three rounds of questioning included: make wellness part of the residency vocabulary and culture by beginning wellness conversations in orientation and regularly thereafter; create a culture of safe, confidential disclosure for burnout, depression, suicidal ideation, and impairment; provide (directly or referral) accessible, confidential, affordable mental health services;  develop and maintain a regular recurring or longitudinal wellness curriculum (eg, building skills such as mindfulness, resilience, empathy); identify one or more wellness champions (faculty or resident) with explicit leadership support.

I am very excited that Family Medicine has given so much thought to this important issue.  Three studies in the journal that really add to the discourse!  Thanks.

References

(1)   https://www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being/Resources

(2)   Ofei-Dodoo S, Callaway P, Engels K. Prevalence and Etiology of Burnout in a Community-Based Graduate Medical Education System: A Mixed-Methods Study. Fam Med 2019; 51(9): 766-71.

(3)   Buck K, Williamson M, Ogbeide S, Norberg B. Family Physician Burnout and Resilience: A Cross-sectional Analysis. Fam Med 2019; 51(8): 657-663.

(4)   Penwell-Waines L, Runyan C, Kolobova I, et al.  Making Sense of Family Medicine Resident Wellness Curricula: A Delphi Study of Content Experts.  Fam Med 2019; 51(8): 670-6.

What are some of the impacts of the Duty Hour Restrictions on Residency Training?

A new study was published in BMJ online this week (1) about the impact of work hour reform. The authors, Dr. Chaiyachati and colleagues performed a time-motion observation of internal medicine residents at six residency programs that were a part of the iCompare group (Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education).

Eighty interns were observed by 23 trained observers. They began recording the residents’ activities as soon as they arrived at the hospital. They stopped collecting data when the intern finished their shift. The residents’ time was divided into activities and coded into seven major categories (4 Required: Education, Rounds, Work, & Handoffs AND 3 Other Applicable: Direct Patient Care, Indirect Patient Care, & Miscellaneous). Residents were observed between May 10, 2016 and May 31, 2016 for 94 weekday shifts and a total of 2173 hours. 

The authors found that residents worked a mean of 10.5 hours per shift (9.6 to 12.5 hours).  Overnight call shifts were 20.9 hours long (16.7 to 26.7 hours). Indirect patient care was the most frequently observed activity across all 6-hour time periods in the day. Direct and Indirect patient care was often seen in multitasking. More than half of the time recorded by the observers included residents multitasking other activities with indirect patient care. More than 10 hours of a 24 hour period was spent interacting with the electronic medical record.

At AMEE 2019 in Vienna, I went to a session in the Postgraduate Training (Residency) tract.  The session was led by Dr David Gachoud and colleagues at the Lausanne University Hospital in Lausanne Switzerland (2). His team had originally used the time and motion study technique in 2015 to evaluate Internal Medicine residents’ time usage.  One of their findings was that residents switched tasks on average 15 times per minute. One outcome of this study was to work with their residents to improve the schedule, specifically to increase the amount of time that was available to prepare for morning rounds by delaying the start of rounds by one hour every morning. They also hired some new secretarial staff to relieve the administrative burden of the residents. 

In this study, they recorded 63 day shifts between May and July 2018.  What they found was a little surprising: ward rounding duration was decreased by 25 minutes and time allocated to direct patient contact went down by 18 minutes.  The percentage of rounding time remained at about 50 percent between the two studies (2015 to 2018).

So, two really interesting studies of time and motion in internal medicine residency programs. This seems to be a time-intensive but really useful method to look at work hours. And more importantly the actual work that is being done by residents during their shifts.   

References

(1)   ​Jena AB, Newhouse RL, Farid M, Blumenthal D, Bhattacharya J. Association of residency work hour reform with long term quality and costs of care of US physicians: observational study.  BMJ 2019; 366: 14134 (Published online 10 July 2019)

(2)   Gachoud D, Monti M, Marques-Vidal P, Kraege V, Aebischer O, Garnier A. Impact of Increased Preparation Time for Residents Before Ward Rounds: The MED2DAY study. AMEE 2019  Short Communications #4R4. August 26, 2019 Vienna Austria.

AMEE 2019 Update

AMEE 2019 UPDATE

I was excited to get to attend and present at the Annual Conference of the AMEE which is the Association for Medical Education in Europe. AMEE is a worldwide organization with members in 90 countries on five continents. AMEE promotes international excellence in education in the health professions across the continuum of undergraduate, postgraduate and continuing education. We have been going to AMEE for several years because of the outstanding plenaries, the energy of the participants, and the high quality and diversity of the presentations.

Since I am almost wholly absorbed in Residency Education at this point in my career, I tried to make sure to hit as many of the session on Postgraduate Education as possible. The Europeans (and most of the rest of the world) call Residency training as the postgraduate period. It makes sense, they go to medical school (undergraduate) then graduate from medical school and have further “postgraduate” training.  This year, AMEE had a track for Postgraduate sessions.  I attended almost all of them and I wanted to highlight a few of my observations.

1) International but similar problems—I saw presentations from the Netherlands, the United Kingdom, Thailand, Australia, the United States, Taiwan, Canada, Japan, Singapore, Denmark, Switzerland, Scotland, Argentina, Colombia, and New Zealand. That is mind boggling.  All these were talks just about residency training.  And everyone is grappling with similar issues such as resident well-being, burnout, quality of feedback, teaching a safety culture, curricula, and faculty development.  It is a little reassuring and a little depressing.

2) Resident well-being is an international issue—I thought it was interesting that so many different counties and cultures have this problem. Residents are overworked and underpaid.  They are underappreciated everywhere. One internal medicine program in the Switzerland rearranged their entire rounding schedule to try and address issues of lack of teaching time and administrative burden for the inpatient rounding teams. A pediatrics program created a new resident organization to address the burnout and disaffection that came to their department after increasing stress and a resident suicide attempt. An Internal Medicine program in Singapore created an Escape room orientation game to build teamwork and interdependence.

3) Challenges in the residency curriculum are not the ACGME’s fault—every country and program and specialty has challenges.  Many of the programs had developed amazing and unique ways of addressing their curricular hurdles. A program in Canada was working on a pilot program to help the resident inpatient teams to come to a shared understanding of the purpose of the patient’s hospital admission.  I thought this program was particularly interesting as we have seen delays in treatment and discharges because of the shift-based teams that care for a patient. Twice daily attending changes can cause all kinds of disruptions.  A surgical program in the UK found that their program was put on notice for their poor performance on a national residency survey. They spent the next six years working on the educational environment, support for teachers, and improving the learning conditions in order to address their deficiencies.

4) Simulation is important but it doesn’t solve every problem.  A great talk by a young educator from Scotland looked at the deficiencies of teaching with Simulation. He had several great findings. For one, the simulations no matter how realistic never had the heavy weight of an actual clinical situation. Residents always know that they will eventually find out what the answer is in a simulation not so much in real life.  Another finding was that simulations are always done during the workday, but the most challenging clinical situations always happen to a resident at night or on the weekend.  Every good story from my residency training period begins with “one night when I was on call at ….”

All in all, this was another outstanding AMEE conference. Vienna is a great city to visit and we got to learn about another Subway / Metro system.  It was great to see old friends from England, Brasil, St Maarten, St Kitts, Scotland, the Netherlands, and elsewhere.  Also was nice to see Professor Ronald Harden, the General Secretary of AMEE. Also met several new friends from the US, Austria, Canada, Trinidad & Tobago, and Thailand.  If you are a medical educator, I would highly recommend this meeting as a place to learn and meet new colleagues from around the world.

What is wrong with the Match?

On March 15^th, 2019 another group of poor medical students went through the archaic and brutal gauntlet that is known simply as the Match.  The Match is more formally known as the National Resident Match Program. It has existed in virtually the same manner for decades, matching medical students to hospitals with residency programs.  There are some really great things about the Match, and some other things that are problematic.  I thought it would be worthwhile to discuss some of these today. 

The Match began in 1952. (1) Prior to the Match, senior medical students around the country would work all year to secure an internship. They were looking for a hospital that had a good reputation and clinical mentors that would teach them.  Often these connections were made from their mentors in medical school.  But honestly, the hospitals had all the power in this situation. They were paying little to nothing to the interns. There were no regulations on duty hours or work conditions. And the hospitals had very little responsibility to the interns. Sometimes a medical student would show up to a hospital expecting an intern position only to find out that their position had been given to someone else.  It was in this environment that the Match was created. 

At its simplest, the Match allows medical students to rank the residency programs where they have interviewed and residency programs to rank the medical students that they have interviewed. Afterwards a computer algorithm "matches" the students and the programs.  Every student in the nation finds out their match on Match Day in the middle of March. 

Over the years, the Match has had issues. Medical students have complained on multiple occasions that the algorithm favors the hospitals. In fact, a detailed analysis of incomplete Match data reported that the algorithm favored hospitals and that the NRMP had misrepresented that knowledge to medical students for years. (2) In 2002, a group of medical students filed a class-action lawsuit against the NRMP and several large teaching hospitals. The suit claimed that the Match unfairly kept residency wages low because of the lack of competition for residency positions. This suit was dismissed in 2004, after the US Congress passed a law that gave the NRMP anti-trust protection. (3) In 2015 an MIT Professor published an analysis of 2003 to 2011 Match data in the American Economic Review. He concluded that the Match lowered resident salaries by an average of $23,000 per year. (4)

But overall, I believe that the NRMP has worked hard to make the Match fair and accessible to everyone-students and residency programs, but there will always be questions when the stakes are this high.  The Match determines where a medical student / resident will spend the next three to eight years of their life. The medical student is moving to a new city, finding a place to live, and uprooting their spouse and/or family.  They may be joining a training program after spending one day interviewing and meeting program faculty and the other residents. And to top this all off, their peer residents are completely unknown to them until after the Match. They do not even know who their residency classmates will be, their partners if you will, until Match Day. Imagine that. You take a job, not even knowing who you will be working with, for up to 80 hours a week.  That takes some faith!

And there is some data that shows that the quality of the hospital that a resident trains in will affect the quality of care that they deliver to their patients for decades. (5) In a study of Obstetrics & Gynecology residency graduates, those who trained in hospitals in the bottom quintile for risk adjusted complications such as laceration, hemorrhage, and infection had 33% higher complication rates once they were practicing physicians when compared to physicians who trained in higher quality of care hospitals. It is not just in obstetrics. A 2016 study of General Surgery residency graduates found that patients operated on by surgeons who were trained in high quality residency programs (top tertile for adverse outcomes) were less likely to experience an adverse event than were patients operated on by surgeons trained in residency programs that were ranked in the bottom tertile. Adverse events included death, complications, and increased length of stay. (6)

So, I guess my bottom line is that Match Day remains an important milestone for physicians.  The Match is not perfect but this year it brought my institution  a crop of new resident physicians.

Our first residents as a new Sponsoring Institution.  I hope we were their first choice!

References

(1)   Roth AE. The Origins, History, and Design of the Resident Match. JAMA  2003; 289 (7): 909-912.

(2)   Williams KJ. A reexamination of the NRMP matching algorithm. National Resident Matching Program. Acad Med 1995; 70 (6): 470-6.

(3)   Robinson S. Antitrust Lawsuit Over Medical Residency System Is Dismissed. New York Times. Published 8/14/2004

(4)   Agarwal N. An Empirical Model of the Medical Match. American Economic Review 2015; 105 (7): 1939-1978.

(5)   Asch DA, Nicholson S, Srinivas S, et al. Evaluating Obstetrical Residency Programs Using Patient Outcomes. JAMA  2009; 302 (12): 1277-1283.

(6)   Bansal N, Simmons KD, Epstein AJ, et al. Using Patient Outcomes to Evaluate General Surgery Residency Program Performance. JAMA Surg 2016; 151 (2): 111-119.

A Wellness Framework, Part 2

A Wellness Framework (Part 2)

In 2009, Levy (3) described that resident physicians had many sources of stress (as any physician can attest to), but that many resident stressors are considered to be part of the job. For the most part, at least historically, we have just accepted them. The Resident Service Committee of the Association of Program Directors in Internal Medicine (APDIM) divided these into three categories including: professional (patient responsibility, supervision of junior learners, difficult clinical situations), situational (long hours, sleep deprivation, clerical responsibilities), and personal (financial, family, isolation). (4) In 1981, Dr Small described what he termed as “house-officer stress syndrome”.  Almost all residents experience four of the seven attributes of this syndrome, episodic cognitive impairment, anger, cynicism, and family discord. The other three are more problematic and may suggest further resident impairment.  These include depression, suicidal ideation, and substance abuse. (5)

Harassment can be a cause of resident stress. Historically, there was a high tolerance for harassment in medical training. In fact, one of my favorite stories is of a senior surgical resident whose favorite saying was “stupid, medical students.”  We didn’t even think twice about it.  A talk I attended at AMEE 2018, looked at the prevalence of bullying and harassment in Radiology residents. They found that more than 50% percent of the trainees had experienced harassment but only a small percent were willing to report the harassment. 

Burnout is another risk factor for resident physicians.  A study of Internal Medicine residents found that by the end of the first year of residency, more than 50 percent of residents met the criteria for burnout (emotional exhaustion and depersonalization). (6) A cross specialty study by Martini and colleagues, found that burnout varied by specialty during residency. (7) The overall burnout rate was 50% and ranged from 27% to 75% among different specialties. The variation among specialties was not statistically significant.

Depression and suicidal ideation are another area. It is not clear if the suicide rate for resident physicians is higher than the general population, but studies suggest that it is higher for physicians overall. The ACGME is concerned. (8) Part of the impetus for the ACGME focus on Well-being is tied to the deaths of residents and physicians due to suicide. There is also this concern that the lack of Well-being in residency carries on into a physician’s career. I experienced this in my own professional career when my boss, the CEO of our hospital system, killed himself unexpectedly in 2016. A systematic review of 14 international studies of suicide in physicians, in articles published from 1963 to 1991, found higher rates of suicide in physicians compared with the general population The higher risk was from 1.1 to 3.4 in male physicians and from 2.5 to 5.7 in female physicians. (9)  A cohort study from 1979 to 1995 in  England and Wales found elevated suicide rates in female physicians. (10)

Fortunately, there are some things that help but more research is needed to determine best practices and interventions. Universal opt-out programs seem to help. Basically, all residents need to be set up to meet with your wellness counselling center at the beginning of residency. This seems to make them more comfortable in reaching out to the counselors when they need assistance. (11)  Making residents comfortable with the concept of seeking out mental health services is an integral part of ensuring wellness. Small groups, such as the Balint groups that are common in Family Medicine programs, seem to be helpful, and not just as “bitch” sessions. But more broadly as a way to discuss difficulties that residents at different levels are experiencing.

So, what did we do in our institution? We started with the Core Values of our institution. These values were coalesced during a year-long process that included representation from all of our employees, from housekeepers to vice presidents, from nurses and physicians, from volunteers to our board members.  It was an inclusive process.  We believe that our core values define the ethos of our institution. Therefore, it makes sense that these values should inform the wellness program for our residency training programs. Our Core Values are: Respectful Compassion, Responsible Stewardship, Deep Interdependence, Passion for Excellence. 

We have tried to hardwire these into the operations of our GME office. We hired a Director of Resident Wellness. We created a GME / Resident Wellness committee. We engaged with our organizational EAP program. We looked for Institutional and Physician Champions. And at the leadership level, I have tried to keep this front of mind. So far, while there have been barriers, we are trying to keep pushing forward. Not everyone thinks that this is important, but there has been some recognition by physicians. The Medical Staff Executive Committee even hosted a speaker to discuss burnout. But in a world that is ruled by RVU generation, there is still resistance to the concept of physicians working less hard or focusing on wellness or anything outside of medicine. There is still the belief that residents already have it easy and they should not complain. The argument often goes, “I worked hard in residency and look how great I am”, so the residents should work just as hard in their training programs. 

Clearly, there is still a lot of work to do…   

  References

1. Maslach C, Jackson SW, Leiter MP. Maslach Burnout Inventory. 3rd ed. Mountainview, CA: Consulting Psychologists Press; 1996.

2. Eckleberry-Hunt J, et al Changing the Conversation From Burnout to Wellness: Physician Wellbeing in Residency Training Programs. J GME  2009; 26(1): 225-230.

3. Levey RE. Sources of Stress for Residents. Acad Med.  2001;76(2): 142-150.

4. Stress and impairment during residency training: strategies for reduction, identification, and management. Ann Intern Med  1988;109:154–61

5. Small GW. House officer stress syndrome. Psychosomatics. 1981;22:860–9.

6. Rosen IM, Gimotty PA, Shea JA, et al. Evolution of sleep quantity, sleep

deprivation, mood disturbances, empathy and burnout among interns. Acad Med. 2006;81(1):82–85.

7. Martini S, Arfken CL, Churchill A, et al. Burnout comparison among residents in different medical specialties. 2004; 28(3):240–242.

8. Nasca T.  President’s Address. 2018 ACGME Annual Educational Conference. Orlando, Florida. 

9. Lindeman S, et al. A systematic review on gender-specific suicide mortality in medical doctors. Br J Psychiatry. 1996;168:274-279.

10. Hawton K, et al. Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J Epidemiol Community Health. 2001;55:296-300.

11. Batra M, et al. Improving Resident Use of Mental Health Resources: It's Time for an Opt-Out Strategy to Address Physician Burnout and Depression 2018; 10 (1): 67–69.