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Article of the Month

 , January 02, 2018

Resident Wellness—A Chief Resident’s Perspective

Faysal G. Saab, MD, Christine A. Haynes, MD, MPH, Angelica L. Zen, MD, Jessica R. Howard-Anderson, MD, Kristin E. Schwab, MD

Dr. Saab (FSaab@mednet.ucla.edu) is a clinical instructor in the Departments of Medicine and Pediatrics at the David Geffen School of Medicine at UCLA Medical Center. Dr. Haynes (Christine.Haynes@dhha.org) is a clinical instructor in the Department of Medicine at the University of Colorado School of Medicine and Denver Health and Hospital Authority. Dr. Zen (Angelica.l.zen@kp.org) is an associate physician in the Department of Adult and Family Medicine at Kaiser Permanente Oakland Medical Center. Dr. Howard-Anderson (Jrhowa4@emory.edu) is a fellow physician in the Division of Infectious Diseases at Emory University School of Medicine. Dr. Schwab (KSchwab@mednet.ucla.edu) is a fellow physician in the Division of Pulmonary and Critical Care at the David Geffen School of Medicine at UCLA Medical Center.

Wellness is a new buzzword throughout the medical community. Healthcare systems struggle to prevent burnout and encourage wellness for physicians at every stage of their training and careers, enough so that it was the focus of the Society of General Internal Medicine (SGIM) national meeting in 2017. The topic has increasingly captured the attention of residency programs, especially given the rigor of academic training programs and the various pressures they exert—intellectually, physically, and emotionally. Suicides and major depressive episodes are illustrations of the challenges faced by residents, but often overshadow the less dramatic but similarly important struggles that all residents increasingly face.1 As residents strive to simultaneously provide outstanding patient care, build on their medical education, and excel in research activities, they often feel overwhelmed, and their profession conflicts with their efforts to maintain a personal life.

It is no secret that the heavy workload during residency is a major negative contributor to resident wellness.2 At the onset of our chief residency in internal medicine, we collectively agreed that while we could not modify ACGME duty hour rules and while there was value in our rigorous training, we could focus on promoting the well being of our residents within the confines of this system. With the complete support of our program leadership, we were allowed the opportunity to innovate and advocate for our residents. We set out to both implement new programs and re-interpret existing rules in order to create an environment that prioritized wellness and cultivated a more balanced life for our residents.

Scheduling and the Jeopardy System
At the beginning of the year, our chief group agreed that the jeopardy system should apply to any case where a resident felt unfit to work. Traditionally, this included sick days and instances of a personal or family emergency. Yet we believed that it should also include days when a resident felt particularly exhausted, depressed, or stressed. Whether it was due to lack of sleep from a sick child at home or feeling burnt out from a prolonged call schedule, we agreed that such residents should be excused both to support their mental health and to protect patient care. Residents are a highly select group of individuals who have continuously proven to be hardworking and ambitious. We believed it was important to trust them and found that they did not abuse the system. Instead of worrying about the short amount of time a resident would miss from their training, we believed it was important to support them through their training and avoid the harmful perception that they were working in an inhumane system.

The Power of Debriefing
Evening resident rounds—where second- and third-year residents come together for separate monthly sessions to discuss difficult cases with their peers—are a longstanding feature of our program. We assign three residents ahead of time to informally share a case that was challenging from a non-medical perspective, often sharing experiences with patient deaths, difficult social situations, or mistakes they feel they have made. For the first time, we began implementing similar forums for the intern class, recognizing that our residents experience challenging cases early on in residency and desire this opportunity for decompression and reflection. Given the high emotional toll of the rotation, we also initiated a similar debriefing intervention with our residents on the solid oncology service, which helped transform it into one of the more highly rated inpatient rotations.

Our program also conducts a rapid mortality review in our intensive care unit, whereby residents review deaths from the previous week with ICU attendings, fellows, and nurses. Chief residents ask the house staff whether anything about the case particularly bothered them. This is intended to extract any lingering feelings of guilt, worry, or unanswered questions they may have about the death. The aim is to establish a sense of closure for the resident and to avoid any instance of prolonged self-blame that would have a negative impact on their mental health.

Professional Services
To further support our residents’ well being, this year our institution developed a Behavioral Wellness Center consisting of psychiatrists, psychologists, and a full-time therapist to serve medical and graduate students and residents and fellows. The Center provides confidential counseling and psychiatric services with no “out-of-pocket” expenses to those seeking care. We were lucky enough to have our institution recognize how invaluable is this service, as having reliable referrals available when residents need them can be challenging.

Stepping Away from Work
In an effort to be able to experience a sense of normalcy while at work, we instituted monthly “Wellness Fridays” whereby residents on outpatient rotations take turns planning an outdoor catered lunch for their co-residents. This is a chance for all residents to have a meal away from the normal noon conference didactics and enjoy the company of their co-workers while decompressing over lawn games and desserts.

One of the most powerful ways to reset from the stress of the work environment is to completely disconnect. In the fall, a full day at our outdoor university recreation center is dedicated to team-building activities with events such as a high and low ropes course and to hear resident feedback on rotations and review program policies and changes. In the spring, we spend two full days at a local beachside resort dedicated to similar activities. Our supportive faculty and fellows cover resident shifts and the accommodations are funded by the department.

Transforming the Program into a Community
This year, we formed a residency council that asks three representatives from each class to solicit their co-residents’ feedback and suggestions and to bring them to a monthly discussion over dinner with a chief. The topics ranged widely and included improving certain call schedules, revising admitting rules, diversifying conference lectures, and requesting work room amenities. The council was successful in cultivating a culture of inclusiveness and open-mindedness, as well as allowing the leadership to hear the thoughts of the residents more frequently.

We also asked our house staff to send us “shout-outs” acknowledging the hard work or impressive skill of a co-resident that were included in our weekly newsletter to the entire program. In response, we were inundated with examples of residents providing exemplary patient care, going above and beyond in their work. We cannot overstate how important it is to openly recognize admirable work, as residents may often feel that their deeds go unnoticed.

Progress, not Perfection
Medicine is caught at a crossroads. It is a fascinating and rewarding career, but the scheduling and emotional demands it requires, especially during residency training, often lead to burnout. With increasing ACGME focus in the Common Requirements on resident well-being and burnout mitigation, programs are looking for strategies to help provide these resources for residents.3 While we await radical innovations that help balance these interests, we believe that there are tangible changes a program can make to improve the resident experience. Given their unique roles as departmental leaders who have a fresh memory of the challenges trainees face, chief residents can play a key role in advocating for house staff wellness.

References
1. Andrew LB, et al. Physician suicide. Medscape. http://emedicine.medscape.com/article/806779-overview. Published June 12, 2017. Accessed November 27, 2017.
2. 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.
3. Common Program Requirements. Accreditation Council for Graduate Medical Education. http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf. Published February 2017. Accessed November 30, 2017.


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