Thriving, Not Surviving, in Residency: JGME-ALiEM Hot Topics in Medical Education Journal Club

This year’s JGME-ALiEM Hot Topics in Medical Education journal club features the systematic review on residency wellness recently published in the Journal of Graduate Medical Education (JGME).  This week, share your thoughts about this timely topic and paper on the blog, on Twitter (follow #JGMEscholar) and during a live Google Hangout with author Kristin Raj, MD (@KristinRajMD), Christopher Doty, MD (@PoppasPearls), and Jonathan Sherbino, MD (@Sherbino). Ultimately, a curated summary of our discussions will be published in the JGME. Some of your best tweets and blog comments will be featured.

Background on Wellness

Residency can be difficult, daunting and arduous. It is a time when you are sometimes forced to prioritize between clinical and academic responsibilities and adequate sleep, exercise, or quality time with your family. The increased workload, stress on personal relationships, and predilection for self-neglect during training create the perfect storm for the degeneration of a resident’s sense of health and well-being. Burnout in physicians has broad implications for the field of Emergency Medicine (EM). Studies indicate that physician burnout influences the quality care, impacts patient safety and satisfaction, and leads to early physician retirement. 1,2

EM was ranked highly in rates of burnout among physicians and one study even has EM ranked highest. Rates of depression amongst physicians in training is approximately 22-35%. 3 This is startling when compared to the rates of depression in the general population, which is approximately 17%.4 What is even more tragic is that due to a multitude of factors, nearly 400 physicians commit suicide every year in the U.S. 5 This is roughly equivalent to losing an entire medical school (all four years) annually!

To tackle this immense and tragic issue, some residency programs have started to develop and expand formal wellness programs at their institution. One of the earliest programs in the U.S. came from Stanford. Their wellness program was developed in 2010 after the death of one of their residents. 6 The AMA Steps Forward program has published a comprehensive module called “Physician wellness: preventing resident and fellow burnout” that lays out key steps to start a wellness program at your institution.

The conversation around wellness initially focused on the endpoint of burnout, such as how to recognize, treat, and prevent it. Recently there has been a call for a shift from a focus on burnout to a focus on preventative strategies and the promotion of wellness right from the start in training. 7,8 There has been an urge to teach individuals the skills needed for resilience and positivity. There has also been a call challenging executive leadership and institutions to tackle the systems-based problems that contribute to physician burnout and disruption in wellness. 1

Featured JGME Paper

Raj KS. Well-Being in Residency: A Systematic Review. J Grad Med Educ. 2016 Dec;8(5):674-684. doi: 10.4300/JGME-D-15-00764.1. PMID: 28018531. [Open access PDF]

ABSTRACT
BACKGROUND:
Rates of physician burnout have increased in recent years, and high burnout levels are reported by physicians in training.

OBJECTIVE:
This review of the research on resident well-being seeks to identify factors associated with well-being, summarize well-being promotion interventions, and provide a framework for future research efforts.

METHODS:
Keywords were used to search PubMed, PsycINFO, and MEDLINE. Studies included were conducted between 1989 and 2014. The search yielded 82 articles, 26 which met inclusion criteria, and were assessed using the Medical Education Research Study Quality Instrument.

RESULTS:
Articles measured resident well-being and associated factors, predictors, effects, barriers, as well as interventions to improve well-being. Factors identified in psychological well-being research-autonomy, building of competence, and strong social relatedness-are associated with resident well-being. Sleep and time away from work are associated with greater resident well-being. Perseverance is predictive of well-being, and greater well-being is associated with increased empathy. Interventions focused on health and coping skills appear to improve well-being, although the 3 studies that examined interventions were limited by small samples and single site administration.

CONCLUSIONS:
An important step in evolving research in this area entails the development of a clear definition of resident well-being and a scale for measuring the construct. The majority (n = 17, 65%) of existing studies are cross-sectional analyses of factors associated with well-being. The literature summarized in this review suggests future research should focus on factors identified in cross-sectional studies, including sleep, coping mechanisms, resident autonomy, building competence, and enhanced social relatedness.

Article Focus

Raj reviews the literature on resident well-being to identify factors associated with wellness. In addition, this paper aims to identify interventions that may promote wellness and suggests a framework for future research.

Overall, this systematic review identified numerous studies that showed that resident well-being was lower than that of the general population. Furthermore, residents suffered from higher rates of emotional exhaustion, work-life balance challenges, and depersonalization than their faculty counterparts.

The paper identified numerous POSITIVE factors that improved well being including:

  • Autonomy
  • Competence
  • Social relatedness
  • Accomplishment of goals
  • Opportunities for learning
  • Positive feedback
  • Positive colleague relationships
  • Engagement in spiritual practices
  • Increasing physical activity
  • Exposure to nature

The paper also identified factors with a NEGATIVE impact on resident well-being and included:

  • Sleep deprivation
  • Strained relationships with family and significant others
  • Drug and alcohol use

Finally, as residency programs develop wellness initiatives, this review suggests that utilization rates may be suboptimal for the following reasons:

  • Stigmatization of mental health within residency education and clinical medicine
  • Resident concern about helpfulness of initiatives
  • Resident time constraints

Watch the Google Hangout

YouTube video coming soon on January 18, 2016

Hot Topics Questions

Post your answer to any question below or discuss via Twitter using #JGMEscholar.

Q1 – This systematic review identified factors (e.g. basic physical needs, social relationships, autonomy, development of competence) that correlate with wellness. What does the construct – “wellness” – mean?

Q2 – Only a single investigator was part of this study? Why? Does this threaten the reliability of the articles selected and the abstraction of relevant data?

Q3 – What can we do to decrease the stigma associated with participating in mental wellness programs or seeking mental health resources?

Q4 – Do you have a wellness program in your residency program? If yes, what does it include? How does it work? What are the benefits?If no, what type of program would you like to see implemented? Why?


Previous JGME-ALiEM Hot Topics journal clubs


Disclaimer: We reserve the right to use any and all tweets to #JGMEscholar and comments below in a curated, commentary for the Journal of Graduate Medical Education Your comments will be attributed. Many thanks in advance for your thoughts and contributions.

1.
Shanafelt T, Noseworthy J. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):129-146. [PubMed]
2.
Lu D, Dresden S, McCloskey C, Branzetti J, Gisondi M. Impact of Burnout on Self-Reported Patient Care Among Emergency Physicians. WestJEM. 2015;16(7):996-1001. doi: 10.5811/westjem.2015.9.27945
3.
Shanafelt T, Hasan O, Dyrbye L, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613. [PubMed]
4.
Daskivich TJ, Jardine DA, Tseng J, et al. Promotion of Wellness and Mental Health Awareness Among Physicians in Training: Perspective of a National, Multispecialty Panel of Residents and Fellows. Journal of Graduate Medical Education. 2015;7(1):143-147. doi: 10.4300/jgme-07-01-42
5.
Sargent DA. Preventing Physician Suicide. JAMA. 1977;237(2):143. doi: 10.1001/jama.1977.03270290043024
6.
Salles A, Liebert CA, Greco RS. Promoting Balance in the Lives of Resident Physicians. JAMA Surg. 2015;150(7):607. doi: 10.1001/jamasurg.2015.0257
7.
Schmitz G, Heron S, Kuhn G, et al. Strategies for coping with stress in emergency medicine: Early education is vital. J Emerg Trauma Shock. 2012;5(1):64. doi: 10.4103/0974-2700.93117
8.
Eckleberry-Hunt J, Van Dyke A, Lick D, Tucciarone J. Changing the Conversation From Burnout to Wellness: Physician Well-being in Residency Training Programs. Journal of Graduate Medical Education. 2009;1(2):225-230. doi: 10.4300/jgme-d-09-00026.1

Author information

Nicole Battaglioli, MD

Nicole Battaglioli, MD

Champion, 2016-17 ALiEM Chief Resident Incubator
Chief Operating Officer, 2016-17 ALiEM Wellness Think Tank
Clinical Associate
Mayo Clinic Health System;

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