Enhancing Wellness Education to Help Residents Prevent Burnout Chris Ebberwein, Ph.D. Ashley Borniger, M.Ed. Stephanie Murray, M.D. Wesley Family Medicine Residency, Wichita

No Disclosures

Participants will be able to: Goals and Objectives Participants will be able to: Define three elements that lead to burnout Describe risks of failing to promote wellness in medical education Consider pitfalls in trying to recognize burnout Use tools for identifying and responding to signs of burnout before they progress

What is burnout? Emotional Exhaustion Depersonalization / Cynicism Reduced Accomplishment / Inefficacy

Emotional Exhaustion Unable to recharge batteries with time off or rest Energy level begins to follow downward spiral Fatigue is interfering with patient care or judgment Resident Story How is your energy level? How would you rate your fatigue lately? How many close calls have you had lately because of fatigue?

Depersonalization / Cynicism Blame patients for stress Patients are generally a problem Sometimes don’t talk about patients (or staff) as people Resident Story What’s it like for you heading into clinic? What patients do you look forward to taking care of? How do you describe your patient panel to others?

Reduced Accomplishment Self-criticism Doubt the quality of performance Doubt the difference their work makes in patients’ lives Resident Story How would you rate yourself these days as a doctor? 0 = unhelpful; 10 = very effective. How are you doing in patient care these days? Any success stories? Any close calls? What happened? (Listen for balance/imbalance in the answer)

Burnout in Medicine One third to ½ of physicians meet burnout criteria Female physicians are 1.6 x more likely to report burnout lack of work control as strong predictor Mayo Study: 53% of medical students have burnout symptoms 300-400 physicians commit suicide each year

Previous Wellness Efforts July Adventure Course – Team building for interns, faculty, chiefs Lectures on fatigue and burnout annually Team Meeting (Fall residency retreat) Behavior Block (lighter than other rotations) Spring “get-togethers” by class Social time (Recruiting events +/-) Advisor check-ins Public recognition of standout efforts/performance Optional: Couples group, Bible Study Conversations about the need to enhance wellness and identify burnout were ongoing, but no significant change in what we were doing (above) moved to the top of the list of program priorities

Burnout Reality Check It can’t happen to me! It can’t happen to me 3rd year resident, great support system I would know what to do Perfect storm Pediatric ICU rotation 35 weeks pregnant Pneumonia 3 hours of uninterrupted sleep at a time Patient care Cried midnight to 3am and decided, might as well go in if I can’t sleep half as efficient Safe/Competent? Hindsight If it happened to me, has it happened to others? Action Meeting arranged by resident with program director, program coordinator (AB) and psychologist (CE) Resident Escape plan Additional wellness prevention planning

Burnout Reality Check It can’t happen to me 3rd year resident, great support system I would know what to do Perfect storm Pediatric ICU rotation 35 weeks pregnant Pneumonia 3 hours of uninterrupted sleep at a time Patient care Cried midnight to 3am and decided, might as well go in if I can’t sleep half as efficient Safe/Competent? Hindsight If it happened to me, has it happened to others? Action Meeting arranged by resident with program director, program coordinator (AB) and psychologist (CE) Resident Escape plan Additional wellness prevention planning

Burnout Reality Check It can’t happen to me 3rd year resident, great support system I would know what to do Perfect storm Pediatric ICU rotation 35 weeks pregnant Pneumonia 3 hours of uninterrupted sleep at a time Patient care Cried midnight to 3am and decided, might as well go in if I can’t sleep half as efficient Safe/Competent? Hindsight If it happened to me, has it happened to others? Action Meeting arranged by resident with program director, program coordinator (AB) and psychologist (CE) Resident Escape plan Additional wellness prevention planning

Resident Catalyst How do we prevent this from happening again? What should I have done? Wanted to be part of the solution. Arranged meeting to discuss options. Meeting arranged by resident with program director, program coordinator (AB) and psychologist (CE) Resident Escape plan Additional wellness prevention planning

QI Project What’s the status of support in the program? Results of initial survey: Residents “I was sick and a faculty asked if there was anything she could do for me.” “Just saying ‘How’s it going?’ and indicating they meant outside of residency.” “Program director took a walk with me to discuss my family concerns.” 21% residents surveyed stated faculty never showed concern towards personal wellness/residents didn’t feel comfortable going to faculty with wellness concerns “I feel if I go to faculty, nothing changes to help.”

QI Project What’s the status of support in the program? Results of initial survey: Faculty “When I know there is an issue, I check in, offer support, and follow-up (most of the time).” 25% faculty surveyed stated they did not pay attention to resident wellness 63% faculty surveyed stated they did not have adequate resources to help residents deal with wellness concerns “How do I recognize unwell residents when they are not verbal with their feelings/concerns?” “What am I allowed to initiate regarding recovery plans?” “What is the right ‘amount’ of response?”

Re-energized Wellness Efforts Continue previous efforts Resident wellness survey (every 2 blocks) Designed to be easy to complete and actionable Resident database Pass around the table at each faculty meeting Dr. E follows up after each faculty meeting with resident advisor Faculty training on recognizing burnout Vital Sign Questions added to advisor check-ins Downsides: Resident wellness survey can be anonymous, so more of a program snapshot than an individualized tool to respond to.

Re-energized Wellness Efforts Emphasize advanced planning with advent of advanced scheduling Intern resource guide Effort to coach interns before arriving Residents choose and keep advisors Effort to enhance relationships Planning quarterly team building events with different groups

Impact QI Results (six months later): Residents “Our faculty genuinely care very much about our wellbeing.” “By emailing, texting, stopping in hallway concerning job search.” “Asked how I was handling residency and how things are going.” 29% residents surveyed stated faculty never showed concern towards personal wellness and 15% didn’t feel comfortable going to faculty with wellness concerns “Have the impression to suck it up.”

Impact QI Results (six months later): Faculty “I listen to updates at faculty meeting and follow-up as appropriate.” “I check in on residents when I see or hear they’re struggling.” 100% faculty surveyed stated they did pay attention to resident wellness 67% faculty surveyed stated they did not have adequate resources to help residents deal with wellness concerns “Time is the major resource residents need to recharge. This is self-limited by residents. Resources are much improved, though.” “There will always be improvement here.”

Block 3 Survey Responses “New to job, too much information, too many unimportant emails, meetings, no downtime.” “Unexpected life events, getting pulled in multiple directions. Faculty could follow up, provide encouragement/support- that goes a long way!” In reference to the open-ended survey question, “What is happening in your work life this block that makes it hard to manage stress?”

Block 3 Survey Responses “Time for exercise. Spending time with family and friends. Enjoying the beautiful weather.” “Great team work, had great seniors who were very supportive in making sure I wasn't overwhelmed.” In reference to the open-ended survey question, “What is happening in your work life this block that helps you manage stress?”

Resident Comments on Wellness Efforts “One of the nice chances is the advanced scheduling—residents will know months in advance, so can actually plan vacations and family events.” “Certainly many more opportunities and outlets if something does come up. Getting assistance is much easier now.” “Have noticed that everyone has been great about checking in on my home life. I also like how everyone has been very flexible and making sure I get to take my pump breaks.” Responses to a question added to the most recent resident survey, requesting their impressions of how wellness efforts have chanced in the last year.

Burnout “Vital Signs” Emotional Exhaustion How is your energy level? How would you rate your fatigue lately? How many “close calls” have you had lately because of fatigue? As a faculty member, I wanted prompts for how to engage residents in this conversation. I also knew my faculty colleagues were in the same boat. We devised these prompts as conversation starters that align with the three elements of burnout.

Burnout “Vital Signs” Depersonalization What’s it like for you heading into clinic? What patients do you look forward to seeing? How do you describe your patient panel to others?

Burnout “Vital Signs” Reduced Accomplishment How would you rate yourself these days as a doctor? 0 = unhelpful; 10 = very effective How are you doing in patient care these days? Any success stories? Any close calls? What happened? (Listen for balance/imbalance in the answer)

Possible Suggestions Have to tailor these to the individual (personality, generational factors, values) Talk it out (advisor, mentor, friend, counselor) Connect with others (don’t isolate) Coping / Stress management (what has worked in the past?) Prioritize self-care Nutrition Physical Activity Rest Personal interests / hobby / fun What we’re calling the vital signs questions, is just one effort to help faculty connect with advisees in regard to wellness, but we also wanted to offer ideas for what to suggest to residents in regard to avoiding burnout.

Future Direction Reassess vital sign questions in January Compile ongoing results of the wellness surveys; Compare times of the year Follow-up faculty training Focus on Prevention Mindfulness practice Relaxation practice Resilience training Emotional regulation practice Physical activity Faculty wellness?

Q&A / Discussion

References AMA Wire. Ways residents have found to conquer burnout. http://www.ama-assn.org/ama/ama-wire/post/ways-residents-found-conquer-burnout. Published Oct 15, 2014. Accessed Sept 15, 2015. AMA Wire. How to beat burnout: Seven signs physicians should know. http://www.ama-assn.org/ama/ama-wire/post/beat-burnout-7-signs-physicians-should. Published March 4, 2015. Accessed Sept 15, 2015. Maslach C, Leiter M. Early predictors of job burnout and engagement. J Appl Psychol 2008;93:498-512.

References Meltzer-Brody S. Five tips to prevent or mitigate physician burnout. http://news.unchealthcare.org/news. Published July, 2014. Accessed Sept 15, 2015. Nedrow A, Steckler NA, Hardman, Physician resilience and burnout. Family Practice Management 2013 Jan-Feb;20(1):25-30.

References Studer Group. Physician burnout: Preparing for a “Perfect Storm.” Straight A Review: A Bulletin for the C-Suite. https://www.studergroup.com/getmedia/fea54126-168b-4ba3-9866-8f584e4e7fa8/physician_burnout_straight_a_review.pdf.aspx. Published Feb 2012. Accessed Sept 15, 2015. Sinha P. Why do doctors commit suicide? The New York Times. http://www.nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide.html?_r=0. Published Sept 4, 2014. Accessed Sept 15, 2015. Tobar A. Tips to fight depression during medical residency. http://www.kevinmd.com/blog/2012/04/tips-fight-depression-medical-residency.html. Published Apr 15, 2012. Accessed 9/15/15.