Resident Wellness and Well-being: Lessons Learned from the Integrative Medicine in Residency Program Patricia Lebensohn, M.D., Sally Dodds, Ph.D., Mary Guerrera, M.D., Dael Waxman, M.D., & Craig Schneider, M.D.

Presentation Objectives ▫Describe the importance of teaching about wellness and well-being during residency. ▫Discuss the definitions of wellness and well-being used in the IMR. ▫Describe the tools used to assess resident wellness and well-being. ▫Review the preliminary findings about IMR resident wellness and well-being. ▫Discuss teaching strategies to promote IMR resident wellness & well- being.

Integrative Medicine in Residency (IMR) is… Competency-based, online, 200-hour, curriculum. In-depth training in Integrative Medicine. Incorporated through all 3 years of Family Medicine residency. Piloted at 8 residencies nationwide. Seamless, online evaluation of the curriculum and the residents. Responds to ACGME competency requirements. Evaluation developed simultaneously with the curriculum.

University of Arizona University of Texas Medical Branch Hennepin County Carolinas Medical Center Beth Israel Maine-Dartmouth Maine Medical Center University of Connecticut IMR Program Locations Moses H. Cone Alaska Family Medicine Univ. of Minn A. Einstein Montefiore Control sites

Importance of Teaching About Wellness & Well-being  Residency is a powerful, formative experience in adulthood.  Establishing physician identity, schema of patient relationships, work habits, and self care.  Physician Burnout  Estimates of physician burnout: 25% - 70%.  Onset linked to residency training.  Distress in Residency  Dramatic increases in depression, anxiety, and drug use.  Increased cynicism, decreased empathy, poorer overall performance.  Consequences  Psychological problems under diagnosed and under treated.  Physician stress and burnout linked to lower-quality patient care.  Habit of ignoring self care perpetuated in life after residency.

IMR and Wellness & Well-being  IMR uniquely positioned to shift graduate medical education toward physician wellness.  Prevention and wellness are central in course content.  Opportunity to explore and describe resident wellness & well-being longitudinally.

IMR Wellness & Well-being Definitions  Wellness behaviors: Specific behaviors and lifestyles that promote optimal physical, psychological, and spiritual health (Carlson et al., 1997).  Sense of Well-being (multiple dimensions):  Satisfaction with Life: Global judgment of quality of life (Diener et al., 1985).  Sense of Happiness: Pleasant affects (Pavot & Diener, 2008).  Psychological well-being: Absence of psychological distress (Ryff et al., 1995; Keyes et al., 2002).  Positive Personal Characteristics: Qualities of mindfulness, a grateful disposition, and emotional intelligence in the context of interpersonal relationships.

Wellness Behaviors Assessed in the IMR Behavior Moderate physical activity (30 min/da) Fruits & vegetables (5/da) Vitamins/other dietary supplements Meditation Prayer PMR/other relaxation Yoga Tai Chi or Qi Gong Behavior Massage Outdoors in nature Nurturing relationships Restful sleep Alcoholic drinks per week Smoking (y/n) Rx for mood, anxiety, stress, sleep (y/n)

Resident Wellness Behaviors (All groups combined) Protective

Resident Wellness Behaviors (All groups combined) Risk

Well-being Measures DimensionMeasure Global life satisfactionSatisfaction with Life Scale (SWLS; Dierner, 1985) Affective traitsPositive & Negative Affect Schedule (PANAS; Watson, 1988) Psychological health Perceived stress Mood state distress Depression Burnout Perceived Stress Scale (Cohen et al., 1983) CES-D (Radloff, 1977) PHQ-9; (Kroneke et al., 2001) Maslach Burnout Inventory (Maslach et al. 1996) Personal characteristics Mindfulness Gratitude Emotional intelligence Freiburg Mindfulness Inventory (Walach, et al., 2006) Gratitude Questionnaire-6 (McCullough, 2002) Trait Meta Mood Scale (Salovey & Mayer, 1995) Interpersonal Reactivity Index (Davis, 1980)

Perceived Stress Scale (e.g., “How often you felt you were on top of things?”) Mean scores at baseline – 2011, 2012, Controls ns Range 1-33 Range 5-27Range 9-30 Possible scores range from 0 – 40.

Perceived Stress Scale Frequency of stress in the past month (at baseline) * *p =.03

Perceived Stress Scale Baseline and 1 st repeated measure 2011 Class (mean scores) n=44; ns * p =.002; ** p =.001 Stress Frequency past 30 days * **

CES-D (Depression screener) – Mean scores PGY1 – All groups (baseline) ns Range 0-34 Range 0-32Range 1-34 Cutpoint =/> 16

CES-D Severity scores in the past month (at baseline)

Range 0-34 Range 0-32 n=46; ns Severity scores2011 Class means *p= <.001 * CES-D Baseline and 1 st repeated measure

PHQ-9 (Depression diagnostic screener) Mean scores at baseline ns Range 0-13 Range 0-14 Range 0-16

PHQ-9 Severity scores at baseline ns

CES-D and PHQ-9 Compared 2011 PGY2

Maslach Burnout Inventory 1 Emotional Exhaustion Subscale (e.g., “I feel emotionally drained from my work”) Mean scores at baseline – 2011, 2012, Controls ns Range 1-33 Range 5-27Range 9-30 Possible scores range from 0 – 54.

Maslach Burnout Inventory 2 EE category scores at baseline *p =.02 *

Mean group scores at baselineSeverity scores t1 – t2 Maslach Burnout Inventory 3 EE Baseline and 1 st repeated measure ns *p=.032; **p=<.001 ** * * *p=<.001

Maslach Burnout Inventory 4 Depersonalization (e.g., “I really don’t care what happens to some patients”) Mean scores at baseline – 2011, 2012, Controls ns Range 0-23 Range 0-18Range 1-20 Possible scores range from 0 – 30.

Maslach Burnout Inventory 5 Dp Score Categories – 2011, 2012, Controls

BaselineSeverity scores t1 – t2 Maslach Burnout Inventory 3 Depersonalization (Baseline &1 st F/U) p = <.001 * ** *** *p = <.001; **p=..001; ***p= <.001

References De Matteo, MR, Sherbourne, CD, Hays, RD, Ordway, L, Kravitz, RL, McGlynn, EA, et al. (1993). Physicians’ characteristics influence patients’ adherence to medical treatment: Results from the Medical Outcomes Study. Health Psychology, 12, 2, Eckleberry-Hunt, J, Lick, D, Boura, J, Hunt, R, Balasubramaniam, M, Mulhem, E, & Fisher, C. (2009). An exploratory study of resident burnout and wellness. Academic Medicine, 84, 2, Eckleberry-Hunt, J, Van Dyke, A, Lick, D, & Tucciarone, J. (2009). Changing the conversation from burnout to wellness: Physician well-being in residency training programs. Journal of Graduate Medical Education, DOI: /JGME-D Gunderson, L. (2001). Physician burnout. Annals of Internal Medicine, 135, 2, Wallace, JE & Lemaire, J. (2009). Physician well being and quality of patient care: An exploratory study of the missing link. Psychology, Health & Medicine, 14, 5,

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