1. Rebuilding the Broken Vessel: a Toolkit for Physician Wellness in Medical Education Alexandra Johnson, MD Jennifer Caragol, MD University of Colorado Department of Family Medicine September 12, 2012

2. Objectives Understand the importance of integrating a physician wellness curriculum into residency. Understand the importance of integrating a physician wellness curriculum into residency. Describe and experience some of the central topics in a physician wellness curriculum. Describe and experience some of the central topics in a physician wellness curriculum. Define “mindfulness” in regards to medical education and medical practice. Define “mindfulness” in regards to medical education and medical practice. Explore how a physician wellness curriculum could potentially address specific concerns or problems that persist in the participant’s unique residency program. Explore how a physician wellness curriculum could potentially address specific concerns or problems that persist in the participant’s unique residency program. Identify how to easily fit a wellness curriculum into an existing residency structure. Identify how to easily fit a wellness curriculum into an existing residency structure.

3. Outline Group mindfulness meditation Group mindfulness meditation Importance of physician wellness Importance of physician wellness Reflective writing exercise Reflective writing exercise –Gratitude Overview of our physician wellness curriculum Overview of our physician wellness curriculum Overview of evaluations of curriculum Overview of evaluations of curriculum Discussion and questions Discussion and questions –Handouts: Curriculum Toolkit and References –Exploring how to incorporate a wellness curriculum into an existing residency educational structure

4. Importance of Physician Wellness

5. Why is a wellness curriculum important for residents? Residency is a critical period for the development of habits and systems for practice that can endure throughout one’s medical career. Residency is a critical period for the development of habits and systems for practice that can endure throughout one’s medical career. A goal of residency education is to produce a strong and productive workforce for the delivery of primary care and its subspecialties A goal of residency education is to produce a strong and productive workforce for the delivery of primary care and its subspecialties –60% of practicing physicians report symptoms of burnout – and nearly 50% of medical students across 7 medical schools reported burnout. It is fertile ground for the cultivation and preservation of qualities and skills that make us more effective and happier practitioners. It is fertile ground for the cultivation and preservation of qualities and skills that make us more effective and happier practitioners. See final slide for references.

6. Resident Input Essential Intern curriculum created by residents Intern curriculum created by residents Trial of pre-existing wellness curriculums Trial of pre-existing wellness curriculums –Determined need for curriculum to come from within the residency Importance of handoff Importance of handoff –Identifying successors

7. Defining Mindfulness Mindfulness is the quality of being fully attentive in the present moment for the task at hand, for the experience underway. Mindfulness is the quality of being fully attentive in the present moment for the task at hand, for the experience underway. –It is the opposite of operating automatically –It expands our awareness in and experience of present time so that we may have a broader view from which to respond thoughtfully and with purpose

8. Defining Mindfulness We cultivate greater command over our minds We cultivate greater command over our minds The outcomes of this are endless The outcomes of this are endless Decreasing medical errors Decreasing medical errors Decreasing anxiety or feelings of overwhelm during a busy day Decreasing anxiety or feelings of overwhelm during a busy day Actively managing thoughts to be more available for each patient Actively managing thoughts to be more available for each patient

9. University of Colorado Physician Wellness Curriculum

10. Residency Curriculum Redesign First Year - Three month-long basic sessions (July, November, and May), titled Chautauqua. First Year - Three month-long basic sessions (July, November, and May), titled Chautauqua. Second Year - Six-week immersion in PCMH concepts. Second Year - Six-week immersion in PCMH concepts. Third Year – Four-week dedicated PCMH month for furthering personal projects Third Year – Four-week dedicated PCMH month for furthering personal projects

11. Physician Wellness Curriculum One 90-minute session during each Chautauqua month One 90-minute session during each Chautauqua month –Self-Awareness –Gratitude –Renewal Three 60-minute sessions during the 2 nd year PCMH block. Three 60-minute sessions during the 2 nd year PCMH block. Six 60-minute didactic sessions throughout the year with all residents Six 60-minute didactic sessions throughout the year with all residents

12. Dual Purposes of the Wellness Curriculum 1. To support and encourage wellness among resident physicians with the intention of –Preventing Burnout –Preserving Empathy –Improving Job Satisfaction –Maintaining receptivity to learning 2. To teach critical skills for the successful practice of medicine and delivery of patient-centered care –Training in Mindfulness –Training in Listening Skills –Self-awareness activities including self-assessment and self-care goals –Exploring our practice of empathy

13. Gratitude writing exercise Take 5 minutes to reflect on and write down an experience of gratitude in your professional life Take 5 minutes to reflect on and write down an experience of gratitude in your professional life These experiences are not always positive, sometimes our greatest learning is in time where we have made mistakes or struggled These experiences are not always positive, sometimes our greatest learning is in time where we have made mistakes or struggled We will then anonymously read these papers We will then anonymously read these papers Opportunity to use generous/reflective listening Opportunity to use generous/reflective listening

14. Gratitude writing exercise ‘ To say we feel grateful is not to say that everything in our lives is necessarily great. It just means that we are aware of our blessings’ ‘ To say we feel grateful is not to say that everything in our lives is necessarily great. It just means that we are aware of our blessings’ Practicing gratitude can increase happiness levels by 25% Practicing gratitude can increase happiness levels by 25% Raising your ‘happiness set point’ Raising your ‘happiness set point’ Emmons R, McCulloch M. Counting Blessings Versus Burdens: An Experimental Investigation of Gratitude and Subjective Well-Being in Daily Life. Journal of Personality and Social Psychology. 2003, 84 (2): 377-389

15. Physician Wellness Toolkit

16. Evaluation Five distinct workshops were evaluated between July 2009 and September 2010 (36 evaluations). Five distinct workshops were evaluated between July 2009 and September 2010 (36 evaluations). –Three in Chautauquas #1, #2, and #3. –Two workshops on burnout. One set of evaluations from 2012 One set of evaluations from 2012 Overall evaluation of the Physician Wellness curriculum (7 residents). Overall evaluation of the Physician Wellness curriculum (7 residents).

17. Evaluation The content was useful: The content was useful: –Very useful 26 –Useful 9 –Not very useful 1 The instructor was clear: The instructor was clear: –Very clear 27 –Clear 9 –Not very clear 0 The presentation was: The presentation was: –Very organized 24 –Organized 12 –Not very organized 0 The presenter’s teaching style was: The presenter’s teaching style was: –Very interesting 28 –Interesting 7 –Not very interesting 0 The time allocated was: The time allocated was: –Too long 0 –Just about right 34 –Too brief 2

18. Comments about the Curriculum Burnout Burnout “I thought burnout was a great topic to help reflect on my quality of life as a resident.” “Normalize the topic of burnout but awareness that each physician is vastly different with how to reach burnout, what to look for, avoid, prioritize.”

19. Comments about the Curriculum Intrinsic Value for your Medical Practice Intrinsic Value for your Medical Practice “Yes, this is a great exercise. I think the meditation before was key. Good to have time to sit and reflect. I also liked how they were shared and we could only listen. It was refreshing not to have physicians who are naturally problem solvers comment or try to solve my reflections and for me to do the same in return.”

20. Comments about the Curriculum Mindfulness Exercises and Caring for Your Patients Mindfulness Exercises and Caring for Your Patients “Refreshing and important teaching exercise about listening. Reminded me about “being present” with patients and that sometimes I need to stop my brain and just listen.”

21. Comments about the Curriculum Reflective Writing Exercises Reflective Writing Exercises “I liked the reflective writing exercise on “rebalance, renew, refresh.” Made me remember what I can do for myself to recapture my soul.” “I felt it really helped me to think about where I am now and how I’m feeling, as well as starting to think about what I needed to do to progress forward.” “I felt it was helpful to help regain my passion for medicine.”

22. Comments about the Curriculum Mask Exercise Mask Exercise “Awesome. Brought lots of emotions and spurred more reflection the days following this exercise. Helped me connect certain emotions with previous patient interactions which if I stop to be mindful about these will help me in care of future patients.”

23. Comments about the Curriculum Chatauqua 1: Self-awareness Chatauqua 1: Self-awareness “I try to hide the fact that I worry about being an adequate doctor and that I am fearful about providing excellent care... I feel uncomfortable sharing it because I don’t want others to think that I don’t deserve to be here” “I try to hide the fact that I worry about being an adequate doctor and that I am fearful about providing excellent care... I feel uncomfortable sharing it because I don’t want others to think that I don’t deserve to be here” “My classmates are kind and compassionate, and I should not be afraid of judgement when sharing with them’ “My classmates are kind and compassionate, and I should not be afraid of judgement when sharing with them’

24. Next steps… Plans for a study of gratitude practices among residents and clinic staff and the effect this has on personal wellbeing and job satisfaction Plans for a study of gratitude practices among residents and clinic staff and the effect this has on personal wellbeing and job satisfaction Develop/refine curriculum for use with faculty Develop/refine curriculum for use with faculty Continue to refine curriculum and use feedback to improve relevancy and satisfaction Continue to refine curriculum and use feedback to improve relevancy and satisfaction

25. Our experience of the world is a reflection of our state of mind

26. References 1. McCray LW, Cronholm PF, Bogner HR, Gallo JJ, Neill RA. Resident physician burnout: is there hope? Fam Med. 2008 Oct;40(9):626-632 2. Ludmerer KM. Resident Burnout: Working Hours or Working Conditions? Journal of Graduate Medical Education: December 2009, Vol. 1, No. 2, pp. 169-171. 3. Krasner M, Epsetin R, Beckman H, et al. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. JAMA. 2009;302(12):1284-1293. 4. 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: December 2009, Vol. 1, No. 2, pp. 225-230. 5. Dyrbye LN, Thomas MR, Massie FS; et al. Burnout and suicidal ideation among US medical students. Ann Intern Med. 2008;149(5):334-341. 6. Spickard A Jr, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA. 2002; 288 (12); 1447-1450. 7. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and Self-Reported Care in an Internal Medicine Residency Program. Ann Intern Med. 2002; 136(5): 358-367. 8. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114(6):513-519. 1. McCray LW, Cronholm PF, Bogner HR, Gallo JJ, Neill RA. Resident physician burnout: is there hope? Fam Med. 2008 Oct;40(9):626-632 2. Ludmerer KM. Resident Burnout: Working Hours or Working Conditions? Journal of Graduate Medical Education: December 2009, Vol. 1, No. 2, pp. 169-171. 3. Krasner M, Epsetin R, Beckman H, et al. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. JAMA. 2009;302(12):1284-1293. 4. 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: December 2009, Vol. 1, No. 2, pp. 225-230. 5. Dyrbye LN, Thomas MR, Massie FS; et al. Burnout and suicidal ideation among US medical students. Ann Intern Med. 2008;149(5):334-341. 6. Spickard A Jr, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA. 2002; 288 (12); 1447-1450. 7. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and Self-Reported Care in an Internal Medicine Residency Program. Ann Intern Med. 2002; 136(5): 358-367. 8. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114(6):513-519. 9. Emmons R, McCulloch M. Counting Blessings Versus Burdens: An Experimental Investigation of 9. Emmons R, McCulloch M. Counting Blessings Versus Burdens: An Experimental Investigation of Gratitude and Subjective Well-Being in Daily Life. Journal of Personality and Social Psychology. 2003, 84 (2): 377-389 Gratitude and Subjective Well-Being in Daily Life. Journal of Personality and Social Psychology. 2003, 84 (2): 377-389