What is wellness?
Increasing rates of suicides, depression and burnout and decreasing personal and professional satisfaction among physicians emphasize the importance of creating a wellness culture within graduate medical education (GME) programs. In fact, the increasing number of residents and fellows who describe experiencing burnout highlights a growing crisis within the medical workforce. Physician burnout is a long-term stress reaction characterized by depersonalization, including cynical or negative attitudes toward patients, emotional exhaustion, a feeling of decreased personal achievement and a lack of empathy for patients. Conversely, wellness consists of multi-dimensional aspects that in combination lead to optimal levels of health and emotional and social functioning. A concerted effort to increase wellness and resiliency during medical training will produce physicians who are less stressed and better able to engage with their patients and provide higher quality care.
The most important patient we have to take care of is the one in the mirror.
Five steps to create a wellness culture
- Create a framework
- Develop a program
- Foster at individual level
- Empower faculty and trainees to confront burnout
- Create a sustainable culture of wellness and resiliency
Create a wellness framework
To create a sustainable, engaging wellness program, a framework must first be built. This will require the time and dedication of key people, especially residents who can lead their program and organization to make a commitment to the wellness of fellow trainees and potentially the entire medical staff.
AIdentify a group or team of trainees and faculty members who can serve as wellness advocates or champions
Many programs have enlisted the support of chief residents, the program director and others who have a particular interest in wellness. Others have hired new faculty members who, in addition to their clinical expertise, have expressed an interest in wellness. Start a special interest group to involve those who have an interest in wellness from the very beginning. The wellness team may want to consider including a social worker or psychiatrist as an advisor as well.
BSecure leadership support
Set up a meeting with your program director, involving the wellness champions who have been identified. Bring examples of what other programs have done (see case studies) and examples of the benefits of a wellness program. An organizational commitment to wellness leads to a healthy workforce and better patient care. The responsibility of wellness must be shared within the program.
Why is wellness important?
Employers have found that happy, engaged workers are more productive. Years ago, companies such as Goldman Sachs and Google made an organizational commitment to create wellness programs for their employees. The cultural shift has been dramatic, resulting in a more productive, satisfied workforce with happier clients and better outcomes. The story of Goldman Sachs’ resiliency program’s success can be found here. The same impact can be made in the field of medicine.
What can we do to help our leaders understand the value of wellness?
The more data you can show leaders, the better. The stressful, high-stakes work of taking care of patients, combined with an intense medical training period can compromise residents’ and fellows’ wellness. As training programs continue to prioritize clinical competency and knowledge, educating trainees on how to better care for themselves is becoming increasingly important. Further, integrating wellness within a program enhances trainees’ ability to fulfill the six core competencies as described by the Accreditation Council for Graduate Medical Education (ACGME).
Work-related exhaustion is one of the many variables contributing to increased medical errors; a physician whose health is compromised is more likely to provide suboptimal care. Lastly, there is an undeniable link between physician well-being and physician satisfaction. To learn more about this topic among trainees, stay tuned for the results of the national 2015 survey on the determinants of resident satisfaction, which was conducted by the AMA Resident and Fellow Section.
If wellness is considered a vital quality indicator, then a training program without a wellness focus could prove catastrophic for the individual, patients and the organization. Physicians who are mentally and emotionally detached from their work are unlikely to provide quality care or positive patient/physician interactions. To ensure a healthy physician workforce, prioritizing wellness is a must and requires concerted efforts by both the individual and the training program leadership.
CIdentify your program’s and/or institution’s definition of wellness
It is important to focus on a specific definition that is agreed upon by the wellness team members. What does it mean to be well? What aspects of wellness should be included as part of the wellness program’s scope? Completing this exercise will unite the team around what is most important.
DEvaluate the current state of wellness and burnout
As the group begins its work, understanding the current state of wellness will help the team focus efforts and initiatives in addressing burnout as experienced by residents and fellows in your training program. Administer a survey to assess wellness at the beginning of the year. Plan to reassess wellness periodically throughout the course of the year as interventions are introduced to see if your changes are making a positive impact. Encourage trainees to respond to the survey honestly and reflectively with the understanding that individual responses will remain confidential.
ESchedule times for the wellness team to regularly discuss wellness survey results
The team may decide to include the program’s wellness score on the department dashboard or scorecard, so everyone becomes accustomed to thinking about wellness as a quality indicator. Based on survey findings, the team can develop action plans to address themes or take recommendations into consideration, such as scheduling more wellness activities for trainees.
What if we have concerns about the time and energy required for regular wellness assessments?
Data is important for developing a framework upon which to build a wellness program. Regular surveys and reviews of survey data also show a commitment to measuring and responding to wellness concerns and recommendations that have been shared by trainees. In addition, people who are committed to wellness can often make a big impact by simply being active listeners and good observers of their colleagues and identifying when someone needs help. When someone does need help, he or she may not be comfortable indicating it on a formal survey or at a staff meeting.
What if we think a member of our training program is burned out or in distress?
Someone may not indicate on a survey that they need help, so do not rely on the survey as the sole source of information. Trainees should be made aware that they can speak in confidence about personal wellness concerns or issues with a wellness champion or leader in their training program. Leaders should make resources available confidentially for people who seek help. This is an integral aspect of wellness program development.
Develop a wellness program
AInnovate and design custom interventions that meet the needs of both individual trainees and the training program
Use results from the initial wellness survey to understand where to start. Consider holding an initial brainstorming session with the wellness team to determine which interventions or activities could increase wellness among trainees.
- If trainees are having a hard time transitioning into their new roles, provide peer support or a “buddy” program where new trainees can be paired with someone in postgraduate year (PGY) 2, who was in their shoes the previous year.
- If the threats to wellness involve working too many hours, the wellness group can work with program leaders to manage the amount of time trainees work to mitigate burnout.
- If trainees feel like the program is “all work and no play,” schedule group wellness events. These are an opportunity for everyone to have fun and connect with one another outside of the workplace (not to identify who seems stressed or down). Plan activities such as:
- Movie nights or dinners
- Holiday potlucks
- Ballroom dancing classes including spouses and significant others
- Local charity work (e.g., volunteer at a soup kitchen)
- Lunchtime exercise or yoga classes
- Participation in a local 5k or color run
- Sporting events (e.g., playing in a recreational league, watching a televised match or attending a university game)
- Watching popular shows as a team
- Painting or pottery classes
- Exploring the local environment (e.g., experience a local jazz club in New Orleans, a hike in Colorado or a bus tour in New York City)
BEducate trainees, staff and faculty on what wellness is and how to achieve it
Incorporate wellness into the fabric of the training program. This may include relevant sessions, workshops, lectures or grand rounds. Ideally, these activities would be incorporated into the curriculum and would not require significant amounts of time outside of regular responsibilities. The wellness team should strive to develop a holistic, engaging wellness curriculum that exposes all trainees to important wellness practices that will make an impact on each trainee’s life as a doctor.
CRe-evaluate and redesign
Continue to ensure that wellness initiatives and programs are aligned with achieving the program’s wellness priorities. Use the same measurement instruments throughout the year, and compare results. The preliminary assessment can serve as a benchmark that clarifies the needs of the trainees and informs the direction of the wellness program. On subsequent monthly or quarterly wellness assessments, monitor how the culture is changing. Open-ended survey questions that require written answers are a great way to learn more about the state of wellness in the training program and about what interventions or activities would lead to meaningful improvements in wellness. For example, ask trainees to rate the wellness activities from the previous three months, and ask them to recommend new activities for the upcoming months.
The cyclical nature of residency and fellowship training programs requires constant innovation. The best programs are structured and proactive, effectively establishing and then sustaining a supportive culture of learning and wellness. Keep track of the activities that the wellness program hosts or sponsors, and how well trainees respond to them at the event and on post-event surveys. Use this feedback to establish which events should be held annually (e.g., a holiday potluck and wellness grand rounds) or even quarterly. The wellness team will likely need to tailor aspects of the program every year to meet the needs of the current residents and fellows.
Foster individual wellness
In addition to providing opportunities for residents and fellows to experience a supportive program environment that is committed to wellness, it is important to give trainees the tools to develop individual wellness. Through a supportive environment, trainees will become engaged in wellness activities and will make them a part of their life. The wellness program can help foster individual wellness in many ways, including these tactics to increase engagement:
- Creating “buzz” around wellness events and activities
- Visible recognition (e.g., name a wellness champion for each PGY)
- Social events (e.g., field day, softball tournament, dance-off)
- Engage spouses and significant others
- Send notifications about wellness activities and events from someone whose endorsement matters (e.g., program director or wellness champion)
- Assign “wellness partners” of faculty and trainees who will engage in goal-oriented discussions on emotional, spiritual, physical and social aspects of wellness, to help trainees develop a personal wellness approach
- Develop a physician support group for trainees and faculty members
- Relax, renew and re-energize through hosted events (e.g., retreats with team-building and self-awareness exercises, stress management approaches)
For residents, there are six key aspects1 of personal well-being. Incorporate lessons on each of these aspects into your wellness program, and as much as possible, build them into the existing training program framework:
- Nutrition (e.g., healthful food options and scheduled time to eat)
- Emotional health
- Preventive care (e.g., dental care and provisions to see a primary care physician)
- Financial health (e.g., debt management, retirement planning and emergency fund support)
- Mindset and behavior adaptability
Use these six keys to personal well-being to shape the wellness program’s activities. Bring in a financial counselor to have informal discussions with interested residents. Make sure residents have free access to a gym that is located in or near the medical center. The wellness team can sponsor department meetings to ensure that healthful food is available. Program leadership can commit to giving trainees an occasional weekday afternoon off for personal meetings or doctor appointments.
Avoid burnout by taking a proactive approach to your own wellness #STEPSforward
What are some effective personal strategies to achieve wellness?
There are many strategies that residents and fellows can use to take wellness into their own hands.2 Work with other trainees and leaders in your program to create an environment where these wellness tactics can be applied on an individual level.
Balance personal and professional goals
- Clarify what is most important in your personal and professional life
- Identify conflicts
- Learn techniques to adapt your daily routine around factors that are out of your control (e.g., your work schedule)
Shape your career and identify stressors
- Determine whether you need to make career changes
- Identify what energizes you and what drains you
- Decide how stressors can be modified
Nurture wellness strategies
- Eat and sleep
- Mindfulness-based stress reduction
- Personal interests
Our physicians and staff are overwhelmed. How can we find time to implement wellness initiatives?
The fact that faculty members are overwhelmed is itself justification for taking the time to engage in wellness activities. With strong leadership support for wellness initiatives, time can be found for wellness. Whether it is through annual faculty retreats or at one of the many faculty meetings held each month, wellness activities and discussions can be integrated into existing training program events. Helping trainees find time for self-care should be an institutional priority. Prioritizing self-care is often natural after wellness is discussed in grand rounds or highlighted at a department meeting.
Empower faculty and trainees to confront burnout
The hierarchy of the medical profession can make residents and fellows feel uncomfortable approaching a more senior member of the medical staff about wellness issues. While creating an anonymous reporting system can be helpful, trainees should be encouraged and empowered to seek and offer help as needed. The wellness team’s role in accepting feedback and acting on it is crucial to the wellness program’s success. Empowering all trainees and members of the medical staff to identify signs of burnout and act on them engages everyone in the issue of wellness and can create a sense of community around a topic that impacts all physicians—and all of their patients.
Create a sustainable culture of wellness and resiliency
Continue to survey trainees on a regular basis, and give new residents the opportunity to become involved as members of the wellness team. Include people who become interested at any point; if someone becomes interested in their final year of training, welcome them onto the wellness team. Continue to include faculty advisors and enable them to become more involved in wellness work as well. Effective leadership involvement by leaders and impactful recruitment of new members, coupled with a strong framework (e.g., regular survey administration, annual wellness grand rounds and regular wellness activities planned by the wellness team) will ensure the longevity and success of the wellness program.
What is the ultimate goal of the wellness program?
In time, residents and fellows will have built a community where everyone prioritizes wellness. New trainees will be welcomed into a robust framework where physicians are resilient, engage in wellness activities and are in tune with their level of wellness throughout their training. This increased self- and environmental-awareness will become an important part of learning during crucial developmental years for young physicians. These lessons will help keep the residents and fellows well enough to care for themselves and their patients as the training program seeks to prepare them for a successful career in medicine. They will likely experience longer, more fulfilling careers due to their ability to remain resilient and combat physician burnout.
Only by applying robust measures of wellbeing, engaging physicians in reflection and conversation about promoting it in the workplace, tracking it as a meaningful outcome and making changes to enhance its realization, will physicians and their organizations thrive in their service to patients.3
Even small changes can make a big difference
There is no change too small when it comes to addressing burnout and improving the wellness and resiliency of residents and fellows. Programs that prioritize their trainees’ wellness will produce more engaged physicians who can provide quality care to their patients. If your training program is hesitant to commit to developing a wellness program, align with others who are interested in wellness and create a special interest group or club. Host a grand rounds speaker and invite your colleagues and faculty to wellness events. Your involvement may make a big difference to someone who needs it. In time, your activities will gain support to create a more formal program.
A commitment to wellness will help ensure that residents and fellows are involved and engaged in their training program as well as in their care of patients. Equipping trainees with skills to foster their own wellness will serve them, their families and their patients throughout their careers. The strategies, tools and resources in this module can assist you in creating a wellness culture that fits your training program’s needs.
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- Shersher J. Six key aspects of personal well-being. Telephone interview by Okanlawon T. July 25, 2015.
- Shanafelt TD, Kaups KL, Nelson H, et al. An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons. Ann Surg. 2014;259(1):82-88.
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STEPS in practice
How’s it working in Jacksonville, FL?
Background: Nearly half of physicians surveyed for Medscape’s 2014 Physician Lifestyle Report reported experiencing burnout. Available interventions geared towards residents and fellows lag in comparison to those that exist for senior physicians. “I experienced a lot of burnout and fatigue as a resident,” says Olufunso Odunukan, MBBS, MPH, a cardiology fellow in Mayo School of Graduate Medical Education at Mayo Clinic, Jacksonville, Florida. He adds, “Despite the ample evidence of the large burden, I grew frustrated at the lack of interventions to curb stress and fatigue among residents and fellows and felt we had to do something.”
Action: Dr. Odunukan pioneered the Fellows’ and Residents’ Health and Wellness Initiative (FERHAWI) in collaboration with the Center for Humanities in Medicine at Mayo Clinic’s campus in Florida to combat stress and fatigue among medical trainees by providing creative outlets in the arts and humanities. Dr. Odunukan acknowledges that decreasing burnout among physicians is a multi-pronged effort that involves systematic change. “This particular effort is more about protecting time in residents’ and fellows’ curricula—currently our lives—to incorporate the arts as a way to combat fatigue and stress,” he says. The FERHAWI program addresses ACGME’s competencies of professionalism, interpersonal skills and communication, and aligns with the fatigue management portion of its clinical learning environment review program.
In a preliminary analysis, Dr. Odunukan reported that internal medicine residents who engaged in a watercolor painting activity reported less fatigue and improved work-related motivation compared to their counterparts who were randomized to a usual noon conference. A longitudinal cohort study of the program conducted for three months, with arts and humanities activities held every two weeks, replicated these initial findings. Using qualitative research methods, the group also investigated the use of other stress-reducing techniques, such as meditation, to determine which activities or combinations of activities yielded the best effects.
Results: The Internal Medicine residency now earmarks one noon conference every month as “Humanities Thursday” for activities including facilitated discussions of artwork, guided visual imagery and arts projects, such as watercolor painting, screen printing and origami. The FERHAWI initiative also includes weekly ballroom dancing and other activities aimed at decreasing burnout both for residents and fellows and for their spouses or significant others.
Preliminary results suggest that integrating arts and humanities into the educational curriculum may be a feasible intervention to address the prevalent issues of fatigue, stress and low motivation among graduate medical trainees. Dr. Odunukan and his colleagues are looking to expand this initiative to other training programs within the Mayo Clinic’s School of Graduate Medical Education.
How is it working in Palo Alto, CA?
Background: Four years ago, the Stanford Department of General Surgery was rocked by news that one of their star trainees, who had recently left Stanford to pursue his vascular surgery fellowship training in Chicago, committed suicide. Dr. Greg Feldman, MD, was one of the most accomplished resident physicians the program had ever seen. He was warm, outgoing and seemed happy. He was described by a fellow trainee as “extremely good at balancing his work and non-work life and cared about getting other residents to have fun both at work and outside the hospital.” His death shocked the Stanford surgery department. Faculty, staff and residents alike were stricken with grief. How can someone so amazing, so talented and so “happy” commit suicide? Why? What went wrong? What was missed? These questions remain unanswered.
Action: As the healing process continued at Stanford, the program leadership decided to take action by addressing underlying issues affecting resident physician health. Thomas Krummel, MD, chair of the Department of Surgery, asked Ralph Greco, MD, Program Director of the General Surgery Residency, to develop a wellness program for residents. With a committee comprised of three faculty members and four residents, Balance in Life (BIL) was created. BIL is a holistic, multifaceted program with the primary aim of educating about and facilitating physical and mental health among resident trainees.
Results: Four years since its inception, BIL’s active leadership team has created a wellness-focused training environment for surgery residents. They have established a “resident-only” clubhouse where physicians can have a quiet space to discuss and reflect on their days. They have developed a system that provides protected, weekly time when trainees can meet with a therapist alone or as a group in a confidential setting. They have implemented a curriculum that enhances wellness and teamwork. A strong sense of community has emerged since the initiation of yearly retreats, team sports events and other outings. Finally, a “big-sib/little-sib” mentoring program that pairs younger trainees with more experienced ones provides guidance for new members of the program.
BIL remains deeply embedded in the ethos of this world-class training program and creates an environment where asking for help is welcomed, encouraged and supported. In BIL, Dr. Feldman’s legacy is a successful program that promotes wellness and balance in the lives of current and future trainees. In helping residents address challenges during the rigorous training years, the BIL program ensures that these physicians will be better prepared to handle the continued stressors they will face in years of practice over long, successful careers.
We know that we cannot claim that our program will prevent suicide. Our goal was to do everything we could to prevent residents from thinking that suicide is a way to deal with problems and remove the stigma of asking for help.
How’s it working in Nashville, TN?
Background: Early on during his tenure as Dean of Student Affairs at Vanderbilt School of Medicine, Scott Rodgers, MD, a board-certified psychiatrist and alumnus of the medical school, observed how the current structure of medical education nationwide was creating a toxic environment where the emphasis for students was on surviving, not thriving. Students were suffering from depression, experiencing symptoms of burnout and lacking mental resiliency. Running on fumes, these students then went on to residency training programs at a point where they were already on the edge of burnout.
Action: In 2005, Dr. Rodgers and a group of students formed what is now known as the Student Wellness Program, a medical school-wide initiative that has since become a premier model for other medical schools and even graduate training programs. The program includes activities such as yoga classes, community service events, healthy cooking classes, forums on nutrition and sleep and a mentoring program that pairs second-year students with first-year students. The College Cup, an annual “field-day” competition among the advisory college system, is a marquee wellness event designed to keep students happy and healthy. “The energy level was high, spirits were up, and the sense of community and support this event strives to achieve definitely came shining through,” said Matt Zackoff, former co-president of the student wellness program and former co-director of the College Cup.
Results: The Student Wellness Program is the first published model of a comprehensive medical student wellness initiative. This school-sponsored initiative has had a tremendous impact over the last ten years, with nearly every student participating in at least two wellness activities during their training. In addition to participation, student response has been highly satisfactory, as evidenced by their positive feedback. The successful wellness culture at the medical school level has spurred interest from graduate medical education leaders to create other initiatives and models for their residency programs at Vanderbilt.
Dr. Rodgers makes it clear that the key to the program’s success is “empowering and partnering with those who have the most at stake—the medical students themselves.” The commitment to wellness described in this vignette may inspire your wellness team to adopt a similar approach or activities that have impacted the lives of many students since the program’s inception.
How’s it working in Birmingham, AL?
Background: The University of Alabama at Birmingham Tinsley Harrison Internal Medicine Residency program has always held dear our namesake’s thoughts on medical education. Dr. Harrison believed that medical education required both the head and the heart. This was represented in his equation, E=hH², where the “h” represented the head (the medical knowledge) and the “H” represented the heart of medicine. Both are important, but giving your heart to teaching and learning was the more crucial part of the equation and thus it was capitalized and squared in his equation. Despite learning about burnout, many concepts do not become “real” until personally experienced. Some of the major components of burnout, including depersonalization, emotional exhaustion, and lack of autonomy, can drain the hearts of residents. The Tinsley Harrison Internal Medicine Residency Program sought to create a committee to preserve the hearts of residents and reemphasize Dr. Harrison’s inspiring thoughts on medical education.
Action: To focus on combatting the individual components of burnout and preserving the hearts of residents, the residency program created a resident driven committee, the Resident Wellness Committee. To prevent depersonalization, community service projects were organized that specifically did not involve the provision of medical care. The goals of these projects were to get residents out of the hospital to see different aspects of their community and spend time together. The community service also aimed to diminish feelings of inadequacy. To address emotional exhaustion, we pioneered a Memorable Patient Lecture series. In this series, faculty share positive patient stories, focusing on reflections about a specific patient he/she may have known for years or decades, a type of relationship residents have yet to experience in their early careers. For the lack of autonomy, we initiated a problem solving subcommittee with the goal of tackling 1-2 resident stressors a year with resident-driven solutions.
Results: Since the creation of the Resident Wellness Committee in 2013, residents have participated in community garden projects, The Over the Mountain Miracle League to help children with disabilities play baseball and Habitat for Humanity. The committee, comprised of residents from all levels of training, meets quarterly to plan future projects. The Memorable Patient Lecture series has had seven speakers from 2013-2015, including the Department Chair of Medicine and the Residency Program Director. Feedback from these presentations has been highly positive with attendees expressing “very heartfelt” and “great realistic discussion.” The problem solving committee addressed scheduling stressors by creating a new cross-cover system on General Medicine wards. The Resident Wellness Committee has enjoyed time together away from the hospital and has led to the creation of a standing social gathering and sports clubs. Early feedback suggests that combatting the individual components of resident burnout can be an effective way to preserve the hearts of residents.
The Resident Wellness Committee continues to be a positive influence for residents. Dr. Nicholas Hoppmann (PGY3) led the efforts to create this committee, with the support and encouragement of Program Director, Dr. Lisa Willett and Associate Program Director, Dr. Jason Morris. This summary was provided by chair of the committee, Nicholas Hoppmann (PGY3). To learn more about the committee please visit the link below.
Tell your story
Have you implemented your own idea and want to share it with the community or suggest a module?
Downloadable toolsGo to Resource Library
The tools and resources here can offer implementation support for your practice. You can download and modify them to fit your specific needs.
Physician wellness: preventing resident and fellow burnout module
Download a printable PDF version of this module.
PDF, 556 KBPreview
Physician wellness: preventing resident and fellow burnout PowerPoint
Use this PowerPoint presentation to review this module with your team.
PPT, 1,296 KBPreview
How FERHAWI meets ACGME core competencies
Learn how one residency program demonstrates that their wellness program meets ACGME competencies.
PDF, 214 KBPreview
Wellness activities and workshop topics
A list of suggested activities and workshop topics for resident programs and trainees to consider to help establish a culture of wellness.
MS WORD, 32 KBPreview
AMA Wire - Preventing Resident and Fellow Burnout
Article adapted from the AMA Wire® that summarizes the STEPS Forward module on Preventing Resident and Fellow Burnout.
PDF, 143 KBPreview
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