From a curricular standpoint, wellness can be an elusive concept. It is easy enough to label a specific educational endeavor as “wellness” or “impairment prevention.” However, there are so many factors that can negatively or positively influence the wellness of our learners, educators, staff, and patients that sometimes it’s hard to decide where to focus our efforts. Since I have been grappling with this on an institutional level for the past fifteen years or so, I thought it might be useful to share some of my experiences. At my institution (Southern Illinois University School of Medicine Springfield, IL), wellness initiatives for undergraduate and graduate medical education programs are managed separately, so I will only discuss GME here. I’ll mainly discuss efforts to address this topic institutionally, across all GME programs, although many of the pieces could be tailored to a specific program or department. On an institutional level, all of the steps require a mental health content expert/educator and the support of the GME institutional leader and the Dean. (At present, I happen to be the associate dean for graduate medical education (ADGME) as well as a psychiatrist so planning meetings are much shorter!) As is often sadly the case, our journey began in 2001 with a resident suicide. The ADGME asked me to help put together an institutional curriculum for residents on physician impairment and suicide. As we spoke with the folks from the department who had lost their resident, it became clear that we needed much more than just a lecture or two for residents. We learned that the resident who killed herself had been struggling both academically and socially. The program director and faculty were very aware that she was struggling and that their traditional academic outreach/interventions didn’t seem effective. They were worried about her, and when she did not appear for work that day, many worried that she had indeed attempted suicide. But because her behaviors of concern at work were performance-based, and the resident had not shared her level of depression with anyone, they did not know how to articulate their concerns, and did not know who to call for help or advice. We ended up with a four step approach.
Impairment Policy
Our impairment policy had been a very traditional model, which assumed impairment was synonymous with substance abuse. We expanded it to include information on behaviors (including academic/performance issues) that PDs might see that are associated with impairment and clear steps on who to call for advice. As we had hoped, this document is used as much as an educational tool as a protocol by program directors. Although the number of residents who have mandated fitness evaluations is very small, program directors have become more comfortable saying to residents in academic difficulty “I’m worried that your performance issues might be related to depression or anxiety and I would really encourage you to have an evaluation.”
Easy Access to a Psychiatrist
Our Springfield residents are employed by 1 of 2 affiliate hospitals. They all have access to a traditional employee assistance program (EAP) with free short term access to a panel of MSW therapists. In early discussions with residents about care options, we were surprised to get strong and consistent feedback from PGY1’s that they would not feel comfortable going to see a social worker. They felt only a psychiatrist or other physician would understand what they were going through. (This was in the early 2000’s and at that time we had no social workers or therapists embedded in any of our non-psychiatry training sites.) We were able to access some financial support from the medical school to contract with a number of community psychiatrists for what is, in effect, a psychiatric EAP. (We did not approach the residents’ employing hospital because they already provided an EAP program and would see this as a duplication of services.) We cover one initial evaluation and up to six follow-up visits. From the beginning, we made the decision and the commitment to residents that we don’t track anything except number of users and cost of the program for budgeting purposes. In any given year an average of just under 2% of residents utilize the service. The average number of visits per resident is about 3.5. The cost is covered through the central GME office and turns out to be somewhere between $3000-4000 per year (We have about 280 residents, so this comes out to about $10.75 - $14.30 per resident per year.) The psychiatrist submits a bill to the GME office with the date of service and the time (over or under 30 minutes). We do not collect residents’ name, diagnosis or treatment. A resident is given an access number that they give directly to the psychiatrist for billing. We do not make referrals, although in rare cases a PD or resident has requested my help in expediting an appointment.
Education for Residents
One face-to-face session on physician wellness and impairment prevention is required for all PGY1’s. We offer it twice in September to accommodate schedules and to keep the group size manageable. In the early years, the session was three hours in length and had, in addition to group discussions, a fairly evidence based literature review on depression, impairment and suicide. At the beginning, we had some trepidation of about how it would be received by the residents and concerns that that the folks who needed it the most would be the least receptive. After a couple of years the data piece was truncated tremendously when it became clear that the vast majority of residents recognize the value of this topic and do not need data to convince them. In fact, the amount of data was counterproductive, leaving the residents with a sense of a self-fulfilling prophecy. In its current form, the session is 90 minutes and is a combination of small and large group discussion, think -pair-share exercises and brief personal reflections. We cover the following topics:
Although the content and focus has changed over the years from a primarily impairment focus to a wellness focus, we never lose sight of the fact that the primary goal of this session is for residents to feel safe reaching out and to seek/accept help if they need it. We also want to leave them with some practical tools. For the first 10 years or so, we included training in progressive relaxation. Because they require less time to teach and have a little more efficacy data, we’ve replaced that experience with brief training on writing a gratitude letter and the Three Good Things exercise.
Education for Program Directors and Resident Leaders
Every fall there I do a brief review of resident mental health at the monthly or quarterly meetings of our GMEC, House Staff Association, and Program Coordinators Association. We just recently started including program coordinators in this and, in retrospect, we should have included them years ago. They often know the residents better than PDs and are huge resident advocates. The sessions are very brief. They focus on risk factors, behavioral signs of impairment or depression and, most importantly, who to call if they’re worried about a resident. (Because I wear both hats, this person is usually me. In a system where the ADGME is not also a psychiatrist the protocol would look different.) The sessions are supplemented with a lot of one-on-one with individual program directors about residents of concern. We also do (at the suggestion of the House Staff Association) a midyear mailing to all of our residents on self-care and a little reminder where to go to for help if needed.
Some Lessons Learned and Still Learning
We started this initiative in 2001. The 2003 introduction of duty hours did not reduce PGY1’s perceived stress at all. In fact, my sense has been that it’s made things harder for at - risk residents, who often struggle with time management. However, regular feedback does seem to reduce PGY1’s perceived stress. At the beginning, the group discussions centered on a ubiquitous anxiety that stemmed from not knowing where they stood. A couple years after the wellness initiative started, we also embarked on a project to get all SIU faculty skilled in giving regular feedback. The angst about not knowing where they stood plummeted. I’ve subsequently read literature that supports an inverse relationship between feedback and resident burnout, so I was not imagining it! An unsurprising lesson was that the support of institutional leaders is absolutely vital. A lesson that was more surprising, is that PDs and residents from the get-go have been highly receptive of the resources. No one had to be convinced of the value.
If you are still reading, I appreciate your attention and persistence in my musings about this very important topic. If you would like to learn more about our efforts or any of the curricular materials we use, call me at 217-545-8852 or email me at kbroquet@siumed.edu. I love to talk about this stuff.
AAP Bulletin – Spring 2016, Page 3 of 7
