Resident Wellness Program Manual REVISED 2.16.18

University of Maryland Prince George’s Hospital CenterFamily Medicine Residency Program Wellness Handbook Program Director: Dr.. Family Medicine Residency ProgramResident Wellness Progra

University of Maryland Prince George’s Hospital Center

Family Medicine Residency Program

Wellness Handbook

Program Director: Dr Stacy Ross

Wellness Director: Dr Keith Foster

Author: Sarah Kin, MD Wellness Resident 2015-2016

Family Medicine Residency Program

Resident Wellness Program Curriculum

TABLE OF CONTENTS

 The Need for a Wellness Program… Pg 1

 Statistics on Physician Burnout and Depression……… ……… Pg 2

 Research on Efficacy of Mindfulness Program on Physician Wellness…… Pg 3

 PGHC Family Medicine Wellness Program Curriculum……… Pg 3-6

 Wellness topics and lecture ideas……….… Pg 7-8

Handouts Assessing Physician Wellness and Burnout:

 Burnout Self-Test: Maslach Burnout Inventory (MBI)

Treating physicians resources

List of local providers

List of mental health and substance abuse treatment centers (local and national level)

UM Prince George’s Hospital Center’s Employee Benefits: Employee Assistance Program (EAP)

The Need for a Wellness Program

As individuals, we are happiest and healthiest when we adopt healthy lifestyle choices.This includes physicians and physicians in training Healthy doctors live longer, leadmore satisfying lives and are safer practitioners When physicians are well, patient care is

at its highest quality and the public benefits In fact, studies show a physician’s wellness

is associated with fewer medical errors, enhanced satisfaction and a positive environment

in the workplace.1

In today’s society the work of a physician can be stressful, including but not limited toworking longer hours, dealing with increasingly complex patients, managing moreextensive time-consuming electronic charting and managing the business side ofmedicine At times, physicians must work in extremely high pressured environments withlimited resources This can leave physicians feeling overworked and exhausted.Oftentimes physicians fail to take good care of their own physical and emotional health.This is evident by the growing numbers of physician’s reporting episodes of burn out, aswell as the frequency of depression, substance use disorders and suicide reported in theliterature.Error: Reference source not found This problem is exacerbated by a physicians’avoidance of taking time out for their own self-care or seeking and accepting assistancewhen in need.2

Among residents, stressful aspects unique to physician training can contribute tosymptoms of fatique or burnout and have detrimental effects on residents’ mental health.Contributing factors include working long and irregular hours with little or no controlover their schedule; balancing the demands of multiple Attending physicians and higher-level trainees; having to make difficult and possibly life-altering decisions while atgreater risk for errors due to inexperience or insufficient training; frequent shifts inworkplace and co-workers; and potential social isolation due to having less time to spendwith family and friends

On average the United States loses as many as 400 physicians to suicide each year, anumber higher than most other professions.3 Tragically this number includes Physiciansuicide while in residency In the fall of 2014, two medical residents in their secondmonth of residency training in different programs jumped to their deaths in separateincidents in New York City In 2015 an Emergency Medicine resident in Kentucky tookhis life These devastating tragedies bring to light the importance of recognizing andprioritizing physician mental health and well-being through support and interventionduring training

Implementing a structured wellness program incorporated into the typical Resident workday is a method of countering these concerns about Resident burnout and its tragicconsequences This wellness program will help residents to learn effective stress

1 Waguih William IsHak, MD, FAPA, Sara Lederer, PsyD, et al Burnout During Residency Training: A Literature Review J Grad Med Educ 2009 Dec; 1(2): 236–242.

2 Dyrbye, Liselott N MD, MHPE, et al Ability of the Physician Well-Being Index to Identify Residents in Distress Journal of Graduate Medical Education: March 2014, Vol 6, No 1, pp 78-84.

3 American Foundation for Suicide Prevention 2016 Physician and Medical Student Depression and Suicide Prevention <http://afsp.org/our-work/education/physician-medical-student-depression-suicide-

management practices and develop healthy coping techniques that will serve to combatburnout and depression in both their personal and professional lives.

Statistics on Physician Burnout and Depression

Burnout is commonly defined as a collective loss of enthusiasm for work, includingemotional numbness, feelings of depersonalization, and a low sense of personalaccomplishment A national survey published in the Archives of Internal Medicine in

2012 indicated that US physicians suffer more burnout than other American workers.4

Furthermore, in the 2018 Medscape Physician Lifestyle Report, 46% of all physiciansresponded that they had experienced burnout, a substantial increase from the Medscape

2013 Lifestyle Report in which burnout was reported in slightly under 40% ofrespondents The highest burnout rates were found in critical care (54%) and neurology(55%) Approximately half of all family physicians reported experiencing symptoms ofburnout Of greater concern, among internists and family physicians who responded tothe Medscape survey, burnout rates rose from 43% in 2013 to 50% in 2015, remaining atthat level through the 2018 survey, an absolute increase of 7% but a 16% rise in incidenceoverall.5 Of note, the 2018 Medscape Lifestyle Report shows a significant genderdifference in reported levels of burnout, with 52% of female Family Physicians reportingepisodes of burnout while only 42% of males similarly report

Burnout rates among residents are also comparably high In an anonymous survey of 504residents done at the University of North Carolina, Chapel Hill collected between Mayand June 2014 across different specialties, investigators found that 70% of residents metcriteria for burnout Among family medicine residents, about 50% endorsed burnoutsymptoms Furthermore, about 17% of these residents met criteria for depression Themost significant factors reported by residents that contributed to burnout included lack oftime to exercise, lack of time to take care of oneself, lack of time to engage in enjoyableactivities outside of work; conflicting responsibilities between work, home, or familyresponsibilities; and time spent on electronic records and documentation This speaks tothe overall struggle of work-life balance in residency.6

It is equally important to recognize that depression is closely related to the burnout seen

in a growing number of physicians Depression increases risk for suicide, worsensquality of life, and often affects the physician's ability to provide quality medical care topatients A December 2015 JAMA article published an extensive systematic review andmeta-analysis that encompassed 54 different studies and 17,560 residents which looked atthe prevalence of depression among resident physicians throughout the world in the lastsix decades The results of this analysis indicated the overall estimate of the prevalence ofdepression or depressive symptoms among resident physicians was 28.8%, with a rangefrom 20.9% to 43.2% across programs.7 This is nearly double the overall lifetime

4 Shanafelt TD, Boone S, Tan L, et al Burnout and satisfaction with work-life balance among US physicians relative to the general US population Arch Intern Med 2012;172:1377-1385.

5 Peckham, Carol Physician Burnout: It Just Keeps Getting Worse Medscape, Family Medicine Jan 26, 2015.

6 Anderson, Pauline “Medical Resident Burnout Reaches Epidemic Levels” Medscape Medical News, May 17, 2015, Speaker: Emily Holmes, MD: American Psychiatric Association 2015 Annual Meeting

7 Mata, Douglas A., MD, MPH, et al “Prevalance of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-Analysis.” JAMA Dec 8, 2015; 314(22):2373-2383

prevalence of depression in the general US population (17%).8 These findings areunacceptably high and suggest that the residency training experience continues to behighly stressful, despite attempts by ACGME to improve resident work hours.

Research on Efficacy of a Mindfulness Program on Physician Wellness

A 2009 study published in JAMA investigated whether an intensive educational program

in mindfulness, communication, and self-awareness was associated with improvement inprimary care physicians' well-being, a decrease in psychological distress, decrease inrates of burnout, and an increased capacity for relating to patients.9 70 primary carephysicians participated in an 8-week intensive mindfulness training (2.5 h/wk, 7-hourretreat), followed by a 10-month maintenance course (2.5 h/mo), which included a series

of courses on mindfulness meditation, self-awareness exercises, narratives aboutmeaningful clinical experiences, appreciative interviews, didactic material, anddiscussion

The results showed a markedly improved sense of wellbeing, decreased perceiveddistress and a decline in reported symptoms related to burnout in all domains Thesephysicians demonstrated improved empathy and mindfulness in their patient interactions.These results were sustained 3 months after the training and maintenance courses Theresults of this study strongly suggest that participation in a mindfulness appreciation andcommunication program is associated with short-term and sustained improvements inwell-being and attitudes associated with patient-centered care

The UMPGHC Family Medicine Residency Program Wellness

Curriculum

Given the above documented potential for distress, fatigue, burnout and depression, aresident wellness curriculum intended to help residents develop lifelong skills to thrive inmedicine is a necessary and beneficial part of training It is designed to help inpreventing burnout which can lead to medical errors and impaired professionalism It isdesigned to reduce the risk of depression and its related danger of suicide Healthierphysicians contribute to improved patient satisfaction.Error: Reference source not found

A wellness program at UM Prince George’s Hospital Center contributes to fulfilling theACGME mandate that “residency programs must be committed to and responsible forpromoting patient safety and resident well-being in a supportive educational

environment” and align with the American Medical Association’s (AMA) Code of

8 Kessler RC, Berglund P, Demler O The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R) JAMA 2003;289(203):3095–105

9 Krasner M, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, et al Association of an Educational Program in Mindful Communication with burnout, empathy, and attitudes among primary care physicians JAMA

Medical Ethics that emphasizes the importance of promoting of health and wellness

among physicians to ensure not only physician safety, but also patient safety

The Goals of the UMPGHC Wellness Curriculum

The goal of the wellness program is to promote the physical, emotional, intellectual,social, and spiritual well-being of residents It will help to promote the resident’s sense ofaccomplishment, satisfaction and belonging The PGHC Wellness Program will strive topromote resiliency, which by definition means “the ability to preserve and remainpositive despite adversity Resilient individuals find meaning in their work They taketime to engage in recreation Resilient individuals maintain a positive outlook and strive

to maintain a work-life balance They identify and focus on their values and priorities.Resilient individuals live the life they have as fully as possible and they avoid adopting asurvival attitude10

Wellness Program Leadership Roles

Program Director:

 Ensures that the wellness curriculum is integrated into residency education and is incorporated into the daily operations of the residency program

 Ensures all ACGME guidelines and hospital policies regarding wellness are met

 Facilitates changes and improvements in the wellness program and for individual residents, if and when appropriate

 Intervenes supportively when issues of Resident fatigue occur, consistent with

programmatic and hospital policy

 Directs necessary interventions in situations where more significant Resident

wellness or impairment issues are identified

Director of Behavioral Health:

 Selects and/or mentors with the Wellness Resident to determine topics for Didactic

‘wellness moments’

 Leads discussions regarding wellness with small resident groups when necessary

 Facilitates meetings with all residents as a forum where residents can voice concerns and receive support for ongoing distress and advice on wellness

 Is the point of contact for residents to discuss mental health and wellness issues providing resources, references and referrals

 Facilitates changes and improvements in the program, if and when appropriate, in coordination with the Program Director

 Coordinates/Presents the Didactic presentations on Wellness

 Introduces and teaches Wellness during Orientation for the new class of residents, in coordination with the Wellness Resident, including review of this Wellness

Handbook

Wellness Resident:

10 Shanafelt TD1, Bradley KA, Wipf JE, Back AL Burnout and self-reported patient care in an internal medicine

residency program Ann Intern Med 2002 Mar 5;136(5):358-67.

 Conducts, with the Director of Behavioral Health, the wellness orientation to Interns

 Presents wellness talks and exercises during didactics once/twice a month

 Distributes articles on wellness quarterly

 Encourages addressing wellness issues on resident and faculty monthly meeting agendas

 Reminds residents and faculty about wellness meetings

 Serves as a point of contact regarding issues or wellness concerns that arise in the program

 Oversees, in coordination with the Director of Behavioral Health, the implementation

of wellness intervention and prevention strategies listed below

Initiatives to foster Wellness Awareness and Wellness Maintenance

 During orientation, new interns will receive an introductory lecture addressingtips for healthy coping strategies, effective time management and stressmanagement This lecture will emphasize positive psychology and education onrecognizing stress and early burnout The lecture is presented by the Director ofBehavioral Health and the Wellness Resident

 Interns will receive a copy of this Wellness Handbook with attached Appendixthat includes support services available and important contact information TheWellness Resident, in cooperation with the Director of Behavioral Health isresponsible for this task

 Continuing topics incorporating stress management and coping strategies will bepresented during Tuesday didactics on a monthly basis in the form of ‘WellnessMoments’ (brief exercises or sharing of information) or full didactic presentations

as part of the longitudinal Behavioral Health curriculum These lectures willinclude guest speakers with practical experience on wellness (mind, body,spiritual) Lectures are arranged by the Director of Behavioral Health and theWellness Resident Topics for discussions will include ‘mindfulness-based’intervention and relaxation techniques combined with healthy diet and exercisetips, as well as occasional ‘simply for fun’ activity

 During orientation, residents will have an annual retreat provided by the program

in which the faculty and residents can get to know the new Intern class

 An effort will be made, with appropriate consent, for the Director of BehavioralHealth and the Wellness Resident to distribute to the new Intern class, prior totheir reporting for orientation, a list of every residents’ and faculty members’contact information, including preferred emails and phone numbers, so Internscan keep in touch and exchange information This effort will increase the sense ofbelonging to the program for new Interns

 The Wellness Resident will regularly provide faculty, residents and Interns withideas for recreation or optional meet-ups on the weekend/days off to promotecomradery and develop social support system

 A “buddy” system will be implemented in which PGY2s are paired with an intern.The intern can forward questions to his/her buddy and seek advice regarding theresidency experience When the intern becomes a PGY2 he or she will then gettheir buddy from the incoming class of interns to continue the tradition.

 A formal review of the ACGME duty hour limitations for residents will occurduring orientation (see Appendix) Interns will be educated on the importance ofthese limits and the basis for their existence Interns will receive a copy of theduty hour limitations in the Wellness Manual at orientation

 During orientation the Maslach Burnout Inventory (MBI), the Physician Being Index, and 8 dimensions of Wellness questionnaires (see Appendix) will beadministered and reviewed with each Intern during the first wellness lecture.Interns and Residents will then be asked to fill out each questionnaire every 6months anonymously (can be put into a drop box without names) at their owntime for review by the Director of Behavioral Health and the Wellness Resident

Well-As needed, a root cause analysis can be investigated and changes implemented asappropriate

Wellness Intervention

 During the wellness discussions at Orientation, Interns will be encouraged to utilizephysician resources when they recognize symptoms of burnout and/or feelintervention is needed These resources include: their Faculty mentor, the Director ofBehavioral Health, websites, self-help books, and apps on physician wellness (SeeAppendix for recommended list)

 Interns will be educated about and encouraged to utilize, if they prefer, appropriatelycredentialed mental health professionals to proactively address concerns about fatiguemanagement, burnout, depression or other manifestations of stress Interns will beeducated about the benefits available within the employee insurance plan and/oremployee assistance program (EAP) Guidance on selecting a professional who isbetter suited for working with physicians will be provided in the orientation Wellnessdiscussions Interns will be educated about available resources from nationalprograms dealing with physician impairment such as the Federation of StatePhysician Health Programs (FSPHP) This information and resource list will also beprovided to residents in the appendix of this Wellness Manual

Wellness Topic Discussions and Lecture Ideas

(Once/twice Monthly during Didactics)

1 Mindfulness-based Stress Relief

a Conscious Stress Release Breathing techniques

b Meditation- walking around the clinic/hospital together, sitting or focusing

on just being present

c Mindful reflection on work-day, this can be done with the person sitting beside you or calling a loved one

d Mindfulness awareness of pleasant and unpleasant events and routine activities and events such as: eating, weather, driving, walking, awareness

of interpersonal communications

2 Journaling

a Reflecting on the day, discussing experiences, intentions, goals, wishes

3 Lecture on how to recognize stress, coping strategies

a Learning the Psycho-physiology of stress, recognizing symptoms of stress

b Stress and Performance, Stress Intervention

c Self care and burn-out

a Healthy foods for the mind, good healthy snacks for work

b Nutritionist/Dietician guest speaker

6 Reviewing Time Management Skills

a Recognizing how you spend your time identify the time wasters, e.g telephone calls, socializing meetings, indecision, lack of planning,

worrying, watching television

b Setting goals set the long term and short term goals, so that you have a clear sense of where to go This will maximize the chance of achieving thegoals

c Prioritizing developing ABC lists to prioritize activities to be done

A must be done

B like to do and need to be done

C like to do if you get all A & B lists' activities done

d Scheduling— after you prioritized the activities, you can then schedule them into daily and weekly timetable

e Saying “NO” – in order to prevent work overload, do not feel guilty to say

“no” if necessary

f Delegating – do not hesitate to seek help when you are short on time and overloaded, you may get others to do those things that do not need your personal attention but need to be done

g Limiting interruptions – try to minimize interruptions such as telephone calls, visitors Stick to your schedule as much as you can

7 Effective Communication

a With patients, other physicians and staff

b Problem-solving

Maslach Burnout Inventory (MBI)

The Maslach Burnout Inventory (MBI) is the most commonly used tool to self-assess whether you

might be at risk of burnout To determine the risk of burnout, the MBI explores three components:

exhaustion, depersonalization and personal achievement The objective is simply to make you aware

that anyone may be at risk of burnout

For each question, indicate the score that corresponds to your response Add up your score for each

section and compare your results with the scoring results interpretation at the bottom of this document.

times per year

Once a month

A few times per month

Once a week

A few times per week

Every day

I feel emotionally drained by my

work.

Working with people all day long

requires a great deal of effort.

I feel like my work is breaking me

down.

I feel frustrated by my work.

I feel I work too hard at my job.

It stresses me too much to work in

direct contact with people.

I feel like I’m at the end of my rope.

Total score – SECTION A

times per year

Once a month

A few times per month

Once a week

A few times per week

Every day

I feel I look after certain patients/clients

impersonally, as if they are objects.

I feel tired when I get up in the morning

and have to face another day

at work.

I have the impression that my

patients/clients make me responsible

for some of their problems.

I am at the end of my patience at the end

of my work day.

I really don’t care about what happens

to some of my patients/clients.

I have become more insensitive to

people since I’ve been working.

I’m afraid that this job is making me

uncaring.

Total score – SECTION B

times per year

Once a month

A few times per month

Once

a week

A few times per week

Every day

I accomplish many worthwhile things in

this job.

I feel full of energy.

I am easily able to understand what my

patients/clients feel.

I look after my patients’/clients’

problems very effectively.

In my work, I handle emotional

problems very calmly.

Through my work, I feel that I have a

positive influence on people.

I am easily able to create a relaxed

atmosphere with my patients/clients.

I feel refreshed when I have been close

to my patients/clients at work.

Total score – SECTION C

SCORING RESULTS - INTERPRETATION

S

e c t i o n A : B u rn o ut*

Burnout (or depressive anxiety syndrome): Testifies to fatigue at the very idea of work, chronic fatigue,

trouble sleeping, physical problems For the MBI, as well as for most authors, “exhaustion would

be the key component of the syndrome.” Unlike depression, the problems disappear outside work.

 Total 17 or less: Low-level burnout

 Total between 18 and 29 inclusive: Moderate burnout

 Total over 30: High-level burnout

S

e c t i o n B : D e p e rsona l iz a t i o n

“Depersonalization” (or loss of empathy): Rather a “dehumanization” in interpersonal relations The

notion of detachment is excessive, leading to cynicism with negative attitudes with regard to patients or

colleagues, feeling of guilt, avoidance of social contacts and withdrawing into oneself The professional

blocks the empathy he can show to his patients and/or colleagues.

 Total 5 or less: Low-level burnout

 Total between 6 and 11 inclusive: Moderate burnout

 Total of 12 and greater: High-level burnout

S

e c t i o n C : P e rs o nal Ac hi e v e m e n t

The reduction of personal achievement: The individual assesses himself negatively, feels he is

unable to move the situation forward This component represents the demotivating effects of a

difficult, repetitive situation leading to failure despite efforts The person begins to doubt his genuine abilities to accomplish things This aspect is a consequence of the first two.

 Total 33 or less: High-level burnout

 Total between 34 and 39 inclusive: Moderate burnout

 Total greater than 40: Low-level burnout

*A high score in the first two sections and a low score in the last section may indicate

burnout Source: http://www.mindgarden.com/products/mbi.htm

Physician Well-Being Index (PWBI)

Research indicates that there is an increasing number of residents who experience distressduring their training with associated negative impact on their competence, career

satisfaction, and quality of care

The PWBI addresses the domains of burnout, depression, stress, fatigue, and mental and physical quality of life (QOL) among physicians It consists of 7 yes/no items and

respondents receive a score from 0 to 7 based on responses

A recent study surveying residents with the PWBI showed that residents with low mental QOL, high fatigue, or recent suicidal ideation were more likely to endorse each of thePWBI items and a greater number of total items (P=.001) At a threshold score of greater

than or equal to >= 5, the PWBI’s specificity for identifying residents with low mental

QOL, high fatigue, or recent suicidal ideation was 83.6%

The PWBI appears to be a useful screening index to identify residents whose degree of distress may negatively impact the quality of care they deliver This tool may be helpful

in identifying residents who may benefit from added resources, or in resident

self-assessment and subsequent help seeking

PWBI Screening Questionnaire:

Instructions: Please answer “yes=1” or “no=0” to the following 7 questions Please answer quickly, with the first response that comes to mind Keep a personal count of the number of “yes” answers

During the past month:

1 Have you felt burned out from work?

2 Have you worried that your work is hardening you emotionally?

3 Have you often been bothered by feeling down, depressed, or hopeless?

4 Have you fallen asleep while stopped in traffic or driving?

5 Have you felt that all the things you had to do were pilling up so high that you could not overcome them?

6 Have you been bothered by emotional problems, such as feeling anxious, depressed, orirritable?

7 Has your physical health interfered with your ability to do your daily work at home or away from home?

Score: / 7