Graduate Medical Education on the Frontlines during the COVID-19 Pandemic in New York City- A Response to Promote Well-being

Introduction: The COVID-19 pandemic has driven many health care institutions in the United States beyond their capacity. Physicians-in-training in graduate medical education programs have suffered the strain of providing patient care during this unprecedented time of crisis. The significant prevalence of pre-existing resident and fellow burnout and depression makes the need for action by institutions to support the well-being of residents and fellows even more urgent. We aim to describe innovative adaptations our Office of Graduate Medical Education implemented with the support of institutional leadership as responses to promote the well-being of residents and fellows on the frontlines during the COVID-19 pandemic. Methods: The Office of Graduate Medical Education (GME), in collaboration with the Office of Well-being and Resilience, developed a set of resources and interventions to support trainees during the pandemic based on four major categories: workplace culture, personal factors and health, mental health support, and workplace efficiency and function. Examination of the capacity of existing services and gaps that needed to be filled in the rapidly evolving early days of the COVID pandemic led to a robust growth in resources. For example, the already established Student and Trainee Mental Health program was able to expand and adapt its role to serve trainee needs more effectively. Results: We expanded resources to target trainee well-being across a broad array of domains within a short time frame. With investment in access to the Student and Trainee Mental Health program, utilization increased by 25.7%, with 1,231 more visits in 2020 compared to the number of visits in 2019, prior to the COVID-19 pandemic. The creation of Recharge Rooms had a positive impact on the well-being of health care workers. After a single fifteen-minute experience in the Recharge Room, an average 59.6% reduction in self-reported stress levels was noted by users. Other interventions were noted to be helpful in regular town hall meetings with trainees. Conclusion: Addressing trainee well-being is an essential aspect of a crisis response. The Mount Sinai Health System was able to care for the physical, mental, psychosocial, and safety needs of our trainees thanks to the collaborative effort of a pre-existing institutional well-being program and the GME Office. The ability to implement such a response was enabled by our well-being foundation, which allowed leadership at the highest institutional level and the Office of GME to provide support in response to this unprecedented crisis.

Feasibility of a “Network of Champions” in implementing a program to address physician well-being

Introduction: Healthcare leaders have been challenged to mitigate burnout and foster well-being among physicians. Professional societies are beginning to address this in a systematic manner. Methods: In 2014, the American College of Physicians (ACP) endeavored to improve well-being for its 160,000 members of internists and trainees through a Well-being Champion (WBC) program based in the majority of its 85 national and international chapters. The program was supported by an evidence-based curriculum, chapter volunteers who served as champions, and in-person and virtual trainings. Training included a 1-2 day program in 2018 and 2019, focused on educating champions on causes of burnout, means of systematically collecting well-being data, and methods for using data for system change to reduce burnout and improve well-being. Results: Training included 158 WBCs in 8 countries. After training, over 90% of champions in both years of the program felt able to articulate the evidence for burnout prevention and suggest interventions, access resources, and administer well-being surveys. While 58% of champions noted high interest in wellness, only 26% had a budget allocated for this, and most budgets were small. Ninety-one percent in both years felt able to analyze survey data and 90% in both years felt able to enhance their own well-being. Eighty-eight to 90% felt able to foster a well-being community and importantly, 85% felt comfortable engaging leadership in this topic. Since 2017, 639 activities were recorded, accounting for 87/158 Champions in 69 Chapters. Annual direct costs varied each year but remained <1% of aggregate member dues. Conclusion: This report describes a model for building regional networks to address physician burnout while promoting well-being and professional fulfillment. After training, champions felt capable of performing key aspects of burnout reduction, including survey administration, data analysis and engaging leadership in systems change. To our knowledge, this is the first model to scale burnout prevention throughout an entire professional society. Using the included program descriptions and curricula, this program may be generalizable for other large professional groups wishing to measure and enhance well-being among their membership.

Demographics, Activities, and Environmental Factors Impact Burnout in a National Survey of Emergency Medicine Residents

Introduction: Burnout in emergency medicine and in residency training has been well-described. The impact of demographic, individual, and programmatic factors on burnout have not previously been determined in a national survey of emergency medicine residents. This study aimed to identify personal and environmental factors impacting resident burnout in a national sample of emergency medicine residents. Methods: A prospective Emergency Medicine Resident Wellness Survey was administered in 2017. We surveyed Respondents on demographic, personal, and environmental factors; each Respondent also completed the Maslach Burnout Inventory - Human Services Survey. Linear regressions were used to identify variables associated with the Maslach Burnout Inventory’s subscales of burnout (depersonalization, emotional exhaustion, and personal achievement). Results: The survey was completed by 1,522 of 7,186 (21.2%) eligible EM residents. Respondents represented 193 of 247 (78.1%) Emergency Medicine residency programs. Increased levels of depersonalization were associated with graduation from a US medical school, female gender, and increase in respondent age. Trainees who were parents and who graduated from an osteopathic (vs. allopathic) medical school were found to have decreased levels of depersonalization. Emotional exhaustion was decreased in respondents who took breaks while on shift and who engaged in regular studying. Conclusion: While some individual characteristics impact burnout, environmental factors also play a significant role, and should be a target of system-level interventions to improve trainee well-being.

Four Weeks of 16:8 Time-Restricted Feeding on Stress, Sleep, Quality of Life, Hunger Level, and Body Composition in Healthy Adults: A Pilot Study on Wellness Optimization

Introduction: Sustainable methods of dietary lifestyle changes are essential to long term weight loss maintenance and enhancement in overall health and wellness A novel modified alternative method to caloric restriction is Time-Restricted Feeding (TRF), a sub-type of Intermittent Fasting. The purpose of this pilot study was to determine the effect of four weeks of TRF (without caloric deficit) on body composition, stress levels, sleep quality, hunger level, and quality of life. Methods: Sixteen participants, 9 males and 7 females, mean age 34.0 ± 11.7 years, completed the four-week protocol. Fasting program was 16 hours from the time of last meal of the evening to start of first meal the following day. Participants were required to consume their normal daily caloric intake within an 8-hour period. Results: There were significant reductions in mean body fat percentage (26.2±2.4 vs. 25.5±2.6, p=0.01), visceral fat (cm2) (98.2±15.3 vs. 94.1±15.7, p=0.003), body fat mass (kg) (21.6±3.0 vs. 21.0±3.2, p= 0.02), trunk fat (kg) (11.5±1.6 vs. 11.0±1.6, p=0.001) and stress levels (14.1±1.9 vs. 11.0±1.4, p=0.03). There was a significant drop in hunger levels over time (χ2 = 16.4, p=0.001). There were no significant changes in sleep quality or quality of life. Conclusion: TRF may be an effective option to decrease stress, body fat, visceral fat, and obesity-related diseases while not disrupting sleep quality and Quality of Life. Our pilot study demonstrated potential health benefits that could be incorporated by healthcare workers into whole-person wellness programs.

Resident-Led Physical Wellness Initiative Linked to Less Burnout for Emergency Physicians during COVID-19 Pandemic

Introduction: The COVID-19 pandemic has taken a significant toll on societal, physical, and psychological health. Emergency physicians (EPs) are susceptible to burnout under ordinary circumstances and may be particularly vulnerable during the pandemic. To reduce pandemic-related burnout, we implemented a residency-led physical wellness initiative and evaluated the effect on burnout among EPs. Methods: In the spring of 2020, we invited all resident and attending EPs in our department to participate in a four-week physical wellness initiative as part of a prospective study. After completing or opting out of this wellness initiative, EPs responded to an online survey comprised of five sections: demographics, participation, opinion on wellness initiative, opinion on the impact of COVID-19, and the Maslach Burnout Index (MBI-HSS). We stratified respondents by initiative participation, described the characteristics of each group, and then compared the perceived impact of COVID-19 and the MBI-HSS results between the two groups. Results: Out of 110 eligible participants, 57 EPs completed the survey (51.8%). Thirty-five respondents completed the wellness initiative. Few (37.1%) documented their progress, though most worked with accountability partners (85.7%). Most enrollees enjoyed participation (Likert Score 3.2-5, CI 2.9-3.5) and would participate again (3.3, CI 3.0-3.6). The reported effect of the COVID-19 pandemic on mental wellbeing was lower for participants, although this was not significant (2.1, CI 1.5-2.1 vs 2.4, CI 2.0-2.7, p=0.312). On the MBI-HSS, participants had a lower emotional exhaustion score (1.4, 95% CI 0.9-1.8) than non-participants (2.2, 95%CI 1.8-2.6, p=0.005).

Reducing "Treble" with Performance Focused Music Programs in Medical School

Introduction: The beneficial impact of performing arts involvement within undergraduate medical education, such as music, has been studied, but support for the arts varies significantly by institution. Research has suggested that medical student involvement in the arts can help develop their identities as physicians and may reduce stress and burnout, an increasingly difficult problem within the medical student community. Methods: We used a mixed-method cross-sectional study design, using a questionnaire and semi-structured interview designed amongst a team of music professionals and healthcare providers with music backgrounds. Out of 511 enrolled medical students, 93 students participated in the study for a response rate of 18.2%. Questions were piloted among eight medical students, with modifications made in response to feedback. Participants were recruited to participate in an online survey via social media. Results: Within our sample, the most popular background instrument was piano (58.5%) and voice (50.0%). Of those who responded, most preferred to perform alone (85.7%) or in small groups (51.4%). 78.8% of respondents agreed that music was essential to their wellbeing. Only 62.5% of the respondents with musical backgrounds still play music or sing. Of those who no longer play music, 90.5% of respondents reported time constraint as the limiting factor, followed by lack of access to instruments (42.9%). Conclusion: This study suggests there are diverse music backgrounds and interests amongst the medical student population. Although most participants believed music was a form of stress relief, undergraduate medical training demands impose time restrictions on student engagement. Investments in music programs that enable adequate involvement and meet student demand have the potential to improve medical student engagement with the arts, alleviate stress, and may even lead to stronger/more empathetic physicians. Periodic needs assessments may be a powerful tool to better align programming to address student desires and reduce barriers.

Emergency Medicine Shift Factors Causing the Most Stress Among Emergency Medicine Residents

Introduction: Past studies demonstrate that stress and anxiety affect emergency medicine physicians, but the causal factors identified are usually from sources outside the work shift. We attempt to show the relationship between intrinsic factors of a work shift and anxiety perceived by residents, while also examining differing gender responses. Methods: In 2018, a cross-sectional survey of emergency medicine residents in the United States was distributed anonymously through the Emergency Medicine Residents Association. The survey consisted of demographic questions, novel questions identifying intrinsic factors, and the Generalized Anxiety Disorder 7-item (GAD-7) scale. Spearman correlation, independent t-test, and multivariate analysis of variance were performed. Results: Data from 573 residents found several stressful factors: working with a nurse perceived to be inefficient, working with no inpatient beds available, and working with a colleague perceived to be inefficient. The majority of respondents reported some general anxiety on the GAD-7 assessment. There was no difference on anxiety level as a function of year of residency (p > .05). There was a significant gender difference on anxiety level, t(571) = -4.8689, p < .05, where male residents reported lower anxiety levels (mean=5.15) as compared to female residents (mean=7.02). Lastly, post-hoc analyses revealed that male and female respondents reported differing levels of stress in response to several intrinsic stress factors. Conclusion: We identified several intrinsic factors during a shift that contribute to resident anxiety and analyzed differing gender responses to these factors; this may provide a framework for residency programs to minimize stressors in the future.

Wellness Review 2021, Part 1

Introduction: This article presents a curated selection of the wellness literature from January to June of 2021. JWellness editors offer a summary of recent publications within the wellness domain to seek an understanding of both burnout prevention and, more importantly, thriving in the medical profession. Methods: For the interval of Jan 1 to June 30, 2021, a UofL librarian queried PubMed for empirical research studies, review articles, and editorials related to healthcare professional wellness. Excluding papers related to COVID-19 (due to extensive prior coverage) and editorials/commentaries, the editors narrowed to 43 articles (systematic reviews, meta-analyses, general reviews, and clinical trials) for this review. Literature in Review: Six chief themes emerged: general wellness / burnout, technology, training, nursing professional wellness, mindfulness and resilience, and physician specialty-specific considerations. We note the predominance of descriptive articles, though this round included more clinical trials and reviews of clinical trials. Overall quality of evidence remains low, however the conglomerate multinational dataset is expanding rapidly. Innovations in electronic documentation, early educational interventions, and diverse studies from various medical specialties converge to provide insight into a state of thriving among healthcare professionals. Conclusion: Current literature into healthcare professional wellness continues to describe burnout, but increasingly includes dedicated wellness interventions. Resilience and mindfulness training work, but system level interventions must accompany efforts. All medical specialties are affected, and the continuing conversation should include healthcare executives and other leadership.

The Words We Use, the Actions We Take, and the Perceptions We Hold: First-step assessments to inform wellness curricula and burnout prevention programming

Introduction: In response to concerns about burnout, many medical schools have been initiating wellness curricula and programming. A key to the success of these efforts is having engagement from targeted audiences. Gathering input from these groups regarding preferred lexicon, wellness actions, and perceptions of judgement or guilt around such actions can help in developing and promoting such curricular and programmatic offerings. Engagement is especially important when it comes to the predictors of burnout (e.g., self-care, self-compassion, and emotional self-disclosure). Methods: Utilizing a focus-group methodology as a preliminary step, medical school faculty and students discussed terms regarding burnout predictors. Thematic analysis using grounded theory was used to analyze transcriptions with the generated preferred terms being incorporated into a follow-up survey. Surveys were completed by 23 faculty, 65 students, 23 residents, and 124 staff (n = 235). The survey asked for ranked preferences of lexicon terms, ratings of engagement and importance around wellness actions, perceptions of judgement and guilt around engaging in self-care, and disengagement and exhaustion via the Oldenburg Burnout Inventory. Results: Overall, results revealed a preference for alternative language (i.e., “personal well-being” (p < 0.001), “being kind to yourself” (p < 0.001), “sharing your feelings” (p < 0.001)) compared to phrases commonly used in the wellness literature (i.e., self-care, self-compassion, and emotional self-disclosure). Engagement in self-care (p < 0.001), and self-compassion actions (p = 0.001) were inversely correlated with burnout, while perceptions of being judged (p < 0.001) and feeling guilty for self-care (p < 0.001) were positively correlated with burnout. Conclusion: Incorporating preferred lexicon terms and mitigation factors (correlating with the reduction of burnout) into wellness curricular development is encouraged as a valuable initial step for medical schools and organizations as they reach out to their intended audiences.