PHYSICIAN WELLNESS/RESIDENTS’ PERSPECTIVE
Strategies to Enhance Wellness in Emergency Medicine Residency Training Programs Shana Ross, DO, MSc*; E. Liang Liu, MD; Christian Rose, MD; Adaira Chou, MD; Nicole Battaglioli, MD *Corresponding Author. E-mail: [email protected], Twitter: @ShanaElisha.
0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.07.007
[Ann Emerg Med. 2017;-:1-7.] INTRODUCTION AND SIGNIFICANCE Burnout syndrome was defined as a separate entity from depression in the 1970s because it was noted to primarily affect an individual’s relationship to work. It is defined as the triad of emotional exhaustion, depersonalization, and a sense of low personal accomplishment.1 Almost half of physicians report burnout, with emergency physicians having the highest rate of burnout, at almost 70%.2 Emergency physician burnout causes self-reported increases in door-tophysician times, reduced communication of pertinent information with health care teams, and reduced direct communication with patients.1 Although burnout is only one metric for physician wellness, broad implications for health care systems and society as a whole.3 In addition to burnout and career dissatisfaction, physicians are also at higher risk for depression and mental illness.4,5 Physician suicide rates are estimated at approximately 400 physicians per year, or the equivalent of 3 to 4 medical school classes in the United States annually.4 On average, physicians are twice as likely as the general population to commit suicide.6 Specifically, female physicians and young physicians are affected most by mental illness and suicidal thoughts.1,7 A 2015 metaanalysis revealed that a staggering 20% to 43% of residents at any given time are facing depression or associated symptoms.8 Physician wellness is important at all stages of training, and resident depression and suicide has recently gained national attention as a critical problem in residencies across all specialties.9,10 Despite this, many emergency medicine residencies have little to no devoted time to address wellness in their educational curricula. Residencies have begun to implement wellness activities, which range from rotations in wellness and leadership to wellness retreats, but so far those efforts have been insufficient to stave off the presence of depression and burnout in residency Volume
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training.11-13 Here we discuss strategies to improve wellness during emergency medicine residency. Strategies include both interventions at the level of the individual resident and the emergency medicine residency training community. WELLNESS STRATEGIES Strategies for Residents Residency wellness starts with the individual resident. Table 1 outlines specific strategies for the individual. Sleep, exercise, and nutrition. Sleep loss can have negative effects on multiple dimensions of a resident’s professional and personal life, including learning and cognition, professionalism, task performance, and personal relationships.14 However, because of the nature of residency training, residents have little control over their sleep patterns and may become dependent on sleep aids.15 Some physicians suggest maintaining anchor sleep to provide a guidepost for the body clock.16 Sleeping close to the beginning and the end of the normal sleep period maintains an “anchor” to one’s circadian rhythm. Eliminating the true overnight shift in favor of “casino shifts” can help to achieve a more ideal schedule and allow more circadian sleep, with some providers working later (6 PM to 3 AM) and others working earlier (3 AM to noon).17 Additionally, chronobiologists recommend clockwise shift rotation to permit circadian stabilization. The human circadian rhythm is a little greater than 25 hours, meaning that it is easier to delay sleep than to advance it.18 Emergency medicine residents often have various shifts in their block schedule. When schedules are available, residents should analyze their pattern of shifts and evaluate for potential violations to the circadian rhythm and be cognizant of this as well when switching shifts. Long shifts and irregular sleep schedules may make exercise a low priority; however, exercise is one of the only Annals of Emergency Medicine 1
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Enhancing Wellness in Emergency Medicine Residency Programs Table 1. Examples of wellness strategies for emergency medicine residents at the individual level. Area of Focus
Examples
Sleep Exercise Nutrition
Maintain “anchor sleep” Watch for circadian violations in shift schedule Organize team sports (eg, soccer, kickball, volleyball, flag football) Form groups to go hiking or biking Group exercise classes (eg, cross-fit or circuit) Spend 10 min a day being physically active Eat balanced meals and healthy snacks Minimize intake of simple sugars Pack meals for shifts that can be made in bulk and easily stored Take a break during shifts to eat a snack Sign up for meal preparation classes Provide healthy options in the resident lounge Join a food co-op market Sign up for a food delivery service Eat more meals at home or with others Avoid eating immediately before sleep Establish care Make routine doctor’s appointments Avoid self-diagnosis and self-treatment Know available mental health and counseling resources Establish work-related boundaries Set aside an hour each day to destress and decompress Set aside a block of scheduled time for personal use Spend some technology-free time each day Plan vacations to be work free Devote and prioritize time to family and friends Take time for personal reflection Learn meditation Join or form a support group Write in journal daily Incorporate tools or apps such as Insight Timer, Aura, Stop, Breathe & Think, and Headspace Spend 2 min a day writing gratitude-based e-mail Reflect on 3 things a day one is grateful for Notice and vocalize when others have helped you After each shift, reflect on the meaningful effect you have had
Personal health
Life outside of residency
Mindfulness
Positivity
interventions shown to improve rejuvenative sleep, reduce stress, and treat and prevent depression.19-21 Physicians, residents, and medical students who participate in regular exercise are sick less frequently and are better equipped to handle the stress of their schedules.22 Exercise has shown to improve memory and cognitive function.23 A goal of at least 150 minutes per week of moderate-intensity aerobic exercise is considered ideal for overall health, but if time is restricted, 75 minutes per week of high- or vigorousintensity training may be more likely to fit into timelimited schedules, with similar benefit.24 Variables in schedules, sleep, and exercise can lead residents to develop poor eating habits, which can lead to a pattern of poor food choices.25 Balanced meals and healthy snacking are essential to maintain energy without peaks and troughs in glucose and insulin levels, which can cause 2 Annals of Emergency Medicine
feelings of fatigue and concentration difficulty during work. Some simple mitigating tips to promote healthier choices include minimizing intake of simple sugars, having healthier choices available in the cafeteria, or packing meals from home.26 Taking even a 15-minute break to eat on shift can offer an opportunity to refuel and improve efficiency.27 Departments might also use meal funds or encourage faculty to bring in healthy snacks for the residents in the emergency department (ED) instead of the frequently found chips and candy. Personal health. Physicians are no more immune to infections or injury than the general population and should continue to seek regular care, including routine preventive care and mental health counseling if needed. One study showed that 71% of physicians surveyed were too embarrassed to consult another physician for evaluation and treatment.28,29 In addition, physicians who experience depression are less likely to seek help, disclose their level of mental stress, or consider counseling. Too often physicians try to self-diagnose and self-treat, which can be potentially dangerous, especially if treatment involves alcohol and drugs.30 Some health systems have started requiring that physicians establish a primary care physician and receive annual physicals to ensure that their physicians are receiving much-needed preventive care.31 Physicians must be encouraged to seek help and allow someone else to manage their physical and mental health, but must also budget the time to do so. Life outside of residency. It is important for emergency medicine residents to consider work-life balance and to establish boundaries. High-status, professional jobs can lead to blurred boundaries between work and home. Contributing factors include increased time demands, autonomy, excessive work pressures, lack of schedule control, and decisionmaking authority.32 Mental health professionals suggest that individuals with stressful jobs set aside an hour each day devoid of work-related activities to refocus and decompress. Individuals who are unable to devote this time to decompression because of time constraints outside of residency can implement other techniques to establish work-home boundaries. Such strategies include prioritizing time for social or family obligations over work demands, scaling back on all obligations, and time blocking, which focuses on scheduling dedicated blocks of time to nonwork and nonclinical tasks.32 Striving to finish charting on shift and dedicating time to address e-mail and administrative duties while in the hospital also helps more clearly separate the line between work and home. Resident physicians should consider using vacation time as a work-free opportunity for rest, relaxation, and reconnecting with friends and family. Volume
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Individuals who have developed a balance between work and home life are more likely to stave off burnout and remain resilient.33 Developing strong ties to friends and family helps build a support network during residency and prevents social isolation during difficult times. Mindfulness. Emergency medicine residency training by nature is stressful, which can plague one’s training experience. Mindfulness is a technique used to reflect on the present situation while acknowledging and accepting one’s feelings, thoughts, and physical being.34 By developing personal awareness, whether in the form of personal reflection, meditation, or participation in debriefings and support groups, individuals can become more aware of their own feelings and better identify when to seek help.34 One may find that during a shift, the seemingly unending demands on one’s time and attention result in compassion attrition. Reflecting for just a moment can help reorient the individual to focus on what is important. Positivity. A culture of positive thinking is paramount to wellness. It may be easy for residents to consider themselves a “black cloud” and to perceive their workloads to be heavier than that of other residents, even though studies have disproved this point.35 Residents should be encouraged and taught to reflect on negative experiences in a more positive way. By noticing and vocalizing when others performed well while avoiding self-criticism, individuals can increase their positivity ratio. A ratio of positive emotions to negative emotions of at least 3:1 is the tipping point to starting to experience increased resilience and happiness.36 Studies show that highly effective teams with positivity ratios greater than 3:1 were more open to new ideas, more interconnected among team members, more successful, and more resilient to adverse outcomes.37 Spending just 2 minutes a day reflecting, composing gratitude-based e-mail, or journaling with a focus on gratitude leads to greater happiness and professional success.38 Physicians’ taking a few minutes after each ED shift to think about the remarkable effect they have in their patients’ lives has been shown to improve short-term stress and feelings of burnout.37 Although the argument can be made that there is insufficient time for all of these exercises on shift, the reality is that replacing the time spent venting during a difficult shift with minutes of positivity can significantly change one’s mind-set for the better. Strategies for the Emergency Medicine Residency Training Community Creating and fostering wellness must be a priority for the emergency medicine training community. Although personal wellness and life outside of work are important, Volume
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finding fulfillment through work and establishing connections with colleagues and patients are equally vital in maintaining individual resilience. Residency training programs play a critical role in creating a healthy and supportive training environment and building a resident’s foundation for lifelong well-being. There is, however, no “one size fits all” solution, initiative, program, or curriculum to optimize resident wellness. Existing budgets, infrastructure, and human resources affect implementation decisions. Residency leadership is encouraged to construct a curriculum that complements their program’s needs. Table 2 outlines program-level initiatives and strategies. Wellness committee and curriculum. Each emergency medicine program should have a wellness committee composed of select resident and faculty members of the residency leadership. This committee should routinely measure, analyze, disclose, and address wellness issues identified by the program’s residents.39-41 Wellness topics can be built longitudinally into residency didactics, providing a low-cost introduction to well-being basics. In addition, residents have significant time constraints; therefore, building wellness into already budgeted didactic time can help involve residents who may not have time otherwise. Residency leadership is encouraged to construct a curriculum that complements their program’s needs. Mentorship. A formal faculty mentorship program and peer mentorship through “residency families” can help guide residents throughout their training. Residency families can provide an informal structure for residents to support one another and discuss wellness concerns as they arise.42,43 Residency families may consist of a single resident from each training year, who together organize informal events to keep track of one another during the year. These families continue to grow each year as the senior resident graduates and can provide postresidency insights. Effective mentorship enhances resident reflection, allowing him or her to critically evaluate his or her own performance, build confidence, improve psychosocial health, and strengthen his or her resilience.42,43 Because mentorship is an acquired skill, programs should provide training to mentors on delivering professional and psychosocial support.42 Programs can also facilitate mentorship by scheduling residency families to work together on shift. Meaningful service. Studies have identified loss of autonomy, inability to control the practice environment, and inefficient use of time because of administrative requirements as contributors to burnout.44 With the many administrative requirements of training, residents Annals of Emergency Medicine 3
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Enhancing Wellness in Emergency Medicine Residency Programs Table 2. Examples of wellness strategies for the residency training community. Area of Focus Wellness committee and curriculum
Mentorship
Meaningful service
Feedback
Debriefing
Awareness
Tribalism
Examples Develop a wellness committee composed of select resident and faculty champions Garner institutional and departmental support for resident wellness Develop and integrate a wellness curriculum Host mindfulness sessions Engage in group reflection Organize small group discussions on wellness Develop a means to evaluate success and needs of the program Schedule wellness events (eg, volunteer events, potlucks, local races, sporting event outings) Establish a formal mentorship program for residents (eg, resident families) Showcase faculty interests to facilitate residents seeking mentorship Develop an alumni base Reduce administrative requirements Refocus residents on educational opportunities Minimize influence of electronic medical record systems (eg, dictation services, software, scribes, smart texts) Provide residents with strategies to manage administrative demands Give residents perspective on the motivation of certain administrative tasks and how it applies to future employment Develop a program culture of recognition, positive reflection, and gratitude Publicly celebrate resident success (informal announcements at residency conference or formal awards such as “resident of the month” or “great saves” awards) Establish a hospital culture of respect and positivity across specialties Train educators to provide respectful, constructive, and effective feedback Train residents about how to receive feedback Provide opportunity for transparent and comprehensive resident evaluation Provide debriefing with the entire care team immediately after a difficult case Establish a culture normalizing difficult emotions and offer assistance in the form of informal support or formal counseling Schedule monthly debriefing sessions to discuss cases from the month Train residents and faculty to be watchful of subtle changes in resident behavior (eg, the “difficult resident,” the chronically late resident) Train residents to self-identify Reduce barriers to counseling Establish a protocol for residency leadership follow-up of at-risk residents Normalize discussions of stress, burnout, and mental health Coordinate opportunities for reflective writing exercises Incorporate wellness and burnout screening surveys (eg, Maslach Burnout Inventory) Encourage and highlight positive interactions with staff and other services Organize interdisciplinary events Use a third-party mediator when needed Recognize that all parties are working toward common goals Encourage faculty to become role models for positive relationships with other services
may feel overburdened by e-mail, paperwork, and other responsibilities that do not directly contribute to education or professional development. Programs across specialties struggle with this balance between education and service needs.45 Although the priority during residency training should preferably be on education and not on administrative tasks, the reality of the job demands a balance between the two. Studies have shown that pursuit and achievement of goals, feelings of competence, and clinical mastery improve resident well-being.46 Meaningful service, gratitude, recognition, and positive reflection can improve resident happiness, health, and sleep habits.47 One particular example of how wellness may be affected by issues relating to service versus education is in documentation using electronic medical records. Surveys 4 Annals of Emergency Medicine
indicate that physicians who are more engaged in their electronic medical records systems are less satisfied with their clinical experience and are at increased risk for burnout.48 Although electronic medical records have many benefits for quality improvement, billing, and patient safety, an unforeseen adverse effect is the pressure on residents to complete documentation from home during nonscheduled hours. As an example of striking a balance between education and service, providing residents with the use of dictation services and software, scribes, and smart texts that make electronic medical record navigation more efficient and less cumbersome could be beneficial. Studies have shown that scribe use leads to a decrease in the extra time providers spend charting.49 Providing residents with resources and guidance on how to navigate the electronic medical records and targeted strategies to help them Volume
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manage daily administrative demands may help maintain better work-life balance. Feedback. Throughout residency training, professional development requires effective and constructive feedback. Factors that make feedback inefficient include feedback that is more skewed toward neutral or positive, with little attention paid to needed improvements; and the use of incorrect or inaccurate measures of success.50,51 Additionally, the sporadic nature of emergency medicine shifts in which residents work with various attending physicians makes reinforcement of feedback difficult. Poorly implemented or disrespectful feedback is detrimental to resident wellness, and receptiveness to feedback depends on the environment and the context.50 Providing effective feedback is a learnable skill, and resident development is enhanced when educators are trained to provide constructive and effective feedback regularly.52-54 Both educators and residents may benefit from learning the skills of effectively giving and being receptive to feedback.50 Although current literature lacks direct links between effective feedback and wellness, feedback when implemented correctly not only improves clinical performance but also is important in refining the resident’s ability to self-evaluate and self-regulate. The affirmation of skills and competence gained through positive feedback helps residents build confidence essential for independent practice.50,55 Debriefing. Emergency medicine residents are often faced with tragic or difficult cases, but are not always taught the coping skills needed to process these events, making them vulnerable to mental distress. How a physician deals with patient death and illness can negatively affect wellness.31 By gathering the care team to debrief after a difficult case, each team member has an opportunity to reflect and process some of his or her emotions, review the facts of the case, and obtain closure.56 Team members should be reminded that they are not alone in their emotions and do not have to address them alone. In addition to debriefing sessions after a difficult case, it may also be helpful to hold set monthly debriefing sessions for residents to reflect and discuss their cases from that month. This process allows residents and faculty to share their approaches and mind-set to remain resilient in these scenarios. Awareness. Residents may experience symptoms of depression or deal with feelings of inadequacy and selfdoubt during residency. Residents at risk can often be “high-functioning,” making the signs and manifestations of mood disorders difficult to identify. Residency leadership, faculty, and fellow residents should be Volume
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watchful of subtle changes in resident behavior such as the resident who becomes difficult or absent during the course of residency training. Because identification of a resident in trouble may be difficult, each resident should be given the tools needed to self-identify. Counseling services should be available and easily accessible. Programs should minimize the barriers of cost, time, and stigma so that residents will feel more empowered to seek counseling services.57 Both residents and residency leadership should be well versed in the process to obtain counseling. Merely directing a resident in trouble toward generic, institutional counseling may feel like cursory dismissal. Physicians in general are unlikely to be transparent about their mental health and typically fail to seek treatment themselves; residency leadership can and should actively participate in ensuring that residents are receiving the help they need. Opening and maintaining a dialogue between residents and faculty about stress, burnout, and mental health is critical to help normalize these issues and create a culture that is expecting and accepting of resident struggles. Tribalism. Various aspects of wellness in emergency medicine rely heavily on the prevailing social culture in the ED and in the general house of medicine. Some of this culture revolves around tensions between groups, such as nurses versus physicians, surgery versus medicine, and orthopedics versus emergency medicine. Individuals who work in an ED often form a bonded and cohesive “tribe,” which can be a benefit when they battle the stressors of a busy ED or care for the critically ill. However, this sense of tribalism can create a system of cohesive groups or tribes that believe they are pitted against one another.58 The potential cost of such a strongly bonded tribe is that individuals in the ED may believe that they are constantly facing opposition. Groups must realize that they are actually working toward a common goal: taking care of a mutual patient.59 Faculty should lead by example and encourage positive relations with other services and staff. Focusing on shared values and goals, such as high-quality, patient-centered care, can help unify providers into a more inclusive tribe encompassing the entire house of medicine. CONCLUSION Burnout changes the way a physician thinks, acts, and cares for patients.2 This applies as well to resident trainees. To provide quality care for patients, residents need to be aware of personal and programmatic wellness strategies. For the resident, exercise, sleep, and nutrition can improve individual performance. Mindfulness of one’s physical and emotional state can help to identify weak areas in one’s Annals of Emergency Medicine 5
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life. Through the support of the residency training community, residents can foster resilience and prevent burnout. The wellness committee within a residency functions as a mindful eye to support individuals who may be experiencing poor practices, or who may need additional support from peers. Bringing together the emergency medicine community, as well as the other Graduate Medical Education programs in the house of medicine, through teamwork and awareness will foster tighter bonds and create a more resilient group of health care providers for the future. The authors would like to thank Michelle Lin, MD, Christopher Doty, MD, and the Chief Resident Incubator for their support. Supervising editors: Tarak Trivedi, MD; Jason D. Heiner, MD Author affiliations: From the Emergency Medicine Department, University of Illinois Hospital and Health Sciences System, Chicago, IL (Ross); the Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX (Liu); the Emergency Medicine Department, University of California, San Francisco, CA (Rose); the Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA (Chou); and the Department of Emergency Medicine, Mayo Clinic Health System, Rochester, MN (Battaglioli). Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. REFERENCES 1. Shanafelt T, Sloan J, Habermann T. The well-being of physicians. Am J Med. 2003;114:513-519. 2. Shanafelt T, Boone S, Tan L, et al. Burnout and satisfaction with worklife balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377-1385. 3. Lu D, Dresden S, McCloskey C, et al. Impact of burnout on selfreported patient care among emergency physicians. West J Emerg Med. 2015;16:996-1001. 4. Ungerleider N. The hidden epidemic of doctor suicides. Available at: http://www.fastcompany.com/3056015/the-hidden-epidemic-ofdoctor-suicides. Accessed May 18, 2017. 5. Schernhammer E, Colditz G. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161:2295-2302.
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6. Council on Scientific Affairs. Results and implications of the AMA-APA Physician Mortality Project, stage II. JAMA. 1987;257:2949-2953. 7. Gy}orffy Z, Dweik D, Girasek E. Workload, mental health and burnout indicators among female physicians. Hum Resour Health. 2016;14:12. 8. Mata D, Ramos M, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians. JAMA. 2015;314:2373-2383. 9. Sinha P. Why do doctors commit suicide? Available at: http://www. nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide. html. Accessed July 4, 2016. 10. Carroll A. Silence is the enemy for doctors who have depression. Available at: http://www.nytimes.com/2016/01/12/upshot/silenceis-the-enemy-for-doctors-who-have-depression.html. Accessed July 8, 2016. 11. Runyan C, Savageau J, Potts S, et al. Impact of a family medicine resident wellness curriculum: a feasibility study. Med Educ Online. 2016;21:30648. 12. Linzer M, Levine R, Meltzer D, et al. 10 Bold steps to prevent burnout in general internal medicine. J Gen Intern Med. 2013;29:18-20. 13. Wei J, Rosen P, Greenspan J. Physician burnout: what can chairs, chiefs, and institutions do? J Pediatr. 2016;175:5-6. 14. Papp K, Stoller E, Sage P, et al. The effects of sleep loss and fatigue on resident-physicians: a multi-institutional, mixed-method study. Acad Med. 2004;79:394-406. 15. Handel D, Raja A, Lindsell C. The use of sleep aids among emergency medicine residents: a web based survey. BMC Health Serv Res. 2006;6:136. 16. Whitehead D, Thomas H, Slapper D. A rational approach to shift work in emergency medicine. Ann Emerg Med. 1992;21:1250-1258. 17. Croskerry P. From mindless to mindful practice—cognitive bias and clinical decision making. N Engl J Med. 2013;368:2445-2448. 18. American College of Emergency Physicians. How to design the optimal schedule for working shifts. Available at: https://www.acep.org/ content.aspx?id¼22728. Accessed April 10, 2017. 19. Brand S, Gerber M, Beck J, et al. High exercise levels are related to favorable sleep patterns and psychological functioning in adolescents: a comparison of athletes and controls. J Adolesc Health. 2010;46:133-141. 20. Salmon P. Effects of physical exercise on anxiety, depression, and sensitivity to stress. Clin Psychol Rev. 2001;21:33-61. 21. Mead G, Morley W, Campbell P, et al. Exercise for depression. Cochrane Database Sys Rev. 2008;4:CD004366. 22. Williams A, Williams C, Cronk N, et al. Understanding the exercise habits of residents and attending physicians: a mixed methodology study. Fam Med. 2017;47:118-123. 23. McMorris T, Tomporowski P, Audiffren M. Exercise and Cognitive Function. Hoboken, NJ: Wiley; 2009. 24. Løppenthin K, Esbensen B, Jennum P, et al. Effect of intermittent aerobic exercise on sleep quality and sleep disturbances in patients with rheumatoid arthritis—design of a randomized controlled trial. BMC Musculoskelet Disord. 2014;15:49. 25. Mota M, De-Souza D, Rossato L, et al. Dietary patterns, metabolic markers and subjective sleep measures in resident physicians. Chronobiol Int. 2013;30:1032-1041. 26. Shanafelt T, Oreskovich M, Dyrbye L. Avoiding burnout: the personal health habits and wellness practices of US surgeons. J Vasc Surg. 2012;56:875-876. 27. Ariga A, Lleras A. Brief and rare mental “breaks” keep you focused: deactivation and reactivation of task goals preempt vigilance decrements. Cognition. 2011;118:439-443. 28. Davidson S, Schattner P. Doctors’ health-seeking behaviour: a questionnaire survey. Med J Aust. 2003;179:302-305. 29. Schwenk T, Davis L, Wimsatt L. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010;304:1181-1190. 30. Uallachain G. Attitudes towards self-health care: a survey of GP trainees. Ir Med J. 2017;100:489-491.
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31. West C, Dyrbye L, Rabatin J, et al. Intervention to promote physician well-being, job satisfaction, and professionalism. JAMA Intern Med. 2014;174:527-533. 32. Moen P, Lam J, Ammons S, et al. Time work by overworked professionals. Work Occup. 2013;40:79-114. 33. Kim M, Windsor C. Resilience and work-life balance in first-line nurse manager. Asian Nurs Res. 2015;9:21-27. 34. Rabow M, McPhee S. Doctoring to heal: fostering well-being among physicians through personal reflection. West J Med. 2001;174: 66-69. 35. Tanz R, Charrow J. Black clouds. Am J Dis Child. 1993;147: 579-584. 36. Mishra A. Positivity, by Barbara Fredrickson. The Journal of Positive Psychology. 2009;4:578-580. 37. McCue J. A stress management workshop improves residents’ coping skills. Arch Intern Med. 1991;151:2273-2277. 38. Achor S. The Happiness Advantage. London, England: Virgin; 2011. 39. Eckleberry-Hunt J, Van Dyke A, Lick D, et al. Changing the conversation from burnout to wellness: physician well-being in residency training programs. J Grad Med Educ. 2009;1: 225-230. 40. Keim S, Mays M, Williams J, et al. Measuring wellness among resident physicians. Med Teach. 2006;28:370-374. 41. Okanlawon T. Physician wellness: preventing resident and fellow burnout—STEPS Forward. Available at: https://www.stepsforward.org/ modules/physician-wellness. Accessed August 5, 2016. 42. McKenna K, Hashimoto D, Maguire M, et al. The missing link. Acad Med. 2016;91:1197-1199. 43. Davis O, Nakamura J. A proposed model for an optimal mentoring environment for medical residents: a literature review. Acad Med. 2010;85:1060-1066. 44. Shanafelt T. Enhancing meaning in work. JAMA. 2009;302:1338-13340. 45. Galvin S, Buys E. Resident perceptions of service versus clinical education. J Grad Med Educ. 2012;4:472-478. 46. Raj K. Well-being in residency: a systematic review. J Grad Med Educ. 2016;8:674-684.
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47. Emmons R, McCullough M. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. J Pers Soc Psychol. 2003;84:377-389. 48. Shanafelt T, Dyrbye L, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-848. 49. Allen B, Banapoor B, Weeks E, et al. An assessment of emergency department throughput and provider satisfaction after the implementation of a scribe program. Adv Emerg Med. 2014;2014:1-7. 50. Bing-You R. Why medical educators may be failing at feedback. JAMA. 2009;302:1330-1331. 51. Yarris L, Linden J, Gene Hern H, et al. Attending and resident satisfaction with feedback in the emergency department. Acad Emerg Med. 2009;16:S76-S81. 52. Ende J. Feedback in clinical medical education. JAMA. 1983;250:777-781. 53. Wilkinson S, Couldry R, Phillips H, et al. Preceptor development: providing effective feedback. Hosp Pharm. 2013;48:26-32. 54. Shrivasta S, Shrivasta P, Ramasamy J. Effective feedback: an indispensable tool for improvement in quality of medical education. Journal of Pedagogic Development. 2014;4:12-20. 55. Weinstein D. Feedback in clinical education. Acad Med. 2015;90:559-561. 56. Chung A. Wellness and resiliency during residency: debriefing critical incidents and podcast. Available at: https://www.aliem.com/2017/ 01/wellness-resiliency-debriefing-critical-incidents/. Accessed April 13, 2017. 57. Ey S, Moffit M, Kinzie J, et al. “If you build it, they will come”: attitudes of medical residents and fellows about seeking services in a resident wellness program. J Grad Med Educ. 2013;5:486-492. 58. Weller J. Shedding new light on tribalism in health care. Med Educ. 2012;46:134-136. 59. Forrest C. How to build trust and fight tribalism to stimulate innovation—TechRepublic. Available at: http://www.techrepublic.com/ article/how-to-build-trust-and-fight-tribalism-to-stimulate-innovation/. Accessed April 17, 2017.
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Strategies to Enhance Wellness in Emergency Medicine Residency Training Programs Shana Ross, DO, MSc*; E. Liang Liu, MD; Christian Rose, MD; Adaira Chou, MD; Nicole Battaglioli, MD *Corresponding Author. E-mail: [email protected], Twitter: @ShanaElisha.
0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.07.007
[Ann Emerg Med. 2017;-:1-7.] INTRODUCTION AND SIGNIFICANCE Burnout syndrome was defined as a separate entity from depression in the 1970s because it was noted to primarily affect an individual’s relationship to work. It is defined as the triad of emotional exhaustion, depersonalization, and a sense of low personal accomplishment.1 Almost half of physicians report burnout, with emergency physicians having the highest rate of burnout, at almost 70%.2 Emergency physician burnout causes self-reported increases in door-tophysician times, reduced communication of pertinent information with health care teams, and reduced direct communication with patients.1 Although burnout is only one metric for physician wellness, broad implications for health care systems and society as a whole.3 In addition to burnout and career dissatisfaction, physicians are also at higher risk for depression and mental illness.4,5 Physician suicide rates are estimated at approximately 400 physicians per year, or the equivalent of 3 to 4 medical school classes in the United States annually.4 On average, physicians are twice as likely as the general population to commit suicide.6 Specifically, female physicians and young physicians are affected most by mental illness and suicidal thoughts.1,7 A 2015 metaanalysis revealed that a staggering 20% to 43% of residents at any given time are facing depression or associated symptoms.8 Physician wellness is important at all stages of training, and resident depression and suicide has recently gained national attention as a critical problem in residencies across all specialties.9,10 Despite this, many emergency medicine residencies have little to no devoted time to address wellness in their educational curricula. Residencies have begun to implement wellness activities, which range from rotations in wellness and leadership to wellness retreats, but so far those efforts have been insufficient to stave off the presence of depression and burnout in residency Volume
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training.11-13 Here we discuss strategies to improve wellness during emergency medicine residency. Strategies include both interventions at the level of the individual resident and the emergency medicine residency training community. WELLNESS STRATEGIES Strategies for Residents Residency wellness starts with the individual resident. Table 1 outlines specific strategies for the individual. Sleep, exercise, and nutrition. Sleep loss can have negative effects on multiple dimensions of a resident’s professional and personal life, including learning and cognition, professionalism, task performance, and personal relationships.14 However, because of the nature of residency training, residents have little control over their sleep patterns and may become dependent on sleep aids.15 Some physicians suggest maintaining anchor sleep to provide a guidepost for the body clock.16 Sleeping close to the beginning and the end of the normal sleep period maintains an “anchor” to one’s circadian rhythm. Eliminating the true overnight shift in favor of “casino shifts” can help to achieve a more ideal schedule and allow more circadian sleep, with some providers working later (6 PM to 3 AM) and others working earlier (3 AM to noon).17 Additionally, chronobiologists recommend clockwise shift rotation to permit circadian stabilization. The human circadian rhythm is a little greater than 25 hours, meaning that it is easier to delay sleep than to advance it.18 Emergency medicine residents often have various shifts in their block schedule. When schedules are available, residents should analyze their pattern of shifts and evaluate for potential violations to the circadian rhythm and be cognizant of this as well when switching shifts. Long shifts and irregular sleep schedules may make exercise a low priority; however, exercise is one of the only Annals of Emergency Medicine 1
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Enhancing Wellness in Emergency Medicine Residency Programs Table 1. Examples of wellness strategies for emergency medicine residents at the individual level. Area of Focus
Examples
Sleep Exercise Nutrition
Maintain “anchor sleep” Watch for circadian violations in shift schedule Organize team sports (eg, soccer, kickball, volleyball, flag football) Form groups to go hiking or biking Group exercise classes (eg, cross-fit or circuit) Spend 10 min a day being physically active Eat balanced meals and healthy snacks Minimize intake of simple sugars Pack meals for shifts that can be made in bulk and easily stored Take a break during shifts to eat a snack Sign up for meal preparation classes Provide healthy options in the resident lounge Join a food co-op market Sign up for a food delivery service Eat more meals at home or with others Avoid eating immediately before sleep Establish care Make routine doctor’s appointments Avoid self-diagnosis and self-treatment Know available mental health and counseling resources Establish work-related boundaries Set aside an hour each day to destress and decompress Set aside a block of scheduled time for personal use Spend some technology-free time each day Plan vacations to be work free Devote and prioritize time to family and friends Take time for personal reflection Learn meditation Join or form a support group Write in journal daily Incorporate tools or apps such as Insight Timer, Aura, Stop, Breathe & Think, and Headspace Spend 2 min a day writing gratitude-based e-mail Reflect on 3 things a day one is grateful for Notice and vocalize when others have helped you After each shift, reflect on the meaningful effect you have had
Personal health
Life outside of residency
Mindfulness
Positivity
interventions shown to improve rejuvenative sleep, reduce stress, and treat and prevent depression.19-21 Physicians, residents, and medical students who participate in regular exercise are sick less frequently and are better equipped to handle the stress of their schedules.22 Exercise has shown to improve memory and cognitive function.23 A goal of at least 150 minutes per week of moderate-intensity aerobic exercise is considered ideal for overall health, but if time is restricted, 75 minutes per week of high- or vigorousintensity training may be more likely to fit into timelimited schedules, with similar benefit.24 Variables in schedules, sleep, and exercise can lead residents to develop poor eating habits, which can lead to a pattern of poor food choices.25 Balanced meals and healthy snacking are essential to maintain energy without peaks and troughs in glucose and insulin levels, which can cause 2 Annals of Emergency Medicine
feelings of fatigue and concentration difficulty during work. Some simple mitigating tips to promote healthier choices include minimizing intake of simple sugars, having healthier choices available in the cafeteria, or packing meals from home.26 Taking even a 15-minute break to eat on shift can offer an opportunity to refuel and improve efficiency.27 Departments might also use meal funds or encourage faculty to bring in healthy snacks for the residents in the emergency department (ED) instead of the frequently found chips and candy. Personal health. Physicians are no more immune to infections or injury than the general population and should continue to seek regular care, including routine preventive care and mental health counseling if needed. One study showed that 71% of physicians surveyed were too embarrassed to consult another physician for evaluation and treatment.28,29 In addition, physicians who experience depression are less likely to seek help, disclose their level of mental stress, or consider counseling. Too often physicians try to self-diagnose and self-treat, which can be potentially dangerous, especially if treatment involves alcohol and drugs.30 Some health systems have started requiring that physicians establish a primary care physician and receive annual physicals to ensure that their physicians are receiving much-needed preventive care.31 Physicians must be encouraged to seek help and allow someone else to manage their physical and mental health, but must also budget the time to do so. Life outside of residency. It is important for emergency medicine residents to consider work-life balance and to establish boundaries. High-status, professional jobs can lead to blurred boundaries between work and home. Contributing factors include increased time demands, autonomy, excessive work pressures, lack of schedule control, and decisionmaking authority.32 Mental health professionals suggest that individuals with stressful jobs set aside an hour each day devoid of work-related activities to refocus and decompress. Individuals who are unable to devote this time to decompression because of time constraints outside of residency can implement other techniques to establish work-home boundaries. Such strategies include prioritizing time for social or family obligations over work demands, scaling back on all obligations, and time blocking, which focuses on scheduling dedicated blocks of time to nonwork and nonclinical tasks.32 Striving to finish charting on shift and dedicating time to address e-mail and administrative duties while in the hospital also helps more clearly separate the line between work and home. Resident physicians should consider using vacation time as a work-free opportunity for rest, relaxation, and reconnecting with friends and family. Volume
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Individuals who have developed a balance between work and home life are more likely to stave off burnout and remain resilient.33 Developing strong ties to friends and family helps build a support network during residency and prevents social isolation during difficult times. Mindfulness. Emergency medicine residency training by nature is stressful, which can plague one’s training experience. Mindfulness is a technique used to reflect on the present situation while acknowledging and accepting one’s feelings, thoughts, and physical being.34 By developing personal awareness, whether in the form of personal reflection, meditation, or participation in debriefings and support groups, individuals can become more aware of their own feelings and better identify when to seek help.34 One may find that during a shift, the seemingly unending demands on one’s time and attention result in compassion attrition. Reflecting for just a moment can help reorient the individual to focus on what is important. Positivity. A culture of positive thinking is paramount to wellness. It may be easy for residents to consider themselves a “black cloud” and to perceive their workloads to be heavier than that of other residents, even though studies have disproved this point.35 Residents should be encouraged and taught to reflect on negative experiences in a more positive way. By noticing and vocalizing when others performed well while avoiding self-criticism, individuals can increase their positivity ratio. A ratio of positive emotions to negative emotions of at least 3:1 is the tipping point to starting to experience increased resilience and happiness.36 Studies show that highly effective teams with positivity ratios greater than 3:1 were more open to new ideas, more interconnected among team members, more successful, and more resilient to adverse outcomes.37 Spending just 2 minutes a day reflecting, composing gratitude-based e-mail, or journaling with a focus on gratitude leads to greater happiness and professional success.38 Physicians’ taking a few minutes after each ED shift to think about the remarkable effect they have in their patients’ lives has been shown to improve short-term stress and feelings of burnout.37 Although the argument can be made that there is insufficient time for all of these exercises on shift, the reality is that replacing the time spent venting during a difficult shift with minutes of positivity can significantly change one’s mind-set for the better. Strategies for the Emergency Medicine Residency Training Community Creating and fostering wellness must be a priority for the emergency medicine training community. Although personal wellness and life outside of work are important, Volume
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finding fulfillment through work and establishing connections with colleagues and patients are equally vital in maintaining individual resilience. Residency training programs play a critical role in creating a healthy and supportive training environment and building a resident’s foundation for lifelong well-being. There is, however, no “one size fits all” solution, initiative, program, or curriculum to optimize resident wellness. Existing budgets, infrastructure, and human resources affect implementation decisions. Residency leadership is encouraged to construct a curriculum that complements their program’s needs. Table 2 outlines program-level initiatives and strategies. Wellness committee and curriculum. Each emergency medicine program should have a wellness committee composed of select resident and faculty members of the residency leadership. This committee should routinely measure, analyze, disclose, and address wellness issues identified by the program’s residents.39-41 Wellness topics can be built longitudinally into residency didactics, providing a low-cost introduction to well-being basics. In addition, residents have significant time constraints; therefore, building wellness into already budgeted didactic time can help involve residents who may not have time otherwise. Residency leadership is encouraged to construct a curriculum that complements their program’s needs. Mentorship. A formal faculty mentorship program and peer mentorship through “residency families” can help guide residents throughout their training. Residency families can provide an informal structure for residents to support one another and discuss wellness concerns as they arise.42,43 Residency families may consist of a single resident from each training year, who together organize informal events to keep track of one another during the year. These families continue to grow each year as the senior resident graduates and can provide postresidency insights. Effective mentorship enhances resident reflection, allowing him or her to critically evaluate his or her own performance, build confidence, improve psychosocial health, and strengthen his or her resilience.42,43 Because mentorship is an acquired skill, programs should provide training to mentors on delivering professional and psychosocial support.42 Programs can also facilitate mentorship by scheduling residency families to work together on shift. Meaningful service. Studies have identified loss of autonomy, inability to control the practice environment, and inefficient use of time because of administrative requirements as contributors to burnout.44 With the many administrative requirements of training, residents Annals of Emergency Medicine 3
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Enhancing Wellness in Emergency Medicine Residency Programs Table 2. Examples of wellness strategies for the residency training community. Area of Focus Wellness committee and curriculum
Mentorship
Meaningful service
Feedback
Debriefing
Awareness
Tribalism
Examples Develop a wellness committee composed of select resident and faculty champions Garner institutional and departmental support for resident wellness Develop and integrate a wellness curriculum Host mindfulness sessions Engage in group reflection Organize small group discussions on wellness Develop a means to evaluate success and needs of the program Schedule wellness events (eg, volunteer events, potlucks, local races, sporting event outings) Establish a formal mentorship program for residents (eg, resident families) Showcase faculty interests to facilitate residents seeking mentorship Develop an alumni base Reduce administrative requirements Refocus residents on educational opportunities Minimize influence of electronic medical record systems (eg, dictation services, software, scribes, smart texts) Provide residents with strategies to manage administrative demands Give residents perspective on the motivation of certain administrative tasks and how it applies to future employment Develop a program culture of recognition, positive reflection, and gratitude Publicly celebrate resident success (informal announcements at residency conference or formal awards such as “resident of the month” or “great saves” awards) Establish a hospital culture of respect and positivity across specialties Train educators to provide respectful, constructive, and effective feedback Train residents about how to receive feedback Provide opportunity for transparent and comprehensive resident evaluation Provide debriefing with the entire care team immediately after a difficult case Establish a culture normalizing difficult emotions and offer assistance in the form of informal support or formal counseling Schedule monthly debriefing sessions to discuss cases from the month Train residents and faculty to be watchful of subtle changes in resident behavior (eg, the “difficult resident,” the chronically late resident) Train residents to self-identify Reduce barriers to counseling Establish a protocol for residency leadership follow-up of at-risk residents Normalize discussions of stress, burnout, and mental health Coordinate opportunities for reflective writing exercises Incorporate wellness and burnout screening surveys (eg, Maslach Burnout Inventory) Encourage and highlight positive interactions with staff and other services Organize interdisciplinary events Use a third-party mediator when needed Recognize that all parties are working toward common goals Encourage faculty to become role models for positive relationships with other services
may feel overburdened by e-mail, paperwork, and other responsibilities that do not directly contribute to education or professional development. Programs across specialties struggle with this balance between education and service needs.45 Although the priority during residency training should preferably be on education and not on administrative tasks, the reality of the job demands a balance between the two. Studies have shown that pursuit and achievement of goals, feelings of competence, and clinical mastery improve resident well-being.46 Meaningful service, gratitude, recognition, and positive reflection can improve resident happiness, health, and sleep habits.47 One particular example of how wellness may be affected by issues relating to service versus education is in documentation using electronic medical records. Surveys 4 Annals of Emergency Medicine
indicate that physicians who are more engaged in their electronic medical records systems are less satisfied with their clinical experience and are at increased risk for burnout.48 Although electronic medical records have many benefits for quality improvement, billing, and patient safety, an unforeseen adverse effect is the pressure on residents to complete documentation from home during nonscheduled hours. As an example of striking a balance between education and service, providing residents with the use of dictation services and software, scribes, and smart texts that make electronic medical record navigation more efficient and less cumbersome could be beneficial. Studies have shown that scribe use leads to a decrease in the extra time providers spend charting.49 Providing residents with resources and guidance on how to navigate the electronic medical records and targeted strategies to help them Volume
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manage daily administrative demands may help maintain better work-life balance. Feedback. Throughout residency training, professional development requires effective and constructive feedback. Factors that make feedback inefficient include feedback that is more skewed toward neutral or positive, with little attention paid to needed improvements; and the use of incorrect or inaccurate measures of success.50,51 Additionally, the sporadic nature of emergency medicine shifts in which residents work with various attending physicians makes reinforcement of feedback difficult. Poorly implemented or disrespectful feedback is detrimental to resident wellness, and receptiveness to feedback depends on the environment and the context.50 Providing effective feedback is a learnable skill, and resident development is enhanced when educators are trained to provide constructive and effective feedback regularly.52-54 Both educators and residents may benefit from learning the skills of effectively giving and being receptive to feedback.50 Although current literature lacks direct links between effective feedback and wellness, feedback when implemented correctly not only improves clinical performance but also is important in refining the resident’s ability to self-evaluate and self-regulate. The affirmation of skills and competence gained through positive feedback helps residents build confidence essential for independent practice.50,55 Debriefing. Emergency medicine residents are often faced with tragic or difficult cases, but are not always taught the coping skills needed to process these events, making them vulnerable to mental distress. How a physician deals with patient death and illness can negatively affect wellness.31 By gathering the care team to debrief after a difficult case, each team member has an opportunity to reflect and process some of his or her emotions, review the facts of the case, and obtain closure.56 Team members should be reminded that they are not alone in their emotions and do not have to address them alone. In addition to debriefing sessions after a difficult case, it may also be helpful to hold set monthly debriefing sessions for residents to reflect and discuss their cases from that month. This process allows residents and faculty to share their approaches and mind-set to remain resilient in these scenarios. Awareness. Residents may experience symptoms of depression or deal with feelings of inadequacy and selfdoubt during residency. Residents at risk can often be “high-functioning,” making the signs and manifestations of mood disorders difficult to identify. Residency leadership, faculty, and fellow residents should be Volume
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watchful of subtle changes in resident behavior such as the resident who becomes difficult or absent during the course of residency training. Because identification of a resident in trouble may be difficult, each resident should be given the tools needed to self-identify. Counseling services should be available and easily accessible. Programs should minimize the barriers of cost, time, and stigma so that residents will feel more empowered to seek counseling services.57 Both residents and residency leadership should be well versed in the process to obtain counseling. Merely directing a resident in trouble toward generic, institutional counseling may feel like cursory dismissal. Physicians in general are unlikely to be transparent about their mental health and typically fail to seek treatment themselves; residency leadership can and should actively participate in ensuring that residents are receiving the help they need. Opening and maintaining a dialogue between residents and faculty about stress, burnout, and mental health is critical to help normalize these issues and create a culture that is expecting and accepting of resident struggles. Tribalism. Various aspects of wellness in emergency medicine rely heavily on the prevailing social culture in the ED and in the general house of medicine. Some of this culture revolves around tensions between groups, such as nurses versus physicians, surgery versus medicine, and orthopedics versus emergency medicine. Individuals who work in an ED often form a bonded and cohesive “tribe,” which can be a benefit when they battle the stressors of a busy ED or care for the critically ill. However, this sense of tribalism can create a system of cohesive groups or tribes that believe they are pitted against one another.58 The potential cost of such a strongly bonded tribe is that individuals in the ED may believe that they are constantly facing opposition. Groups must realize that they are actually working toward a common goal: taking care of a mutual patient.59 Faculty should lead by example and encourage positive relations with other services and staff. Focusing on shared values and goals, such as high-quality, patient-centered care, can help unify providers into a more inclusive tribe encompassing the entire house of medicine. CONCLUSION Burnout changes the way a physician thinks, acts, and cares for patients.2 This applies as well to resident trainees. To provide quality care for patients, residents need to be aware of personal and programmatic wellness strategies. For the resident, exercise, sleep, and nutrition can improve individual performance. Mindfulness of one’s physical and emotional state can help to identify weak areas in one’s Annals of Emergency Medicine 5
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life. Through the support of the residency training community, residents can foster resilience and prevent burnout. The wellness committee within a residency functions as a mindful eye to support individuals who may be experiencing poor practices, or who may need additional support from peers. Bringing together the emergency medicine community, as well as the other Graduate Medical Education programs in the house of medicine, through teamwork and awareness will foster tighter bonds and create a more resilient group of health care providers for the future. The authors would like to thank Michelle Lin, MD, Christopher Doty, MD, and the Chief Resident Incubator for their support. Supervising editors: Tarak Trivedi, MD; Jason D. Heiner, MD Author affiliations: From the Emergency Medicine Department, University of Illinois Hospital and Health Sciences System, Chicago, IL (Ross); the Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX (Liu); the Emergency Medicine Department, University of California, San Francisco, CA (Rose); the Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA (Chou); and the Department of Emergency Medicine, Mayo Clinic Health System, Rochester, MN (Battaglioli). Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. REFERENCES 1. Shanafelt T, Sloan J, Habermann T. The well-being of physicians. Am J Med. 2003;114:513-519. 2. Shanafelt T, Boone S, Tan L, et al. Burnout and satisfaction with worklife balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377-1385. 3. Lu D, Dresden S, McCloskey C, et al. Impact of burnout on selfreported patient care among emergency physicians. West J Emerg Med. 2015;16:996-1001. 4. Ungerleider N. The hidden epidemic of doctor suicides. Available at: http://www.fastcompany.com/3056015/the-hidden-epidemic-ofdoctor-suicides. Accessed May 18, 2017. 5. Schernhammer E, Colditz G. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161:2295-2302.
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6. Council on Scientific Affairs. Results and implications of the AMA-APA Physician Mortality Project, stage II. JAMA. 1987;257:2949-2953. 7. Gy}orffy Z, Dweik D, Girasek E. Workload, mental health and burnout indicators among female physicians. Hum Resour Health. 2016;14:12. 8. Mata D, Ramos M, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians. JAMA. 2015;314:2373-2383. 9. Sinha P. Why do doctors commit suicide? Available at: http://www. nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide. html. Accessed July 4, 2016. 10. Carroll A. Silence is the enemy for doctors who have depression. Available at: http://www.nytimes.com/2016/01/12/upshot/silenceis-the-enemy-for-doctors-who-have-depression.html. Accessed July 8, 2016. 11. Runyan C, Savageau J, Potts S, et al. Impact of a family medicine resident wellness curriculum: a feasibility study. Med Educ Online. 2016;21:30648. 12. Linzer M, Levine R, Meltzer D, et al. 10 Bold steps to prevent burnout in general internal medicine. J Gen Intern Med. 2013;29:18-20. 13. Wei J, Rosen P, Greenspan J. Physician burnout: what can chairs, chiefs, and institutions do? J Pediatr. 2016;175:5-6. 14. Papp K, Stoller E, Sage P, et al. The effects of sleep loss and fatigue on resident-physicians: a multi-institutional, mixed-method study. Acad Med. 2004;79:394-406. 15. Handel D, Raja A, Lindsell C. The use of sleep aids among emergency medicine residents: a web based survey. BMC Health Serv Res. 2006;6:136. 16. Whitehead D, Thomas H, Slapper D. A rational approach to shift work in emergency medicine. Ann Emerg Med. 1992;21:1250-1258. 17. Croskerry P. From mindless to mindful practice—cognitive bias and clinical decision making. N Engl J Med. 2013;368:2445-2448. 18. American College of Emergency Physicians. How to design the optimal schedule for working shifts. Available at: https://www.acep.org/ content.aspx?id¼22728. Accessed April 10, 2017. 19. Brand S, Gerber M, Beck J, et al. High exercise levels are related to favorable sleep patterns and psychological functioning in adolescents: a comparison of athletes and controls. J Adolesc Health. 2010;46:133-141. 20. Salmon P. Effects of physical exercise on anxiety, depression, and sensitivity to stress. Clin Psychol Rev. 2001;21:33-61. 21. Mead G, Morley W, Campbell P, et al. Exercise for depression. Cochrane Database Sys Rev. 2008;4:CD004366. 22. Williams A, Williams C, Cronk N, et al. Understanding the exercise habits of residents and attending physicians: a mixed methodology study. Fam Med. 2017;47:118-123. 23. McMorris T, Tomporowski P, Audiffren M. Exercise and Cognitive Function. Hoboken, NJ: Wiley; 2009. 24. Løppenthin K, Esbensen B, Jennum P, et al. Effect of intermittent aerobic exercise on sleep quality and sleep disturbances in patients with rheumatoid arthritis—design of a randomized controlled trial. BMC Musculoskelet Disord. 2014;15:49. 25. Mota M, De-Souza D, Rossato L, et al. Dietary patterns, metabolic markers and subjective sleep measures in resident physicians. Chronobiol Int. 2013;30:1032-1041. 26. Shanafelt T, Oreskovich M, Dyrbye L. Avoiding burnout: the personal health habits and wellness practices of US surgeons. J Vasc Surg. 2012;56:875-876. 27. Ariga A, Lleras A. Brief and rare mental “breaks” keep you focused: deactivation and reactivation of task goals preempt vigilance decrements. Cognition. 2011;118:439-443. 28. Davidson S, Schattner P. Doctors’ health-seeking behaviour: a questionnaire survey. Med J Aust. 2003;179:302-305. 29. Schwenk T, Davis L, Wimsatt L. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010;304:1181-1190. 30. Uallachain G. Attitudes towards self-health care: a survey of GP trainees. Ir Med J. 2017;100:489-491.
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31. West C, Dyrbye L, Rabatin J, et al. Intervention to promote physician well-being, job satisfaction, and professionalism. JAMA Intern Med. 2014;174:527-533. 32. Moen P, Lam J, Ammons S, et al. Time work by overworked professionals. Work Occup. 2013;40:79-114. 33. Kim M, Windsor C. Resilience and work-life balance in first-line nurse manager. Asian Nurs Res. 2015;9:21-27. 34. Rabow M, McPhee S. Doctoring to heal: fostering well-being among physicians through personal reflection. West J Med. 2001;174: 66-69. 35. Tanz R, Charrow J. Black clouds. Am J Dis Child. 1993;147: 579-584. 36. Mishra A. Positivity, by Barbara Fredrickson. The Journal of Positive Psychology. 2009;4:578-580. 37. McCue J. A stress management workshop improves residents’ coping skills. Arch Intern Med. 1991;151:2273-2277. 38. Achor S. The Happiness Advantage. London, England: Virgin; 2011. 39. Eckleberry-Hunt J, Van Dyke A, Lick D, et al. Changing the conversation from burnout to wellness: physician well-being in residency training programs. J Grad Med Educ. 2009;1: 225-230. 40. Keim S, Mays M, Williams J, et al. Measuring wellness among resident physicians. Med Teach. 2006;28:370-374. 41. Okanlawon T. Physician wellness: preventing resident and fellow burnout—STEPS Forward. Available at: https://www.stepsforward.org/ modules/physician-wellness. Accessed August 5, 2016. 42. McKenna K, Hashimoto D, Maguire M, et al. The missing link. Acad Med. 2016;91:1197-1199. 43. Davis O, Nakamura J. A proposed model for an optimal mentoring environment for medical residents: a literature review. Acad Med. 2010;85:1060-1066. 44. Shanafelt T. Enhancing meaning in work. JAMA. 2009;302:1338-13340. 45. Galvin S, Buys E. Resident perceptions of service versus clinical education. J Grad Med Educ. 2012;4:472-478. 46. Raj K. Well-being in residency: a systematic review. J Grad Med Educ. 2016;8:674-684.
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47. Emmons R, McCullough M. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. J Pers Soc Psychol. 2003;84:377-389. 48. Shanafelt T, Dyrbye L, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-848. 49. Allen B, Banapoor B, Weeks E, et al. An assessment of emergency department throughput and provider satisfaction after the implementation of a scribe program. Adv Emerg Med. 2014;2014:1-7. 50. Bing-You R. Why medical educators may be failing at feedback. JAMA. 2009;302:1330-1331. 51. Yarris L, Linden J, Gene Hern H, et al. Attending and resident satisfaction with feedback in the emergency department. Acad Emerg Med. 2009;16:S76-S81. 52. Ende J. Feedback in clinical medical education. JAMA. 1983;250:777-781. 53. Wilkinson S, Couldry R, Phillips H, et al. Preceptor development: providing effective feedback. Hosp Pharm. 2013;48:26-32. 54. Shrivasta S, Shrivasta P, Ramasamy J. Effective feedback: an indispensable tool for improvement in quality of medical education. Journal of Pedagogic Development. 2014;4:12-20. 55. Weinstein D. Feedback in clinical education. Acad Med. 2015;90:559-561. 56. Chung A. Wellness and resiliency during residency: debriefing critical incidents and podcast. Available at: https://www.aliem.com/2017/ 01/wellness-resiliency-debriefing-critical-incidents/. Accessed April 13, 2017. 57. Ey S, Moffit M, Kinzie J, et al. “If you build it, they will come”: attitudes of medical residents and fellows about seeking services in a resident wellness program. J Grad Med Educ. 2013;5:486-492. 58. Weller J. Shedding new light on tribalism in health care. Med Educ. 2012;46:134-136. 59. Forrest C. How to build trust and fight tribalism to stimulate innovation—TechRepublic. Available at: http://www.techrepublic.com/ article/how-to-build-trust-and-fight-tribalism-to-stimulate-innovation/. Accessed April 17, 2017.
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