All in the Family
A novel burnout-prevention initiative is helping Department of Family Medicine residents improve work-life balance and patient care.
“Physician, heal thyself.”
The biblical admonition to keep your own house in order has taken on new meaning as graduate medical programs across the country implement changes in their training to help residents maximize their own health, as well as that of their patients.
“Physician burnout, including that occurring in medical residents, has sparked a national conversation,” said Joan E. St. Onge, M.D., senior associate dean for graduate medical education. “Burnout threatens both physical and emotional health, and is blamed for an increasing number of suicides, among both residents and practicing physicians. It is a crisis that requires an aggressive response.”
That response began in May 2017, when the Accreditation Council for Graduate Medical Education (ACGME) — the body responsible for accrediting the majority of training programs for physicians in the United States — called for programs across the country to develop wellness activities for physicians-in-training as a way to prevent burnout and depression.
At the University of Miami Miller School of Medicine, the Department of Family Medicine and Community Health developed a novel program — called “Fifth Wednesday” — in which the residents play a leading role in achieving those goals.
“Very few months have five Wednesdays,” said Heidi Allespach, Ph.D., the department’s behavioral medicine director. “Holding a special event on that day helps send the message that we really want to break away from the residents’ regular training routine. We also put the residents in charge — asking them to come up with ideas for the program sessions and then, after selecting one, making it happen. We thought the program would be more effective if they took ownership.”
Wednesday in the Park
Three Fifth Wednesday events were held during the past academic year. The program got a rousing kickoff on Wednesday, August 30, in Miami’s Morningside Park, with a mix of physical activities and games, short success talks by residents and faculty, and a picnic table overflowing with food selected and prepared by the residents. Sebastian the Ibis, UM’s mascot, paid a surprise visit to raise the group’s energy level even higher.
“It’s very difficult to become a physician,” said E. Robert Schwartz, M.D., chair of the department. “Residents spend a lot of hours working, and they have a lot of stress in their lives. Getting us out into the park to do some relaxation, some meditation, some sports, and some sharing of personal issues was a wonderful idea. Self-disclosure — how you eat, how you sleep, how you work, your relationships — becomes a useful part of your tools as a physician. And in many cases, it’s more important than the medicines that you prescribe.”
One resident came up with the idea for an exercise called “Vitality Rounds,” in which residents celebrate success stories and good patient outcomes.
That resident, Bryan Pardo, M.D., said, “I thought it would be cool to share not only when things go wrong but also some of the times when things go right.”
Faculty members immediately bought into the idea.
“This approach is different,” said Kassandra Bosire, M.D., family medicine’s residency director. “It’s what did you do right, and why was that a good outcome? Everything in that conversation is positive.”
The atmosphere of openness expressed through stories told by their faculty instructors had a special impact on the residents.
“Being here and being able to see the balance my faculty has really inspires me to live by their example — especially for my patients,” said resident Linda Alvarez, M.D.
Spring Cleaning Comes Early
Spring — or spring cleaning, at least — came early to the Jefferson Reaves Sr. Health Center in Overtown. On January 31, at the suggestion of resident Pollyanna Sanchez-Martinez, M.D., family medicine’s second Fifth Wednesday event was a major reorganization initiative at the clinic where the department’s physicians-in-training have provided health care services to underserved residents for many years.
“My parents were immigrants — my mom from Haiti, my dad from the Dominican Republic — and I was the second-youngest kid of six,” said Dr. Sanchez-Martinez. “I got into medicine because I watched my parents put aside health care to work and help us kids. I wanted to be the doctor for people who need me, someone they can trust.
“The patients at Jefferson Reaves are primarily indigent, many are undocumented, and all of them have health issues,” she continued. “They represent the full spectrum of need, and we play a major role in their health care. As residents, we’re blessed, because we get 30-minute patient encounters. The problem was that we have to fill out a lot of forms and documents. It was often difficult to locate them, and sometimes, after searching, we would find we had run out. Dealing with all that paperwork took precious time away from patient care. The lack of organization was frustrating to us, and we found the nurses at the clinic felt the same way.”
Determined to create an event in which the residents could become organizers in order to help themselves become better physicians, Dr. Sanchez-Martinez spent two days at the clinic taking an inventory of every form. Then to put some competitive spirit into the cleanup exercise, she and two fellow residents — Dr. Pardo and Makandall Saint-Eloi, M.D. — divided the group into four teams. Each team was assigned a specific project that would make the clinic more functional, ranging from redesigning how forms and supplies are stocked to improving computer access to opening up treatment space by rearranging furniture and equipment.
“This exercise was super helpful,” said resident Ingrid L. Gutierrez, M.D. “It’s so nice to be able to give a patient a BP log within seconds. We just grab it from the wall next to the computer and put it in the patient’s hand. It makes me feel accomplished, like I am doing a better job at taking care of my patients. The patients appreciate it, too, because they don't have to wait as long. I am very grateful that my program values and encourages physician wellness.”
Ending the Year with a Splash
Fifth Wednesday closed out the year on May 30 with a more informal poolside event at the home of Dr. Alvarez. The gathering included a self-care reminder meditation, a core-strengthening workout led by resident Lori Marcu, M.D., and a grilling skills demonstration by residents Dr. Saint-Eloi, Edangel Garcia-Chirino, M.D., and Daniel Hernandez, M.D.
But the perfect weather, relaxed atmosphere and views of the bay offered more than just a fun getaway from clinical duties, noted Dr. Gutierrez.
“We had a chance to mingle and catch up with each other,” she said. “It is difficult to do that when we are on inpatient services or spread out at different clinics and offices all over Miami. This session helped foster strong relationships and build camaraderie — the foundations of good teamwork that will be very beneficial in the future if we share a patient with challenging or urgent medical needs.”
With summer here, the Miller School’s clinical departments are assessing how their programs should evolve in Year Two.
“We’re really in the infancy stage in terms of understanding the resident burn-out phenomenon and why it happens,” said Dr. St. Onge. “At the Miller School, it has been under discussion for a while, so our response to the ACGME directive was immediate. At the same time, our programs have a lot of flexibility — we are not being told what to do and how to do it. Each of our clinical departments has had the freedom to develop its own response, but we are trying to address this challenge as an entire community, so representatives have been meeting throughout the academic year to discuss what seems to be working best.”
In family medicine, said Dr. Schwartz, all signs are that the Fifth Wednesday program has had a positive impact.
“The improvement in resident morale this year has been quite noticeable, and we will enhance the program in the next academic year, including expanding it to four sessions,” he said. “Another change will be an increased emphasis on nutrition and its importance for health outcomes — for both residents and patients.”
Dr. Allespach, who is also involved in the development and implementation of physician wellness curricula in the departments of medicine and surgery, has noticed a positive shift in terms of residents’ views about their need for self-care.
“Residents seem much more open to asking for help and talking about burnout than were residents who were in training even five years ago,” she said. “In addition, our current senior residents appear to be much more attentive to making sure that the interns are OK and are doing well.
“My hope is that we will focus next on intentionally addressing each aspect of wellness — professional, emotional, social, physical and spiritual — in a more systematic and intensive fashion,” she continued. “The general surgery residents have already started viewing wellness from this multidimensional framework, and I think all programs would benefit from adopting this perspective. We cannot fully help our patients by solely focusing on their medical problems at the exclusion of the other factors in their lives that contribute to those problems. In the same way, we must take a more global and dynamic view of the well-being of our young doctors in order to help them be the very best they can be in every regard.”