Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at STEPSForward.org
Jill Jin, MD, MPH: Hello, this is Dr Jill Jin and today I am talking with Dr Laura Hanyok, assistant dean for graduate medical education and associate professor of medicine at Johns Hopkins School of Medicine in Baltimore, Maryland. Dr Hanyok, welcome, and you for being with us today.
Laura Ann Hanyok, MD: Thank you and thanks for having me. I'm excited to speak with you today.
Dr Jin: Yeah. Could you please tell the listeners a little bit about yourself and your background?
Dr Hanyok: Sure. So, I am originally from Southern Maryland where I grew up and went to college in Maryland, and after medical school in Chicago, I came to Johns Hopkins where I did my residency at the Bayview Medical Center internal medicine residency program. And since serving as a chief resident there, I've been lucky enough to work as a faculty member. I see patients in my primary care internal medicine office and, for the last four years now, have gotten to work in our graduate medical education office, working with our colleagues in our different training programs to help support the well-being of our residents and fellows, as well as oversee other administrative aspects of their training at Johns Hopkins.
Dr Jin: Excellent. So that's a great segue into our topic of discussion today, which is burnout, and specifically burnout for trainees, which includes residents as well as clinical fellows. So Johns Hopkins School of Medicine recently created a pretty comprehensive wellness initiative for trainees, and I want to hear all about that. So, tell me what motivated you to develop this wellness initiative for residents and fellows?
Dr Hanyok: So, there are a couple of reasons that motivated us. We knew that within our own institution that we had issues with burnout, both for our residents and clinical fellows, but also for other clinicians. And we knew that the needs of our residents and fellows might be a little bit different than the needs of nurses, or attending physicians, or others. So we really thought it was important for our office to develop a strategy that would meet their needs.
Additionally, at the same time, probably some of your listeners know that the ACGME, which accredits our residency and fellowship programs, had recently started having common program requirements focused on the well-being of residents and fellows. So, we thought this was an opportunity to launch things both because it was really important for our institution, but also, frankly, because we also needed to meet those new common program requirements around well-being. So that's what motivated us really to start. It was fortunate that there was also really an interest in doing this kind of across-the-board at Johns Hopkins. So, while we were instituting our resident and fellow wellness initiative, shortly after that, there came other clinicians and other staff members that also had sort of their own well-being initiatives within our institution.
Dr Jin: So, can you expand on- you're talking about the needs, specifically of trainees, of fellows and residents. What are those needs and how are they different than for attendings or a practicing clinician?
Dr Hanyok: Yeah, so I think there are a few different things. There are some practical things that influence their well-being. Most residents and fellows work more hours than even a lot of attendings do. They may be in new places and therefore have not the same social connections if you will, that others may have been in the same place for a period of time. They're getting used to their new professional roles as physicians and still developing as physicians. And we knew that some of those things impacted what they needed and what, frankly, we were able to offer. So, some things that might make sense for a medical student to come to, I'm not sure a yoga session at two o'clock in the afternoon would necessarily work if you were a surgery resident. So, we had to think creatively about how to meet residents and fellows where they were, knowing their schedules were busy.
Dr Jin: Yes, yes. And as a trainee, I imagine there's a little bit more stigma or a little bit more fear of being perceived as weak, or being a little bit more reluctant to come forward about burnout.
Dr Hanyok: I hear you yeah, and I think that actually was a big impetus for some of the system-wide policies that we changed and updated to try to take away some of that stigma, for instance, making sure that it was clear that they can take time away to go to the doctor if they need to. And having that written into our policies for graduate medical education, so they weren't hopefully feeling that stigma of doing something basic like going to the dentist because they need to.
Dr Jin: Right. So how was this program developed? Can you walk us through the step-by-step process?
Dr Hanyok: Sure. So, we took a couple of different inputs, if you will, when we did our needs assessment to decide where to start. Our institution had a couple of surveys that had already told us about some of the needs. So, our Johns Hopkins health system does a system-wide safety culture assessment, which told us a little bit about burnout and some of the needs for our residents and fellows, because most of them participated in that survey. We also have a very active house staff council who represents our residents and they, on a yearly basis, do a wellness survey that asked a variety of questions, including what some of the needs were for our residents. So, we took some of that information and then also looked at what was in the literature to try to give us a sense of what worked. And then lastly, we talked with interested residents, and fellows, and faculty.
We, at the start of the initiative, had a wellness committee that helped us to guide what we were doing and really used them as a soundboard to see both what was needed and also really what was feasible given again sort of time constraints and other constraints that we had. So once we did that, we undertook sort of a multi-pronged approach, if you will. One of the things that was important was really just gathering information and sharing information. So there were a lot of resources out there, but there wasn't a central place to put them. So, our graduate medical education office developed a wellness website that had everything from events that were happening, to very practical things like what do you do if you need to take time off for medical leave or having a child, et cetera. So we focused on making sure we had all of that information in an easy-to-access place that was regularly updated.
And then we every week send an update over email to all of our residents and clinical fellows on campus that not only provides some sort of interested short readings, sometimes podcasts, events happening on campus, but also every week includes all of the contacts they would need to access mental health care or contact our peer support group to provide emotional first aid, for instance. All of those things that could help them are all out there to be able to be easily accessed.
So that was one prong of what we were doing. So, another prong of our initiative was really programming around wellness and well-being, and one of the key parts of that is that we launched Wellness Wednesdays, which happens at our main campus, Johns Hopkins Hospital, every week and at our, I guess, secondary campus, our other teaching campus, Johns Hopkins baby medical center, every month. And that has a variety of things really to support our trainees' well-being. Prior to the pandemic, we had a variety of things like pet therapy, and yoga classes, and seated massages, along with food because food always makes everyone happy. During the pandemic, we've had to cut back on some of those things, but are starting to reintroduce them now. Just last week, we were able to have seated massages again for people to be able to stop in.
So, Wellness Wednesday is sort of the main programming or the most regular program we do, but we also have other selected topics on webinars or otherwise that have been identified by our residents and fellows as helpful things. One last year that was really well received was actually around financial well-being and financial planning for residents and physicians. So, you think about helping burnout in a variety of ways, and for some residents and fellows, things like financial well-being is really important.
And then I think the other piece of the initiative, which is important, but perhaps a little less tangible, is all of the advocacy that our office has done with our house staff council and our clinical fellows council to advance wellness needs on an institution or a school of medicine level. For instance, having free gym memberships for our residents that are subsidized by the hospital, focusing on improving parental leave. Those sorts of positive changes that really an individual residency program couldn't do on its own, that it really needs the larger sort of wellness initiative that our GME office can help spearhead.
Dr Jin: Right, right. I'm so glad you got to that because that's what we at STEPS Forward® are all about, the personal resilience and the yoga and the Wellness Wednesday stuff is essential, but also, it's not going to accomplish too much without the institutional or the organizational level changes in the end. So I'm glad you covered it all and that sounds like it's a very comprehensive program. I also really liked how you guys, with the email updates for the peer support and the resources available for help, you send that out every week because sometimes the first three attempts to reach out, like we were talking about earlier, there's such a hesitancy, but if you get it every week in your inbox, that's sometimes what's necessary.
Dr Hanyok: It is, right, and we also want to decrease the activation energy as much as possible, right? So, even having to take that extra step to say, “What's the wellness website for the GME office to find these contacts,” that may even be too much for people. So, I think some of them may almost get a little annoyed that they get an email from us every single week, but the fact that they notice it is good because you never know when that person is going to need that contact information for themselves or for a colleague. So, if they know every Monday they can go and find this email and it has it, that just lowers the activation energy to reach out for help. And during certain times of the year, if it's early in the year or winter can be a more challenging time, on those wellness emails we remind them of all the different resources that are there to help give them support.
Dr Hanyok: If I could go back to the systems-level issue for a moment, that's something that we always try to keep in mind when we're doing this programming. I mean, as a faculty member, I myself get tired of being told I need to do more self-care. We've heard from our residents that it's just exhausting. It's like they're just adding another box to check off. It doesn't really have an impact. If anything, we want to take some of those boxes away that they have to check off and that really is something that institutionally we need to figure out how to change.
Dr Jin: Yes, a hundred percent, and of course it's much more work, much harder starting from the top down, but slowly but surely just chipping away at those barriers, and that's what we got to do. Speaking of barriers, what challenges did you face in particular?
Dr Hanyok: So, something that wouldn't be surprising to your listeners at all- that really the timing of how to do this is challenging, and we haven't completely overcome that barrier. So, we have Wellness Wednesdays during daytime hours because we need administrative support to be able to hold the activities, so it's harder to do it at seven or eight o'clock at night. So, the timing can be challenging. And we know that we're not necessarily reaching everybody. They may not be able to leave the OR if they're an anesthesiology or surgery resident to get to some of what we're offering. So, before the pandemic, we occasionally had things like dinner activities at five or six o'clock at night that myself or our associate dean for graduate medical education would run to be able to reach people at other times. We also moved things online and as people know, there's pluses and minuses to that, but the pluses are that people can access us anywhere, and we record a lot of things so they can go back for instance and watch financial planning sessions later. But we still haven't overcome the timing barrier all of the way.
I think the other challenge is that we have a diverse group of trainees, so there are a variety of needs, and we know that there are subsets of residents and fellows that have needs that we haven't met yet. For example, parents who are residents and fellows, we've been trying to work on improving options for childcare, for instance, and that's a pretty hard nut to crack. But those sorts of issues we're still working towards, and we know that there are selected groups that may have different needs, so we're trying to reach them.
And then I would tell you, frankly, one of the challenges- that there are so many options now because our institution has done a lot also for staff and faculty, which is wonderful, but almost part of my job sometimes is helping people sort out which is the best thing for me. So, there are a few different ways to access mental health care or counseling right now that are available through our institution, and that's great, and that means that the resident or fellow has to figure out which one is right for them. So, I consider that a good challenge, but now we have to help them navigate those things.
Dr Jin: Yeah. Interesting. It's true. Yeah. So many options, but I love that you're thinking about the parents in particular. I mean, that's a challenge for practicing clinicians, for attendings, and especially in the era of COVID, that's something that the systems are really struggling with of course.
Dr Hanyok: It particularly speaks to me because I'm a parent of two young kids too, and the pandemic has been hard on many people in lots of different ways, and I don't think people who don't have young kids really get how hard it is, right? So, every day, I hope that my son does not get sent home from day care because he had a COVID exposure, and then me and my spouse have to figure out who's going to take care of him for the next two weeks. That's hard enough and I'm a faculty member with flexibility in my life. I can't imagine being a resident with that.
Dr Jin: Same, a hundred percent. So overall, actually, when did you guys initiate this program?
Dr Hanyok: So, it's actually been four years now that we've been working on this. So, it's been in place for a good period of time. It changes and it grows, and we kind of build upon what we've learned, but yeah, it's been in place for a while with a decent amount of adjustments around the time of the pandemic.
Dr Jin: Got it. Okay. So, in the past four years, I am assuming since it's been around and it continues to grow that it has been successful, that you've gotten great feedback from the trainees. Do you have any results or any objective metrics or anything that's been telling in terms of burnout rates?
Dr Hanyok: Good question. So, I would admit that how to measure this has been challenging for us. We do regularly track burnout, though that has been on pause during the pandemic. They've been looking at different and additional metrics at this time. So, we haven't seen meaningful changes in our burnout scores from what we've been doing, though I'm not sure that was necessarily our goal. I would say that we have found from learners that they're engaging more often and more frequently with mental health supports and we consider that a positive thing.
I mean, maybe not positive that they have those needs, but that they're accessing them. So, we believe that we've gotten the word out and that people are aware of what resources exist. This includes our really great peer support program that is called RISE, or Resilience in Stressful Events, and our residents and fellows have been making more use of that peer support program, particularly during the pandemic.
A year after we first started this, we surveyed specifically about Wellness Wednesdays, and about the emails that we sent out and trainees thought that these were very valuable. They enjoyed the programming and the food and the other things that were part of that. And it also gave us some feedback in terms of how to adjust things. And I would say that our house staff council's yearly wellness survey continues to let us know that more of their needs are being met, but also identifying other things that we can keep working on.
Dr Jin: Got it. So, you do a yearly survey to assess for potential growth and improvement?
Dr Hanyok: We do. So, I would say it's not done directly for Wellness Wednesdays or for our messaging, but our house staff council does a yearly wellness survey, which asks about these things and other more system-wide needs or institutional needs. And we found that that has been helpful because the survey is being done by their peers, so we're hoping that they'll be more honest and provide more feedback. And I'll tell you, we also have been very aware of avoiding survey fatigue and lessening survey burden. So, in an ideal world, perhaps we would have a more formalized way to look at some of these specific things, but because both our house staff and our institution have other surveys around well-being, we're trying to make use of the data that's already being collected of adding more surveys about are you well or not, because that may make you less well.
Dr Jin: Do the health staff members of the house staff council get protected time for doing this work?
Dr Hanyok: So, they don't, that's a good question, no. Typically, the chair and the vice chair are either in a research here, if they do research, or they're senior residents, but it is completely volunteer. That's not actually something they've ever asked us about before, but no, they do not get time away specifically to do that.
Dr Jin: Is there ever a shortage of interest?
Dr Hanyok: So, we've never had a shortage of interest for the position in the executive part of the house staff council. They ask for resident representatives from each residency program, and they've always had a representative from each residency program. I'm not sure in the smaller programs if it takes more effort to recruit people or not. The main members of the house staff council meet monthly for an hour, and then part of their work is to gather information and to message out to their colleagues. It's really the three or four, kind of, main members of the house staff council that spend more time doing work and serving as a voice for their colleagues.
Dr Jin: Gotcha. That's always so fascinating to me. I don't think it's necessarily a bad thing that they're not compensated or have protected time because you do want the people who are passionate about it, but it's always, I don't know, it's always both surprising, but also kind of reassuring to hear that there's people kind of passionate about this work, even for peer support, it's all voluntary. And for my institution, at least, there's never a shortage of people who want to be volunteer peer supporters and whatnot.
Dr Hanyok: I mean, my hope is that because they see the impact that their council has, that they're motivated to participate and do things. Yeah, practically, it's also really a wonderful experience if you're interested in hospital administration or any sort of leadership role in the future. The chair of the house staff council sits on the medical board of the hospital. They attend lots of high-level meetings to represent the house staff. So it is a lot of work for them, and they get to learn so much about the inner workings of an academic medical center too, during their tenure.
Dr Jin: So, what plans do you have for growing this initiative in the future?
Dr Hanyok: Yeah, so we're happy that hopefully, the pandemic has stabilized and is slowly improving. So some of what we hope to do is reintroduce some of the things we had before, for instance, having pet therapy dogs come and visit with our residents, doing more food-related activities, which we haven't been able to do quite yet, but we're hopeful in 2022 we can, and really take stock of where our trainees are and what some of the next big steps I guess there should be to focus on well-being.
I would say two concrete things that we're working on now is, we're really excited that our medical school and our medical students are very energized about their own wellness, and knowing the importance of the transition from medical school to residency. We're going to plan a lecture series with our medical students and our office of medical student affairs so we can find, I guess, some common ground to learn from each other and share experiences with medical students and residents. So we're excited to do that.
And then the other thing that I've been working on for a period of time, as well, is working on more well-being and wellness focus on our other primary academic campus, which still has about 150 to 200 trainees on its campus on any day. So, while it's much smaller than Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center also has a good number of residents and fellows who are there every day. So, we've launched kind of their own offshoot of our health staff council, and that Bayview house staff council is starting to advocate for things that may be specific to that campus to meet the needs of its learners.
Dr Jin: Okay, my final question for today is are there any tips or pearls of wisdom you have for listeners looking to implement a similar program at their institution?
Dr Hanyok: So, I think the first thing is to remember that this is supposed to make people's lives easier, and just adding more stuff isn't necessarily going to make people well. So, we've tried to be mindful of finding things that will help their well-being, but are feasible in the time that they have as a resident or fellow and making sure they don't feel that this is just some other self-care thing I need to check off and get back to doing my work, but that it really will be impactful.
The second thing I think is really to listen to your audience. So, talking with our residents and clinical fellows on a regular basis, both informally through their leadership and more formally through their surveys, really help us to decide and prioritize what we really need to focus on.
And lastly, make sure you use the resources that are already out there. If you're in a large health system, there may be a lot of resources available to all of the employees that are there, and making sure that your residents and fellows are aware of those and make use of them. If you're in a smaller program, perhaps there are things available in the community or other things that you can partner with other institutions and schools to do that are already out there to try to not have to build everything from scratch.
Dr Jin: Those are such excellent points. Thank you for your time today, and chatting with me on our podcast, but also for everything you're doing for residents and fellows. And it's so great to hear. It's so inspiring to hear that work and to pass that on to this next generation of doctors. I feel very optimistic about that.
Dr Hanyok: Yeah. Well, thank you. I really appreciate that this is something that your podcast wants to highlight. As you know, it's not just important for our future colleagues and physicians, but I truly believe it makes us better doctors when we take care of ourselves. So, it's good to give people strategies early so we can thrive for the many decades we're going to be caring for our patients.
Dr Jin: Absolutely. Thank you.
Dr Hanyok: Sure. Thank you.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at STEPSForward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, STEPSForward.org
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