Resident and Fellow BurnoutCreate a Holistic, Supportive Culture of Well-Being

Learning Objectives

1. Describe elements needed to create a well-being framework

2. Determine the STEPS needed to develop a well-being program

3. List key aspects of personal well-being

4. Recognize the importance of personal empowerment and a sustainable culture of well-being

The increasing number of residents and fellows who describe experiencing burnout highlights a growing crisis within the medical workforce.¹ Among physicians, rates of suicide, depression, and burnout are higher than the rest of the population, while levels of personal and professional satisfaction are low.² It is becoming more important to identify ways to create a well-being program within graduate medical education (GME) programs. Resident burnout is also impacted by concern of career choice regret.

Physician burnout is a long-term stress reaction characterized by depersonalization, including cynical or negative attitudes toward patients, emotional exhaustion, a feeling of decreased personal achievement, and a lack of empathy for patients. Conversely, well-being consists of multi-dimensional variables that interact to positively impact levels of health and emotional and social functioning. Residents and fellows who attend programs that emphasize and prioritize well-being are more likely to transform into physicians that are less stressed and better able to engage with patients to provide quality care.

1. Create a Framework

2. Gather a Team

3. Develop a Well-Being Program

4. Foster Individual Well-Being

5. Confront Burnout and Create a Culture of Well-Being

Quiz Ref IDTo create a sustainable and engaging well-being program, you need to develop the framework first. This requires the time and dedication of key people, especially residents and fellows who can lead their program and organization to make a commitment to the well-being of fellow trainees and potentially the entire medical care team.

Enlist trainees and faculty to serve as well-being advocates and champions. Many programs involve individuals with a particular interest in well-being, such as:

• Chief residents

• The program director

• Faculty members

• Social workers

• Psychiatrists

After you have identified well-being champions, schedule a meeting with the program director to gain leadership support. An organizational commitment to well-being leads to better chances of achieving a healthy workforce; the responsibility of well-being must be shared across the program. Use the meeting with leadership to discuss how your organization defines well-being, the benefits of a well-being program, and the accomplishments of other successful initiatives.

Defining well-being should be a team effort. Discussion prompts to define well-being include:

• What does it mean to be well?

• What aspects of well-being should be addressed as part of the well-being program's scope?

• What well-being initiatives are currently in place and working well?

• What are the consequences for patients and physicians if well-being is not prioritized?

After developing a definition for well-being, it is important to understand the program's current state of well-being. At the beginning of the year, administer a survey to assess well-being within your program. Encourage trainees to respond to the survey honestly and reflectively, emphasizing that individual responses will remain confidential. Plan to reassess well-being as interventions are introduced to determine whether the changes are making a positive impact.

After the surveys are completed, the well-being team should analyze the results and develop action plans to address any concerning themes. Many programs find this as an opportunity to decide if more well-being activities are needed. You may want to display well-being scores on the department dashboard or scorecard, so everyone is reminded to think about well-being as a quality indicator.

For your program to succeed, you must create a team with representation of all of those who are invested in its success. These include residency leadership, GME office team members, one or more residents, a residency coordinator, and social work or psychiatry backup. If you are not the program director, you must have the cooperation of either the program director or the associate program director. Both will be integral to your well-being program, as some resources will be required and will impact resident time commitments and scheduling. Your GME office and director will be important to both support your program and provide resources in the form of counseling or organization-wide house staff activities. You will need a resident champion, preferably a senior resident who has credibility with their peers. Create a job description and a title, perhaps “Well-Being Lead” to increase the resident champion's buy-in and the buy-in of their peers. By creating a leadership position for a resident or fellow, they will be more likely to perceive the program as being internally driven and representing the needs and interests of the current group of residents.

Quiz Ref IDQuiz Ref IDInnovate and design custom interventions that meet the needs of both individual trainees and the training program. You can begin this process by assessing the results from the initial well-being survey. Consider holding a brainstorming session with the well-being team to determine which interventions or activities could increase well-being among trainees. Based on the survey results, you may want to consider some of the following interventions:

• If trainees are not transitioning well into their new roles, offer peer support with a “buddy” program where they can be paired with a resident or fellow that is a year ahead. The more advanced resident or fellow may offer actionable advice as they recently experienced the same transition.

• If the threats to well-being involve working too many hours, the well-being team can work with program leaders to manage the amount of time trainees work over the different clinical rotations or rearrange clinical schedules to alternate more demanding schedules with electives or consult services.

• If trainees express that the program lacks a strong team culture, schedule group well-being events. These are an opportunity for everyone to have fun and connect with one another outside of the workplace. Plan activities such as:

  • Movie nights or dinners

  • Holiday potlucks

  • Ballroom dancing classes including spouses and significant others

  • Local charity work (eg, volunteer at a soup kitchen)

  • Lunchtime exercise or yoga classes

  • Participation in a local 5k, such as a Color Run™

  • Sporting events (eg, playing in a recreational league, watching a televised match, or attending a university game)

  • Watching popular shows as a team

  • Painting or pottery classes

  • Exploring the local environment

• A yearly or bi-yearly resident retreat may be an important way for the residents to feel empowered to focus on their team-building and camaraderie. This will need the support of the program director, with some financial support, and can be an opportunity for the faculty to show their appreciation of the residents by covering some clinical services.

Literature and examples from other organizations can also be useful starting points.⁶ Here are a few examples of successful well-being programs and activities for fellows and residents at other organizations:

• Balance in Life within the Stanford Department of General Surgery

• Fellows' and Residents' Health and Wellness Initiative (FERHAWI) at the Mayo School of Graduate Medical Education

• Student Wellness Program at Vanderbilt University

• The Resident Wellness Committee within the University of Alabama at Birmingham Tinsley Harrison Internal Medicine Residency Program

• Resident and Fellow Wellness Initiative at Johns Hopkins University

• Ice Cream Rounds at ChristianaCare

After you establish interventions, educate trainees, staff, and faculty on what well-being is and how you plan to achieve it. Incorporate well-being into the fabric of the training program by offering well-being learning sessions or interactive workshops, or by integrating well-being practices into grand rounds. The well-being team should strive to develop a holistic, engaging curriculum that exposes all trainees to important well-being practices to improve each trainee's life as a physician.

The cyclical nature of residency and fellowship training programs requires constant innovation. Continuously re-evaluate your initiatives to ensure that they are aligned with the well-being program's priorities. The preliminary assessment can serve as a benchmark. Keep track of the activities that the well-being program hosts or sponsors and how well trainees respond to them at the event and on post-event surveys. Use this feedback to establish which events should be continued. To learn more about the impact the interventions have had on well-being, use open-ended survey questions asking whether the interventions have made an impact and request information on other activities that they would be interested in. The well-being team will likely need to tailor the program every year to meet the needs of the current residents and fellows.

“The most important patient we have to take care of is the one in the mirror.”

—Robert Wah, MD, Former President (2014-2015), American Medical Association; Reproductive Endocrinology, National Institutes of Health (NIH) and Walter Reed National Military Medical Center

Quiz Ref IDIn addition to providing residents and fellows with a supportive environment that is committed to well-being, it is important to ensure that they have the tools and resources to develop individual well-being. To ensure individual well-being is established, you may consider incorporating the following components to shape the well-being program's curriculum:

• Nutrition (eg, healthy food options and scheduled time to eat)—The well-being team can sponsor department meetings to ensure that healthy food is available.⁷

• Fitness—Make sure residents have free access to a gym located in or near the medical center.

• Emotional health—Relax, renew, and re-energize through hosted events (eg, retreats with team-building and self-awareness exercises, stress management approaches, etc.).

• Preventive care (eg, dental care and provisions to see a primary care physician)—Program leadership can commit to giving trainees an occasional weekday afternoon off for personal meetings or doctor appointments.

• Financial health (eg, debt management, retirement planning, and emergency fund support)—Bring in a financial counselor to have informal discussions with interested residents.

• Mindset and behavior adaptability—Assign faculty and trainee “well-being partners” who will engage in goal-oriented discussions on emotional, spiritual, physical, and social aspects of well-being to help trainees develop a personal well-being approach.

Quiz Ref IDMaintain a strong well-being program through agility and leadership involvement. Be open to adapting strategies to fit the needs of the trainees and strive to survey residents and fellows on a regular basis, often every 4 to 6 months as new residents and fellows enter the program while others graduate. Provide opportunities for all team members to become involved in the well-being program. Continue to include faculty advisors and foster frequent collaboration. The hierarchy of the medical profession can make residents and fellows feel uncomfortable approaching a more senior member of the medical staff about well-being issues. While creating an anonymous reporting system can be helpful, trainees should be encouraged to seek and offer help as needed. Most importantly, create a community that is empowered to identify and act on signs of burnout. The combined agility and leadership involvement will help to ensure the longevity and success of the well-being program.

A commitment to well-being will help ensure that residents and fellows are involved and engaged in their training program as well as in their care of patients. Equipping trainees with skills to foster their own well-being will serve them, their families, and their patients throughout their careers. The strategies, tools, and resources in this toolkit can assist you in creating a well-being culture that fits your training program's needs.

Journal Articles and Other Publications

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