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Physician Well-Being Case Report: Collaborative for Healing and Renewal in Medicine (CHARM)

The Collaborative for Healing and Renewal in Medicine (CHARM) was recently formed by medical educators, researchers, and leaders at academic medical centers to collect and disseminate best practices in wellness initiatives for medical students and residents. The group received grant support from the Alliance for Academic Internal Medicine in January 2016 to create and disseminate products that would enable faculty members to champion wellness programs at their institutions. The ultimate goal of these initiatives is increasing the resilience of medical students and residents to the stresses inherent in clinical training.

CHARM is currently working on developing a variety of materials including training modules, an annotated bibliography of best practices for residency wellness programs, and several manuscripts for publication. The materials will be freely available and will include tips for interested faculty on how to approach leaders and obtain their buy-in for committing the necessary resources for wellness programs.

The two co-chairs of CHARM have championed wellness initiatives at their own institutions for many years. Hasan Bazari, MD, nephrologist, internist, and past director of the Internal Medicine residency program at Massachusetts General Hospital in Boston, has offered “Reflection Sessions” to residents in Internal Medicine for more than eight years. In these sessions, residents dedicate time to reading a poem and reflecting on its themes and the application to their lives and clinical experiences.

The sessions are integrated into the curriculum for trainees in all three years of the residency program. Interns participate in a two-hour session as part of their orientation in the first month of training. During the remainder of the year, they participate in three one-hour sessions, which are scheduled during their ambulatory rotations. Interns also participate in a one-hour session during a retreat held at the mid-point of the year. Second- and third-year residents attend sessions together, participating in a total of three one-hour sessions each year, also held during ambulatory rotations.

According to Dr. Bazari, the meetings provide “an element of consistency through the three years, while in a chaotic environment in which there are a lot of moving parts.” He notes that the group forms a circle of trust, within which seniority falls away as the participants discuss various topics. Death and suffering are common themes, about which the trainees express intense emotions. Sessions also include moments of silence for quiet contemplation. Although it is difficult to measure the impact of the sessions quantitatively, Dr. Bazari has observed the enthusiastic engagement of the trainees during the sessions and believes that they find the discussions to be interesting and helpful. When burnout rates were measured with the Maslach Burnout Inventory in previous years, there was a diminution of burnout over time, though it did not reach statistical significance. The organization plans to continue to measure and compare burnout rates in future years.

Jonathan A. Ripp, MD, associate professor of Medicine at the Icahn School of Medicine at Mount Sinai in New York, has also championed a wellness program for residents in Internal Medicine. Like the initiative in Boston, the program is offered during ambulatory rotations during each of the three years of training. However, the program at Mount Sinai differs in its composition. During the first year of residency, interns receive five hours of mindfulness training from experts in the field. During the second and third years, residents participate in facilitated discussions focused on a published essay, such as those appearing in JAMA's A Piece of My Mind or in The New England Journal of Medicine's Perspective section.

The elements of the wellness program were specifically selected, according to Dr. Ripp, because mindfulness practice and facilitated discussion have an evidence base demonstrating effectiveness in reducing burnout. Topics at the facilitated discussions include handling death and dying, participating in resuscitations, dealing with difficult patient situations, and managing work-home balance. Dr. Ripp has strongly advocated for inclusion of the sessions as part of required training. “It's important that the program is integrated into the existing trainee curriculum schedule, not added on as an extra requirement.” Dr. Ripp notes the difficulty in conducting research on the effectiveness of any interventions to reduce burnout among trainees. “It is challenging to show that any one intervention has an impact. Instead, we must look at the general trend.” He will be assessing pre-and post-program outcomes and will be reporting the results back to his CHARM colleagues.

By championing wellness programs within their own institutions and collaborating with others across the country to identify and spread best practices, Drs. Bazari and Ripp hope to make effective wellness initiatives more widely available. Through greater availability, they hope to foster increased resilience to stress among physicians in training.

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