Learn how ChristianaCare's Center for WorkLife Wellbeing (CWW) uses ice cream sundaes paired with psychologist-led discussions to support resident and fellow well-being and foster personal and professional growth.
Graduate medical education can be a particularly demanding and daunting time period.1,2 Residents' lives are fast-paced and stressful, with external pressures and expectations increasing exponentially over time. Isolation, imposter syndrome, and feeling overwhelmed are common experiences.
Developing the Intervention
To support residents and fellows during these crucial moments in their careers, CWW adapted the concept of Ice Cream Rounds (ICR) commonly used in Canadian Pediatric Residency programs.3
CWW first piloted ICR as a quarterly series for reflection, support, and psychoeducation for residents in 3 specialties: Family Medicine, General Surgery, and Emergency Medicine. Ice cream sundaes were paired with confidential discussions facilitated by a psychologist during protected education time.
Residents in the ICR pilot were exposed to the rapidly evolving national conversation about physician burnout, well-being, and professional fulfillment, and were invited to contribute to this broader conversation with discussions of:
How the theoretical and empirical underpinning espoused by thought leaders meshed with, conflicted with, and/or explained the stressors they experienced in their day-to-day lives
How they could thrive in a profession where discussions of burnout rates, resilience, and suicide sometimes seemed to dominate the conversation
How to balance compassionate care for patients, and sometimes healthy detachment, with attention to personal well-being and the lifelong practice of medicine
What was needed individually and systemically to learn, grow, and be an effective practitioner
Residents spoke with surprising candor about the micro-environments of their unique programs and their perceptions of the interpersonal and intrapersonal challenges that drove many of their experiences. Over the course of the year, residents progressed through a continuum of growth (Figure 1).
Figure 1. ICR Pilot Continuum of Growth
As residents worked to achieve clarity about how their personal and professional values—as well as their character strengths—could drive their career choices following residency, many noted an emerging awareness that in the course of their training, they'd lost touch with the values that initially drew them to medicine. As residents learned a new language to describe their experiences and experimented with using new coping skills, the sessions became more supportive and the tone more intimate.
Current Program Logistics
Today, ICR has been adopted by nearly all ChristianaCare residencies and fellowships as quarterly, hour-long discussions held during regularly scheduled conference time. Scheduling the sessions during protected education time shows that the training programs view well-being as an integral part of the curriculum rather than an add-on for residents to attend to on their own time. ICRs are hosted in private rooms located on 1 of the 2 ChristianaCare campuses, conveniently scheduled for proximity to trainees' rotations. Residents and fellows attend separate ICRs designated for each program across program year (PGY1s through PGY4s). Attendance at ICR ranges from 4 to 65 residents or fellows, depending on the size of the program. Program leaders are not present during ICR discussions, but general topics and themes that emerge are shared during bi-monthly Academic Affairs/Graduate Medical Education Committee (GMEC) forums.
Effective leadership of ICR is critical for fostering social support, psychological safety, and appropriate risk-taking during the discussion. Skilled facilitation includes building clear and appropriate expectations, boundaries, and guidelines. Each ICR begins with a review of purpose and rationale (eg, reflective pause, educational discussion, and support) along with key guidelines, such as maintaining confidentiality and inviting different perspectives. Such norm-setting aligns with group leadership best practices.3,4 The facilitator leads with flexibility, balancing teaching from an experiential, interactive curriculum while also shifting to address the immediate concerns of the trainees. Topics that are unique, engaging, and novel to graduate medical education trainees (eg, the psychology of humor, sleep science, and career and life transitions for high-achieving professionals) are presented according to constructivist learning principles. Awareness of group dynamics and skillful facilitation of group therapeutic factors are key to successful outcomes, as is adopting an informal discussion style and an openness to co-constructing the content with the learners. The goal is a dynamic, flexible, and enriching discussion between the facilitator and learners that accommodates different needs and experiences between programs.
“These sessions are so incredibly helpful for everyone on some level and I really appreciate it. I'm glad you are working to do this and hope it becomes a more frequent integrated part of our curriculum.” – Anonymous resident
A Mechanism for Change
In the second year of ICR, participants began to express a desire to give real-time feedback, which presented an opportunity for trainees to act as change agents for their programs. The value of the perspectives shared in ICR was brought to leadership in Academic Affairs, and it was deemed that the final sessions of each program would be devoted to capturing residents' advice for their program's leadership. Suggestions ranged from upgrading call rooms to standardizing the feedback process to making sessions more engaging and relevant.
A facilitator guided residents and fellows through a discussion that translated complaints to action-oriented change items, which were then rank-ordered as priorities and identified as easy-to-act-on “quick wins.” Meanwhile, Academic Affairs agreed to add a new requirement for residency programs: the creation of unique well-being goals that would respond to and build upon the recommendations and themes shared via ICR. This feedback was then combined with quantitative data from a system-wide physician well-being survey, as well as graduating senior exit surveys. Program directors were asked to co-create wellness goals in partnership with their program's Resident Wellbeing Representative, and to report the goals in their annual performance evaluations.
Residents and fellows gave permission for the discussion of this last session to be transcribed with the protection of anonymity. CWW generated reports for program directors capturing vital themes and guided by a consistent template:
Background: Factors that precipitated the focus group, establishing a timeline
Participants: Highlighting how many individuals participated and their roles while maintaining confidentiality
Things That Are Going Well: Aggregated themes presented in concise bullet points covering the job satisfiers the group identified
Things That Could be Better: Aggregated themes presented in concise bullet points covering the job dissatisfiers the group identified
Recommendations: A co-developed set of specific, actionable recommendations rank-ordered according to level of priority and in terms of being “quick wins”
While ICR has expanded from 2 to 17 residency and fellowship programs (including nearly all but a few of ChristianaCare's 280 trainees), CWW encountered varying degrees of interest, commitment, and openness. Initially, most residents and fellows seemed to perceive this protected education time approach as it was intended—tangible evidence of their program directors' commitment to their well-being. But some residents did not respond as positively. One noted, “In the hour that this session took, I could have caught up on all the administrative tasks that I do not have time to do.” Also, some residents, fellows, and program leaders continue to view well-being efforts as the sole responsibility of individuals rather than a component of overall organizational well-being.
Another barrier is the limited time allocated (4 hours per year) for the multiple goals of ICR.
The last barrier encountered is organizational. With the increase in contacts and disclosures, sensitive information is shared with CWW that occasionally extends beyond issues related to individual well-being to themes of organizational culture. Periodic tension arises between the ethical imperative to maintain trainee confidentiality and leaders' desires to identify and resolve organizational issues and revise relevant policies. For example, residents may divulge their experiences with interpersonal mistreatment as institutions are doing deep exploration of and revision of workplace culture, values, and acceptable behaviors. Sharing resident feedback—even in broad strokes and general themes—could feel like a violation of confidentiality and risk damaging the trust established in the group, yet the opportunity to advocate on behalf of residents could contribute to important institutional change.
ICR are now established as an integral part of the resident and faculty training curricula, and the psychologist role is integrated into the GMEC community. The intervention evolved from a pilot to a cornerstone of resident and fellow professional development.
One year after the pilot launch, 10 programs opted to participate in ICR. Each program scheduled ICR sessions during protected education time, and the CWW accommodated these schedules to ensure no additional time was added to learners' schedules. Two years after the pilot launch, 17 programs adopted ICR; all but 7 individual residents and fellows (who are part of programs with particularly small cohorts where in some cases, only 1 slot exists) now have ICR as part of their curriculum.
In the second year of ICR, residents and fellows were asked to evaluate the sessions with a confidential cell phone survey app. Specifically, participants were asked to rate how helpful the sessions were and to what extent the sessions were worth their time. On average, sessions were rated as helpful or highly helpful by 81% of respondents, and 80% agreed or strongly agreed that the sessions were worth their time.
“Loved it! I've been having a rough time, and this really helped me take a deep breath and understand why.” –Anonymous resident participant
Qualitative feedback about the sessions was also collected. Although the majority of feedback was overwhelmingly positive, some participants commented on the decision to offer ICR during protected education time and require attendance. However, after the program was in place for 3 years, CWW stopped receiving negative feedback about attendance.
Lastly, in addition to perceptions about the program itself, help-seeking behavior of trainees was tracked. Over the course of ICR, approximately 13% of trainees sought out private meetings with 2 leaders of the initiative, Vanessa Downing, PhD, or Mark Mason, PhD, to ask for referrals to counseling and coaching services. This rate remained constant year over year. Future research will examine possible relationships between ICR attendance and attitudes about help-seeking.
Headquartered in Wilmington, Delaware, ChristianaCare is one of the country's most dynamic health care organizations, centered on improving health outcomes, making high-quality care more accessible, and lowering health care costs. ChristianaCare includes an extensive network of outpatient services, home health care, medical aid units, 3 hospitals (1299 beds), a Level I trauma center and a Level III neonatal intensive care unit, a comprehensive stroke center, and regional centers of excellence in heart and vascular care, cancer care, and women's health. It also includes the pioneering Gene Editing Institute and was rated by IDG Computerworld as one of the nation's Best Places to Work in IT. ChristianaCare is a nonprofit teaching health system with more than 260 residents and fellows. We are continually ranked by U.S. News & World Report as a Best Hospital. With our unique CareVio data-powered care coordination service and a focus on population health and value-based care, ChristianaCare is shaping the future of health care. Learn how we deliver greater quality and value at https://christianacare.org.
Impostor syndromeImpostor syndrome:
refers to an internal experience of believing that you are not as competent as others perceive you to be. See also: www.verywellmind.com/imposter-syndrome-and-social-anxiety-disorder-4156469