The Role of Ombuds in Graduate Medical Education: Fostering Wellness and Psychological Safety

Abstract

The authors propose an educational innovation in graduate medical education, the creation of an Education Ombudsperson. Although this role has been implemented for faculty and students within the medical field, it has not been described in residency programs. The Ombudsperson for house staff is distinct from institutional or programmatic leadership. His or her primary role within a department is to foster psychological safety, wellness, advocacy, and professionalism in residency or fellowship programs. This manuscript describes the process for selection, visitor consultation, escalation pathways, and examples of concerns addressed proactively. The Ombudsperson can complement the role of the Program Director, Chair, and Designated Institutional Official in a collaborative model that addresses challenges in the learning environment.

INTRODUCTION

Enhancing psychological safety and well-being in the learning environment is integral to training the next generation of physicians. The youngest physicians in our medical field, residents and fellows, work the longest hours for the lowest pay. Their apprenticeship is a formative experience, during which they experience death, medical errors, and ethical dilemmas for the first time in their professional careers as physicians. There is a growing body of literature in support of collective organization or unionization of house staff to mitigate physician burnout, improve well-being, and foster advocacy.¹ There is also recognition that this movement is a result of working conditions that may be improved in alternative ways.² As medical educators, we sought to better support a vulnerable group of physicians and strengthen the learning environment.

Background

In the area of medical education, the ability of house staff to raise concerns without fear of retaliation allows educators to address challenges to the learning environment.³ The Accreditation Council for Graduate Medical Education (ACGME) has established professionalism and communication as core competencies.⁴ The ACGME's annual survey directly inquires if residents feel comfortable raising concerns and escalating issues of professionalism.

There is literature to suggest that there are significant barriers to creating this environment, including shame, fear of retaliation, and concern for impairing personal reputation.^5-7 Medical educators need to think creatively about how to foster this environment of psychological safety.

The concept of psychological safety is well described by Amy Edmonson.⁸ It is the ability of an organization to promote trust and transparency and create a culture in which employees believe failures are opportunities for growth. In the field of medicine, promoting psychological safety has decreased medical errors and improved patient safety outcomes.^8-10 Curious conversation creates a safe environment in which no one is penalized for seeking guidance or committing medical errors.¹⁰ This is the type of environment that we seek to create in medical education.¹¹

We propose establishment of an Education Ombudsperson (Ombuds) for house staff, distinct from institutional or programmatic leadership, whose primary role is to foster psychological safety, wellness, and professionalism in training programs. There is some evidence to suggest that an Ombuds improves psychological safety in the learning environment.¹² Although the Ombuds Office has been established in academic universities, it typically represents faculty or students. There is a paucity of literature describing the Ombuds role in

Graduate Medical Education (GME).^12,13 The Ombuds can alert leadership to challenges, improve communication, promote professionalism, and strengthen values of the organization. In our residency program, we established an Education Ombuds in September of 2021 to improve the learning and working environment. We outline the definition of an Ombuds, the process for establishment and escalation of concerns, as well as commonly addressed themes or reporting categories. Finally, we describe the benefit to both our program and the institution.

Definitions of Ombuds

The concept of Ombuds dates to 439 BCE¹³ and has been integrated into government organizations, businesses, and academia. According to the International Ombuds Association, an Ombuds works with individuals and groups to provide a safe space to discuss issues, resolve conflict, and identify systemic concerns to the organization for resolution. The International Ombuds Association has Standards of Practice and a Code of Ethics that state that the Ombuds should be independent, impartial, informal, and confidential.^14,15 We have established these 4 fundamental principles (Figure 1) as hallmarks of our Education Ombuds program, adhering to the standards of the International Ombuds Association.

Figure 1.

Fundamental principles of the Ombuds. Abbreviations: GME, Graduate Medical Education; Ombuds, Ombudsperson.

Process for Selection and Visitor Consultation

We recommend selection of the Ombuds by the Chair and Program Director, which must be mutually agreed upon by the Chief Residents. The benefit of an Ombuds within a dedicated training program, rather than at the institutional GME level, is that the faculty member has a closer relationship with the residents and is easily approachable. He or she also understands the field of anesthesiology and can relate to the stresses associated with practice. Finally, we recommend a faculty member who can provide insight and experience from having completed a residency training program in our field.

The Ombuds should clearly delineate the best way to report an issue. We suggest acknowledgement of a correspondence within 24 hours, followed by a scheduled meeting. Open office hours for house staff are helpful in engaging residents who may be reluctant to initiate their own correspondences. The process for visitor or house staff consultation with the Ombuds is entirely voluntary; therefore, anonymous reporting is less likely. Residents who wish to meet the Ombuds are seeking advice and guidance from an independent, impartial, informal, and confidential source.

Escalation Pathways and Leadership Collaboration

The Ombuds conducts monthly meetings with the Chair and Program Director, each with a predefined agenda. The agenda is determined by both Ombuds meetings with trainees and collaborations between the Ombuds and Program Director about how to best approach the Chair on the trainees’ behalf. These meetings can highlight concerns and develop an action plan detailing both improvement and resolution of issues. Including residents in the development and implementation of action plans is important to create practical and sustainable solutions. This involvement is a continuous feedback loop or process that involves frequent input from residents at all times (Figure 2). Although some challenges may be addressed at the department level, others will require escalation outside of the department with the Chair's support.

Figure 2.

Escalation pathway. Abbreviation: Ombuds, Ombudsperson.

These escalation pathways illustrate the tremendous leadership collaboration involved in establishment and implementation of the Education Ombuds. In our experience, the presence of an Ombuds that partners closely with the Chair and Program Director signals teamwork, cohesion, and trust to the trainees. Similarly, the Chair and Program Director can liaison with the Designated Institutional Official to address larger systemic challenges.

Reporting Categories

Based on the Education Ombuds experience in our program, visitor consultation results in 5 major reporting categories (Figure 3), which include professionalism, educational/ training gaps, hospital resources/service obligations, mental health and wellness, and culture. The reporting categories in our residency program echo themes in medical education, documented in the literature, and highlight areas for improvement in the learning environment. Professionalism concerns can range from matters such as a residents seeking advice on how to deal with difficult patients to more serious concerns pertaining to attending physicians’ behavior toward interprofessional teams.^16-18 Confronting microaggressions in the learning environment and adopting strategies for intervention and “upstander” training maintains our commitment to inclusivity and respect in the workplace.^19,20 Bias in medical training, specifically the higher rates of remediation and dismissal in underrepresented groups, is an example of an ongoing challenge in medical education.¹⁷

Figure 3.

Reporting categories.

The second reporting category involves education and training gaps. Examples include gaps in training due to COVID19 for both medical students and house staff.²¹ Other challenges include education in substance use disorder.^22,23 Resources and service obligations is the third reporting category. Cleanliness and availability of a call room, access to healthy food 24 hours a day, and safe transportation to work are examples of common house staff concerns. These became paramount during the initial COVID19 surge.²⁴ Work hours may also be affected by hospital resources and staffing, with implications for wellness of trainees and patient outcomes.²⁵ Although Program Directors and Designated Institutional Officials are especially familiar with these challenges, the partnership with the Ombuds can provide an additional avenue of support for trainees.

Mental health and wellness, the fourth reporting category, are paramount to a nurturing learning environment. Protecting house staff from physical and psychological fatigue while providing them the resources they need to serve our patients takes extensive institutional and national support.^24,26 Our department offers complimentary individualized therapy with providers who have an expertise in mental health. The Ombuds can highlight these resources during visits. Reducing the stigma associated with seeking mental health support is an indispensable part of medical education.^27,28

Finally, culture and morale, the fifth reporting category, is the most intangible. Recognizing house staff at regularly scheduled award ceremonies that celebrate clinical excellence, teamwork, and quality metrics is one way to improve morale. Frequent social gatherings outside of the hospital setting that integrate faculty advisors can provide uplifting avenues to connect. Departmental newsletters and social media also provide a venue for building community across large departments. Our ACGME resident well-being surveys have improved in several domains, which may, in part, reflect this educational innovation. In the 2023 to 2024 academic year, 90.1% of residents responded strongly agree or agree to “I feel more and more engaged in my work” compared with 75.8% in academic year 2020 to 2021 before the implementation of the Ombuds program. Similarly, 97% of residents responded strongly agree or agree to “I work in a supportive environment” in 2023 to 2024 compared with 82% before the implementation of the Ombuds.

Survey Data and Assessment

Since the implementation of the Education Ombuds in our residency program in September of 2021, our ACGME survey data illustrate positive trends in questions regarding confidential reporting of unprofessional behavior, raising concerns without fear of retaliation, and dealing confidentially with problems and concerns. Table 1 illustrates these trends over time with program-specific data compared with nationally compliant benchmarks. Academic year 2023 to 2024 is the first year that our residency program exceeded national percentages in all three question categories. Although there may be external factors contributing to the steady improvement in survey data, we attribute the establishment of the Education Ombuds for house staff as an impactful innovation that has positively enhanced our learning and working environment. Cost, space, and time are challenges to the establishment of the Education Ombuds, although we believe that it is possible to advocate for these resources with Chair and Program Director support, especially when the benefits to the program yield tangible outcomes for the department and institution.

Table 1.

Accreditation Council for Graduate Medical Education Residency Program Survey Data: Program Compliant Percentages

	Pre-Ombudsa	Post-Ombudsa
	AY 2020 to2021	AY 2021 to2022	AY 2022 to2023	AY 2023 to2024
Process in place for confidential reporting of unprofessional behavior	62% (86)	82% (88)	87% (89)	94% (90)
Able to raise concerns without fear of intimidation or retaliation	49% (78)	62% (79)	64% (78)	85% (80)
Satisfied with the process for dealing confidentially with problems and concerns	46% (76)	60% (75)	59% (75)	79% (76)

Abbreviations: AY, academic year; Ombuds, Ombudsperson.

^aProgram compliant percentages with national percentage benchmarks in parentheses.

Benefit to the Larger Organization

The Ombuds role can significantly benefit the university and hospital. Problems can be identified early, and collaboration with institutional leadership can proactively resolve conflicts. In addition, serious matters can be forwarded to appropriate offices more readily in a culture where residents feel free to voice concerns. GME parental leave policies are one such example.²⁹ GME has the opportunity to redesign their guidelines to better support residents, as many national boards have done in the recent years.^30,31 The Ombuds can also serve as a role model or coach for house staff, guiding them in escalation of concerns or redirecting them when needed. The role of the Ombuds provides a well-defined space to support and address residents’ concerns within a residency program. The proposed process offers a confidential venue to respond and address issues unique to a residency program in a more immediate manner by quickly escalating and communicating with program leadership and hospital administration, when necessary. This innovative educational initiative can be implemented regardless of the collective bargaining status of a program or institution. The Ombuds’ ability to act as an impartial resource within a residency program provides an invaluable opportunity to address individual concerns and create meaningful change.

CONCLUSION

In conclusion, an Ombuds program may offer excellent support for GME. Maintaining a status of impartiality, the Ombuds may provide a confidential and safe space to express concerns about the learning environment, identify areas for improvement, and promote wellness. We recommend that this novel Ombuds initiative be explored at other institutions and that additional outcomes of such programs be explored in future studies.