Development of an Emergency Medicine Wellness Curriculum

Abstract

Burnout, the triad of emotional exhaustion, depersonalization, and low personal accomplishment, begins early in medical education and the prevalence continues to increase over time among U.S. physicians. The Accreditation Council for Graduate Medical Education (ACGME) now requires that programs and sponsoring institutions have the same responsibility to address well‐being as they do other aspects of resident competence. Yet, there are no studies published in the emergency medicine (EM) literature that discuss the development and institution of a formal wellness curriculum. The authors conducted a needs analysis among EM residents with the aim of creating a multifaceted 12‐month wellness curriculum. The needs analysis determined that residents are not comfortable with their knowledge of wellness principles. In response, the authors developed a curriculum by integrating components of published non‐EM wellness curricula and online academic wellness programs with commonly accepted domains of wellness. The curriculum was subsequently introduced at five EM residencies. This curriculum represents an example of successful multi‐institution collaboration to meet an ACGME Common Program Requirement.

Physician burnout, the triad of emotional exhaustion, depersonalization, and low personal accomplishment,1 is a common phenomenon among U.S. physicians2, 3, 4 and begins early in medical education, with approximately half of medical students and residents reporting burnout.5, 6 While a number of specific contributors to burnout have been identified,4, 7, 8 they are reflected in the themes of workload, control, reward, community, fairness, and values.9 At 59%, emergency medicine (EM) has the highest burnout rate across specialties.7 Burnout has significant implications as it increases the likelihood of making medical errors,10 decreases career satisfaction and longevity,11, 12 adversely affects self‐reported patient care,13, 14, 15, 16 is associated with physician physical17 and mental illness18, 19 as well as substance abuse,20, 21 and may ultimately impact the U.S. physician workforce.22

Residency is a formative time for physicians to develop professional habits, including learning effective approaches to burnout mitigation, self‐care, and patient–physician relationships, all under the guidance of faculty physicians and residency leadership. Education about burnout and delivery of tools to grow resilience and wellness during residency may provide long‐lasting positive professional and personal effects. The Accreditation Council for Graduate Medical Education (ACGME) recognizes the importance of physician wellness, and their 2017 Common Program Requirements state that Programs and Sponsoring Institutions have the same responsibility to address well‐being as they do other aspects of resident competence.23

Unfortunately, there have been limited organized resources for programs to incorporate into residency wellness training, and to our knowledge no PubMed‐indexed studies exist in the EM literature discussing the development of a wellness curriculum. Therefore, after conducting a multicenter EM residency needs assessment, the authors created a novel, adaptable, sustainable, multifaceted 12‐month wellness curriculum that was subsequently introduced at five EM residencies across the country.

Needs Assessment

Prior to the development of the curriculum, the authors performed a multicenter needs analysis at five ACGME‐accredited EM residencies in February 2017. Each site obtained institutional review board approval for the administration of the survey. The survey was distributed on paper during weekly educational conference, participation was voluntary, and no incentive was offered for participation. Follow‐up was program‐specific, either in‐person or via e‐mail. The four question survey assessed: 1) How important residents believe it is to include information about wellness topics in residency training; 2) How relevant the topic of wellness is to the resident physician; 3) How comfortable the resident is with her/his knowledge of wellness principles; and 4) How valued the incorporation of wellness principles is to the maintenance of her/his career as a practicing EM physician. Residents answered each question using a 100‐point Likert scale, with 0 representing “not at all important” and 100 representing “highest importance.”

A total of 163 of 186 residents at these five programs completed the survey leading to an 88% response rate. The median response for question 1 (importance) was 80 (interquartile range [IQR] = 65–93.5); for question 2 (relevance), 90 (IQR = 75–100); for question 3 (comfort) 70 (IQR = 50–85); and for question 4 (value), 88.5 (IQR = 70.75–100). The authors thereby determined that while the topic of wellness is relevant to the resident and valuable for their career, they are not as comfortable with their knowledge of wellness principles. These findings supported the need to develop a formal residency wellness curriculum.

Curriculum Development

The authors then searched the PubMed (National Center for Biotechnology Information, Bethesda, MD) database as well as the Internet (Google search) using search terms burnout and physician wellness. We identified pertinent articles and online academic wellness programs, specifically focusing on examples of wellness curricula and wellness interventions associated with positive professional and personal outcomes.

The authors designed their multifaceted 12‐month wellness curriculum, “Choose Wellness EM,” based on consensus recommendations of a group of EM educators, composed of the authors and the Emergency Medicine Education Research Alliance (EMERA). The creators' mission is to promote health and resilience through engagement in the six common dimensions of wellness to develop a lifelong approach to self‐care and sustained joy and satisfaction as an emergency physician. “Choose Wellness EM” is openly accessible on the EMERA website (emeranetwork.org), which provides a durable online location for the curriculum.

The Curriculum

The curriculum integrates components of published non‐EM wellness curricula and online academic wellness programs24, 25, 26, 27, 28, 29 with Hettler's commonly cited Six Dimensions of Wellness: Social, Spiritual, Occupational, Physical, Emotional, and Intellectual.30 It includes bimonthly structured didactic elements, individualized interactive instruction (III) assignments, and additional Internet‐based resources.

The six didactic presentations, corresponding to the dimensions of wellness, were created by faculty members at the participating residencies and shared to ensure standardization of content delivery across programs. There was particular emphasis on building resilience across each of the domains. Each lecture was scheduled for 45 minutes with a focus on active discussion, facilitated by the lecturer asking the residents to reflect upon and share their experiences and opinions. These lectures were delivered during the protected weekly EM conference at each of the five sites on a bimonthly basis.

The III assignments also corresponded to the six dimensions of wellness and were assigned for completion in the month preceding each corresponding didactic (Table 1). The III assignments were consistent with the ACGME requirements for asynchronous learning. The evaluative component occurred at the start of each lecture with time devoted to discussing the previous month's assignment.

Table 1.

Individualized Interactive Instruction (III)

Social Watch: “Bite Sized Resilience: Three Good Things” then enroll in a 2017 cohort at http://www.dukepatientsafetycenter.com to receive 2 weeks of e‐mail prompts. Spiritual Read: Weingart S. First Person: Kettlebells for the Brain. Emerg Med News 2017;39:26–7. Read: Be Mindful: ‘Tis the Season to be Mellow. UCLA magazine. Occupational Complete an implicit association test. View: The New York Times Video Series “Who, Me? Biased?” Read: Roberts J. In Focus: How to be a Real EP: Advice for New Graduates (and a Good Reminder for Seasoned EPs, Too). Emerg Med News 2016;38:12–4. Read: Chisolm C. Reflections about “Burn‐Out.” Acad Emerg Med 2009;16:567–71. Physical Keep a sleep journal using one of the following apps: Sleep Diary (iPhone) or SleepBot‐Sleep cycle (Android) × 2 weeks. Commit to a primary care doctor and/or dentist and see them for a health evaluation if not completed in the past year. Emotional Read: Shaw G. Special Report: Who Lives, Who Dies, Who Tells Your Story? The Magic of Narrative Medicine in the ED. Emerg Med News 2017;39:20–1. Journal: about a challenging case or interaction. What did you learn from the experience? How will it shape your practice moving forward? Intellectual Learn a new “super‐user” move with your electronic health record (e.g., Dragon, macros) and be ready to share with your residency colleagues in weekly education conference

In addition, there were corresponding nondidactic components to augment the residents’ experience and provide opportunities to improve their personal and professional wellness (Table 2).

Table 2.

Nondidactic Curricular Elements

Social Schedule a class day off for each postgraduate year class. Arrange discounted tickets to the theater and sporting events. A different faculty member plans a social activity for the residents and department each month (e.g., group outing to a collegiate football game). End‐of‐year barbeque or graduation celebration. Wellness “families”: groups of residents paired with attendings, nurses, and support staff to improve interdisciplinary relationships. Spiritual Group service project (e.g., gardening at a local park). Group yoga class. 10‐minute guided meditation during weekly education conference. Occupational Designation of a faculty and resident wellness champion. Public affirmation of resident personal and professional achievements. Yearly resident “wellness retreat” held off‐site. PGY‐specific orientation at the start of each new academic year to discuss new responsibilities and class‐specific topics. “Attending stories” speaking series allows faculty to discuss aspects of life and work that are overlooked in traditional resident education (e.g., raising children, women in medicine). Pair each junior resident with a senior resident mentor. Physical Team building through participation in a local sprint triathlon or recreational sports league such as team beach volleyball. Group martial arts training. Nutrition education and discussion. Compile a list of primary care physicians and dentists who are dedicated to the treatment of health care professionals. “Weekly Wednesday Wellness” newsletter with nutrition and exercise tips. Emotional Narrative writing series. Conflict management seminar. Provide resources for residents experiencing mental health concerns and psychiatrists dedicated to the treatment of health care professionals. Intellectual Residency improvement committees (e.g., medical student education, resident education, outreach, and clinical operations) meet quarterly with longitudinal projects to improve clinical and education realms. Opportunity for residents to join hospital‐wide committees. Book club that reads works on the New York Times bestseller list. “Practice Excellence Award,” with stickers attached to name badge for visible recognition.

Finally, the authors sought additional Internet‐based resources and mobile application software (apps) to further enhance the curricular experience using technology and educational styles appealing to today's learners. National wellness leaders including Stanford BeWell,27 the BMC Wellness Program,28 and the Duke Patient Safety Center29 agreed to share their copyrighted information without limitation for this educational purpose. Free apps with high user ratings were also identified and included under the appropriate wellness domain (Table 3).

Table 3.

Additional Resources

Social Nedrow A, et al. Physician Resilience and Burnout, Can You Make the Switch? “10 Ways to Build Resilience” from The American Psychological Association. Riches J. Insights on Residency Training: What is Resilience? NEJM Journal Watch. July 15, 2016. Spiritual “Kettlebells for the Brain‐Meditation by Scott Weingart from SMACC 2016 Dublin. “10 simple ways you can practice mindfulness each day” from the Benson‐Henry Institute for Mind Body Medicine at Massachusetts General Hospital. Mobile application software (apps): Headspace (guided meditation); Insight Timer (meditation timer). Occupational “So You've Been Sued” Resource Document from the American College of Emergency Physicians’ legal committee. “Getting Sued. A Resident's Perspective” From the American College of Emergency Physicians. Weinstock MB, Longstreth R, and Henry GL. “Bouncebacks! Emergency Department Cases: ED Returns.” Medically Induced Trauma Support Services. Ofri D. Doctors Have Feelings Too. The New York Times. March 27, 2012. Physical The Boston Medical Center Wellness Program: Self‐Care Assessment Tool; Nutrition Self‐Assessment Tool: Rate Your Plate; Sleep Assessment Tool. Wickwire EM. Anchor Sleep to Survive Shift Work. Sleep Review. March 13, 2016. The Mayo Clinic: Physical Activity Self‐Assessment Tool; Exercise: 7 Benefits of Regular Physical Activity; Tips for Staying Motivated. Mobile application software (apps): MyFitness Pal's Calorie Counter and Diet Tracker; MyNetDiary's Calorie Counter and Food Diary; Myplate; Shopwell; Waterlogged; Fitness Blender; The Dirty Dozen. Emotional Conflict Resolution Skills: ARTS of communication from the American Academy of Communication in Healthcare. Building Team Relationships with RESPECT from the American Academy of Communication in Healthcare. Intellectual Geary A. “Eight Simple Steps to Increase Your Intellectual Wellness” Illinois State University. Intellectual Wellness from the University of California, Riverside. Jenkins C. “5 Reasons Travel is Great for Your Health. Wellness Today by the Institute for Integrative Health” March 8, 2014.

Discussion

Despite the prevalence of burnout and its significant implications, there remain few published residency wellness curricula and no multicenter residency curricular collaborations; outcome assessments of published curricula are also very limited.24, 25, 26, 31, 32, 33, 34 In response to this gap of wellness education in residency training, the authors developed the first formal, sustainable EM wellness curriculum. The curriculum has been introduced at five allopathic ACGME‐approved EM residencies across the country, as an addition to any wellness initiatives already in place at each program. While “Choose Wellness EM” was created by EM educators, its components, including the didactic presentations focusing on fostering resilience, nondidactic elements, and additional resources are easily generalizable to other specialties. This curriculum represents an example of successful multi‐institution collaboration to meet an ACGME Common Program Requirement.

While there have been few publications addressing formal wellness curricula, evaluation of targeted wellness interventions is more common and sustained positive effects of discussion groups on mindfulness, reflection, self‐awareness, and fostering community have been demonstrated.35 Training in resilience, mindfulness, and empathy;36 work condition interventions;37 coping skills;38 and mindful communication39 are all also associated with decreased burnout. A systematic review and meta‐analysis of wellness interventions for residents and practicing physicians demonstrated benefits both from individual‐focused interventions including mindfulness, stress management, and small group discussions and from organizational interventions to impact clinical work processes and work hour limits.40 It is thereby increasingly recognized that a comprehensive and cohesive approach to physician well‐being is most effective.8, 9, 41, 42

Despite feasible implementation of the curriculum, the authors faced several important limitations. While an evidence‐based approach to curriculum development was utilized, “Choose Wellness EM” is not inclusive of all available wellness resources and not all resources have been independently validated as effective. Physician well‐being is complex and different interventions are likely necessary to address different components of wellness.35 As wellness is a rapidly evolving field, ongoing review of the curricular components will be required, and new literature will continue to redefine the most impactful wellness interventions. There were also challenges associated with the multi‐institution collaboration. While the lectures were created and shared to ensure standardized content delivery, one site leader noted difficulty delivering lectures he did not prepare. In addition, not all sites implemented every aspect of the nondidactic curricular elements and there was some site study leadership turnover. Ongoing communication between site leaders has facilitated feedback on content delivery and curriculum progress.

Conclusion

Residencies have a responsibility to educate trainees on the subject of burnout prevention, physician resilience, and well‐being. Further, this needs assessment demonstrated that residents appreciate the relevance and value of wellness for their career but are not comfortable with their current level of knowledge concerning the principles of wellness. In response, the authors created a novel, adaptable, sustainable curriculum with subsequent implementation at five EM residencies. The authors are currently conducting a multicenter study evaluating the effects of implementing this curriculum on resident wellness. An additional postintervention assessment will determine if residents’ views on wellness change as a result of the curriculum.

AEM Education and Training 2018; 2: 20–25.