Dear Editor,
We read with great interest the article by Nori and colleagues who, through use of the Maslach Burnout Inventory and an infectious diseases (ID)–specific job satisfaction survey designed by the authors, measured burnout at an academic ID division in the United States [1]. They demonstrated that despite >90% job satisfaction among their ID faculty, >50% of their faculty respondents experienced burnout [1]. Potential contributors included poor remuneration, lack of staff support, challenges with work–life balance or childcare, teaching and billing expectations, constraints of the electronic medical system, and lack of departmental support for protected scholarly time [1]. Burnout within ID is likely not restricted to faculty alone. Fellows suffer similar challenges and probably have similar (or higher) levels of burnout, but this has not been systematically explored in medical specialty fellowships [2, 3]. Not surprisingly, most interventions to alleviate burnout have also been focused on residents, not fellows [4–7].
Based on data from our Accreditation Council for Graduate Medical Education (ACGME) fellow surveys, internal anonymous surveys of fellows and faculty across our 3 campuses, and an anonymized survey of fellows conducted during a focus group with an external reviewer, we determined that interventions were needed to reduce burnout and enhance the well-being of ID fellows at the University of California, San Francisco. We reviewed the existing literature and consulted with local experts on trainee well-being to determine an action plan based on the pillars of workload reduction, well-being education, enhancing resilience, and community-building. We designed a multitiered approach to enhance wellness among ID fellows and established an ID Fellowship Well-Being Committee (WBC) to lead the effort. The WBC is comprised evenly of faculty and fellows at multiple levels of training from all 3 teaching hospitals associated with our program. Meetings occur every other month, and co-chairs (1 faculty and 1 fellow) formally update the fellowship program director quarterly. Interventions mapped to our wellness pillars are described in Table 1. The main interventions have included educating faculty and fellows on the topics of wellness and burnout, longitudinal reflective writing exercises (exploring topics such as diagnostic uncertainty, efficiency, working with different attendings or different services, and gratitude), initiation of senior fellow wellness activities, and launch of a well-being retreat during the first year of fellowship.
Table 1.
Overview of ID Fellow Well-being Aims and Programming
| Pillars | Interventions |
|---|---|
| Reduction in workload | • Increased clinical support, including pager coverage, on ID consult services at the 2 busiest teaching hospitals |
| • Decreased number of ID Division Grand Rounds presentations required in first year of fellowship | |
| Education in well-being | • ID Division Grand Rounds by the Director of Well-Being for Graduate Medical Education at our institution |
| Enhancing resilience | • Reflective writing exercises |
| • First-year fellow retreat | |
| • Full-day retreat involving pager and service coverage, late start, team-building activity, and gratitude writing exercises, followed by a community building activity with all fellow classes | |
| • Senior (2nd–4th-year) fellow dinner series | |
| • Twice annual dinners with faculty facilitator to decrease isolation, provide space for real-time peer mentorship, and give anonymous feedback about the program | |
| Community building | • First-year fellow retreat, full-day (as above) |
| • Senior fellow dinner series (as above) |
Abbreviation: ID, infectious diseases.
After the retreat, first-year fellows were sent a survey to evaluate the impact of the retreat. Themes identified from the survey included benefits of having protected time together, convening in an informal setting to provide feedback, and spending quality time in a nonclinical setting with co-fellows. Fellows recommended that the retreat continue to be offered annually and cited it as a strength at our annual fellowship external program review. Thus, the WBC plans to continue and improve upon the aforementioned activities.
We plan to monitor data on fellow burnout and make programmatic changes based on trainee input, including providing more opportunities for trainee feedback, developing a peer mentorship program, and designing additional reflective writing exercises. We anticipate that through the reflective writing exercises, we will continue to encourage discussion around difficult topics, normalize experiences, suggest coping mechanisms, and ultimately preserve empathy.
As burnout is likely high among internal medicine subspecialty fellows, interventions are needed to support their well-being. We describe a roadmap for the development of a well-being program at an academic ID fellowship program led by a fellow and faculty committee. We are hopeful that our work will empower other programs to engage in developing their own well-being programs so that we can all help mitigate burnout among ID fellows and faculty by introducing these concepts early in training. Specific steps include performing a needs assessment, creating a charge, determining priorities, attaining division support, educating the local community, forming a well-being committee that meets regularly to design interventions mapped to local priorities, and fostering continued discussion toward cultivating ID divisions committed to trainee and faculty wellness.
Acknowledgments
Financial support. No funding was received for this project or manuscript.
Potential conflicts of interest. All authors: no reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Prior presentations. A poster presentation of the survey data was shared at the ID Week Conference in Washington, DC, on October 5, 2019.
References
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