Establishing a Culture of Intentional Wellness

Abstract

Introduction

Residency training is a peak time of physician distress, but also a venue in which residents can learn skills to thrive in a high-risk career. The goal of this study was to examine residents’ perceptions of the value of teaching wellness as an integrated component of a residency program.

Methods

Researchers at the University of Utah Family Medicine Residency Program conducted a focus group with graduating family medicine residents regarding their perception of wellness and wellness skills, after having completed an intentional wellness curriculum integrated through their 3 years of residency. We used open coding to identify themes of the residents’ perceptions of the wellness curriculum.

Results

Four interconnected themes emerged: (1) describing the relevance of wellness to a medical career; (2) the wellness curriculum as prioritized and intentional; 3) The value of wellness skills learned through the curriculum; and (3) the role of community ethos in maintaining wellness.

Conclusions

Residents consider wellness to be a critical facet of being an effective physician. Our results suggest that a culture of wellness can be created through deliberate and transparent curricular design, helping residents to view wellness as a priority.

Introduction

Medicine is a high-risk career, and residency training is a peak time of physician distress. Rates of burnout and depression are as high as 50%, and higher than the general population at all stages of medical training.¹ Medical residency is an ideal time to teach skills for coping with a high-stress profession, and evidence suggests that training programs can actively promote an environment that protects against burnout.^2–4 The goal of this study was to understand how family medicine residents view wellness, and what they value from a wellness curriculum.

At the University of Utah Family Medicine Residency Program (UUFMRP), we have integrated wellness across training, utilizing principles of positive psychology.⁵ The UUFMRP is a community-based, university-affiliated family medicine residency program with 24 residents (eight residents per year). The wellness curriculum includes: weekly support groups for interns during half the year, and a monthly skills-based support group for all residents integrated into weekly didactics; dedicated wellness time at retreats; a resident “buddy” system; frequent wellness check-ins; and protected time for health appointments for residents. The curriculum focuses on: (1) self-assessment skills and goal-setting regarding wellness; (2) managing stresses of residency and future career; and (3) opportunities for enjoyment, engagement and meaning in work through programmatic structured activities. See Table 1 for a description of program components.

Table 1.

Components of UUFMRP Wellness Program

1. Operations–Intentionally Support Wellness

Policies and procedures support wellness: Chiefs serve as resident liaisons to residency leadership Sick Coverage: backup system that does not need to be “paid back” Medical/mental health appointments supported Self-study option allowed for missed didactics Rotation schedule planned annually by resident preference Rotation schedule flexibility for maternity/paternity leave Lactation support through blocked clinic time Reimbursed cab fare if unable to safely drive home after work Quarterly faculty advisor meetings address wellness Wellness check-in is formally integrated into faculty advisor meeting expectations Residents provide anonymous quarterly feedback to residency program with closed loop communication Reviewed by chiefs and residency faculty, with discussion of outcomes at monthly resident meeting

2. Didactics–Integrate Wellness into Core Curriculum

Intern Orientation establishes wellness as a residency value Develop Personal Wellness Plan © Behavioral goals set at the beginning of intern year (ie exercise three days per week; call my family every day off) Intern Support Group Occurs weekly the first hour of interns’ protected Friday afternoon didactic time. Required for interns and facilitated by behavioral science faculty. Resident “Resilience and Recovery” Group Faculty-led group focusing on stress management and wellness skills (ie, coping with sleep deprivation, handling difficult attending physicians, ethics of prescribing to friends and family); occurs monthly during the first hour of all residents’ Wednesday afternoon didactic time. Required for residents on rotations that allow them to attend didactics. “Patient Safety Conference” Recurring Grand Rounds addresses difficult patients and situations Residency Retreats/Workshops (R1 Retreat, R1 Leadership Workshop, R2 Retreat): Self-assess wellness and refine Personal Wellness Plan © Develop effective communication skills Cultivate identity as a physician and meaning in medicine

3. Frosting–Nurture Connection to Each Other and Community

“Intern Buddy” Each intern is assigned an upper class “buddy” to help with transition to residency Community outreach integrated into curriculum Medical care provided to underserved at community health fair, projects with local community gardens, early literacy books distributed at refugee health fair Social events coordinated by residency Integrates interns into residency and supports global residency community

To evaluate residents’ perception of the value of an integrated wellness program, including their understanding of wellness and skills that they find useful for future careers, we conducted a focus group with outgoing third-year family medicine residents.

Methods

This study sought to understand perceptions of a wellness curriculum and its applicability during a family medicine residency by conducting a focus group with third-year family medicine residents, using phenomenology principles to describe “what [residents] experienced and how they experienced it”.^6,7 The eight graduating residents were invited to participate in this optional group, and all eight consented to participate. Dinner was provided, and residents were thanked for their time with a small gift card. We obtained approval from the University of Utah Institutional Review Board, and followed appropriate participant consenting.

One of the authors (CJF) and a research analyst moderated the focus group using a guided interview schedule (see Table 2); these moderators are not faculty within the department where the residency is located, and are not involved in the wellness curriculum. We asked residents about definitions of wellness, skills needed to promote wellness, and activities they participated in to promote and maintain wellness. A 45-minute audio-recorded focus group was transcribed by a professional transcription service, and the research team checked the transcript twice for accuracy. All three authors independently coded the transcripts, and met twice to co-identify themes from the transcript, resolving any conflicts among codes through in-depth discussion. We used open coding initially for analysis, and moved to selective coding around themes from the transcript.

Table 2.

Focus Group Guided Interview Schedule

How would you define wellness for residents? What skills are needed by residents to develop wellness? What program support should a residency program provide to help residents to develop wellness? What resources are needed by residents to develop wellness? What skills are needed by residents to maintain wellness? What program support should a residency program provide to help residents maintain wellness? What resources are needed by residents to maintain wellness? During your residency program, what are the resources you have had access to that enhanced wellness for residents? Based on the list provided, please discuss as many of these resources as you can. [Table similar to Table 1 was provided.] Have residents accessed any of these resources? In your opinion, were these resources applicable to their needs? Has the intentional wellness curriculum helped you develop as a physician or overall as a person? Do faculty members model wellness themselves? Does the residency culture allow residents to practice wellness? Is there anything else you would like to share with us?

Results

Four interconnected themes emerged from the focus group: (1) residents’ view of wellness, and their understanding of its impact on their current behavior and future career, summarized under “definition of wellness and its relevance”; (2) residents’ perception of how wellness was promoted through the residency curriculum, including the extent to which the program prioritized wellness intentionally (ie, dedicated programmatic and faculty time), summarized under “wellness curriculum is prioritized and intentional”; (3) wellness skills that residents identified as having learned through the wellness program, such as techniques for maintaining personal and professional resiliency, effective coping, and maintaining optimal patient care through difficult times, summarized under “wellness skills and intrapersonal awareness”; and 4) role of the community and interpersonal relationships in wellness, including health of the overall group, summarized under “interpersonal culture of wellness”

Example quotes from focus group participants are shown in Table 3 to illustrate these themes and highlight how they connect to the program's wellness curriculum and link to residents' view of their own wellness behaviors.

Table 3.

Selected Quotes Illustrating Focus Group Themes

Theme 1: Definition of Wellness and its Relevance

When asked to define wellness, residents responded: “Physical and emotional well-being” (resident 1) “Maintain[ing] personal health while attending to work responsibilities” (resident 2) “That ability, I guess, to have balance or to be able to find balance in your life that makes you happy and continue to enjoy what you’re doing” (resident 3) When describing the relevance of wellness in their future practice: “I mean, if you’ve achieved a level of wellness you’re able to be, like, present with your patients” (resident 1) “I think one of the most important points in my residency training when I really started to emphasize on personal wellness was when [faculty member] taught us about how the care of patients is better when the physicians aren’t burnt out. I think she actually showed it to us in the opposite where care is worse. Outcomes are worse when patients are cared for by

2. Didactics–Integrate Wellness into Core Curriculum

“Well, I think one big positive step that this program has already achieved is that the program thinks about it. There’s like a chief’s meeting in the spring when we get new chiefs and you meet the chiefs from other programs. There are a lot of other programs where wellness is just not even in their vocabulary. I think programs need to have that on their radar as a priority, which I think that this program does better than others” (resident 1) “I think we also do a good job of teaching wellness or discussing it early. That’s one of the first things about which we probably talk because it’s kind of needed from the start. They're skills that you'll be using throughout. It's not something that would be very effective if they just waited until third year or something” (resident 3) “A couple of other things with which the program did a good job is the [Residency “Resiliency and Recovery” Group] group meetings that we have . . . . I think that's important because it's regular, it's structured, and it's been nice” (resident 5) “I think that it's also important to note that it's [Residency “Resiliency and Recovery” Group and Intern Support Group] not done outside of our duty hours. It's protected time, meaning that it happens sometimes between 8:00 a.m. and 5:00 p.m. That's helpful. … it's something that's built into the schedule” (resident 4)

Theme 3: Wellness Skills and Intrapersonal Awareness

“Self awareness. You have to recognize cues of, I guess, stressors and things that may begin to impact your health and you have to be aware of those things to recognize when to step back and figure out okay, what changes do I need to make to be more effective, to have that, I guess kind of like you said, the balance, … having that balance in your work life and other aspects of life” (resident 4) “There are times where you probably could spend like four hours doing a discharge summary and it would be like the best discharge summary anyone's ever read. That versus doing a discharge summary in 20 minutes that might be adequate and sufficient, but it's more of a bronze standard than the gold standard” (resident 6) “I think prioritizing is a big part of it [wellness] because some nights you probably have assignments you have to get done, you have notes you have to finish. But some nights it’s okay to not do work or skip an hour sleep to go do something fun to recharge” (resident 5) “I think learning how to prioritize, learning how to budget time for certain tasks, so that the time that you had set aside for pursuing your wellness goals actually gets used for that purpose” (resident 6) “I think also recognizing that there is no perfection. I think a lot of times we get so focused on wanting to do things perfectly and right, instead of thinking well, there are multiple ways to do this. It's a learning process throughout our career, not just as residents, not just…it's always going to be that way. You're kind of cutting yourself some slack instead of being so hard when you come to things. You know you are doing well, but recognizing that it's okay to not be perfect because nobody is” (resident 4)

Conclusions

This qualitative study examined family medicine residents’ perceptions of the value of an integrated wellness program. First, wellness is considered a critical facet of an effective physician. The residents described how attention to wellness was relevant to personal and professional satisfaction, improved patient outcomes, and continuing as a physician. Second, a culture of wellness can be created through deliberate, transparent curricular design. Many facets of this wellness program are commonplace; however, the focus group emphasized the importance of making wellness a program priority by allocating time (our most precious resource) to wellness. Optional after-hours activities are not sufficient; rather, including wellness into the overall curriculum structure highlights wellness as a program priority. Third, residents identified intrapersonal skills of self-awareness and self-management as paramount in cultivating their own wellness. Our curriculum is heavily skills based, and participant comments suggested that they have integrated these skills into their lives. Role-modeling, peer and faculty support, and a sense of responsibility to one another were important factors in creating an ethos of wellness.

This study is limited by small sample size and reflects the views of residents at a single institution. Focus group responses may have been biased by primarily positive framing of questions, or by knowledge that residency faculty were organizing the study; however questions were open ended and the focus group was led by individuals unaffiliated with the residency. It will be critical to understand how residents in different programs with various curricula view wellness. Despite these limitations, the residents’ descriptions demonstrated the value ascribed to an intentional wellness component embedded within training. The themes described provide a framework that can be employed by other programs intent on understanding the value of wellness activities.

In conclusion, residency training is the primary venue for teaching wellness as a foundational skill for a successful medical career. To create a culture of wellness, residencies should be intentional about integrating wellness curricula from the first day of training. Residents view wellness as a priority when program time is dedicated to the curriculum, and when it is part of the program vocabulary. Components of a wellness curriculum are relatively simple to implement, and many residency programs have many components already in place. Focus group participants articulated that introducing wellness early and reinforcing wellness longitudinally is likely an effective means to cultivate long-term provider wellness.