Implementation of wellness into a cardiothoracic training program: A checklist for a wellness policy

Central MessageWe have developed a wellness policy checklist and sample to help guide cardiothoracic surgery training programs with implementation that adheres the ACGME requirements.See Commentaries on pages 1987 1988. We requirements. See Physician impacts patient care education of trainees. Lack physician burnout is characterized by emotional exhaustion, depersonalization, low sense accomplishment.1Schwenk T.L. Davis L. Wimsatt L.A. Depression, stigma, suicidal ideation in medical students.JAMA. 2010; 304: 1181-1190Crossref PubMed Scopus (312) Google Scholar Burnout puts physicians at risk for substance abuse, intent leave practice, suicide.2Dyrbye L.N. Thomas M.R. Massie F.S. Power D.V. Eacker A. Harper W. et al.Burnout among U.S. students.Ann Intern Med. 2008; 149: 334Crossref (743) Unfortunately, 50% 70% trainees report burnout,3Prins J.T. Gazendam-Donofrio S.M. Tubben B.J. van der Heijden F.M. de Wiel H.B. Hoekstra-Weebers J.E. residents: review.Med Educ. 2007; 41: 788-800Crossref (213) 29% experience depression,4Mata D.A. Ramos M.A. Bansal N. Khan R. Guille C. Di Angelantonio E. al.Prevalence depression depressive symptoms resident physicians: systematic review meta-analysis.JAMA. 2015; 314: 2373-2383Crossref (499) 6% 12% ideation.1Schwenk The physical demands long work hours surgical practice been attributed greater rates surgeons.5Balch C.M. Shanafelt T.D. Sloan J.A. Satele Freischlag Distress career satisfaction 14 specialties, comparing academic private settings.Ann Surg. 2011; 254: 558-568Crossref (158) Cardiothoracic surgeons greatest number operating room, positive screening assessment, lower mental quality life score comparison other specialties.5Balch Scholar,6Shanafelt Balch Bechamps G.J. Russell T. Dyrbye D. American surgeons.Ann 2009; 127: 107-115Google In addition individual dangers, can be linked errors, problems professionalism, adverse outcomes.7Panagioti M. Geraghty K. Johnson J. Zhou Panagopoulou Chew-Graham al.Association between safety, satisfaction: meta-analysis.JAMA 2018; 178: 1317-1330Crossref (401) Scholar, 8West C.P. Huschka M.M. Novotny P.J. Kolars J.C. Habermann T.M. perceived errors distress empathy.JAMA. 2006; 296: 1071Crossref (871) 9Han S. Sinsky C.A. Awad K.M. Fiscus L.C. al.Estimating attributable cost United States.Ann 2019; 170: 784-790Crossref (188) Attributable States approximately $4.6 billion dollars annually, which equates an annual $7600 per physician.9Han These alarming statistics prompted Accreditation Council Graduate Medical Education (ACGME) take meaningful action. 2015, organized first Symposium Well-Being promote change wellness.10Accreditation Improving Well-Being, Restoring Meaning Medicine.https://www.acgme.org/What-We-Do/Initiatives/Physician-Well-BeingGoogle 2016, Association Colleges National Academy Medicine formed Action Collaborative Clinician Resilience. 2017, revised its common program requirements include specific action all residency (Figure 1). Many implemented these However, there are no guidelines into programs. purpose this organize approach assess culture within encompasses practices from specialties. An online web search using key words wellness, well-being, burnout, fatigue was conducted completed September 25, 2019. Literature established were reviewed resources ACGME, Colleges, (AMA), Medicine, College Surgeons (ACS), Obstetricians Gynecologists, Johns Hopkins Mayo Clinic, Oregon Health & Science University, University Colorado websites. Recommendations wishing implement adherence A must adhere Each has “enhance meaning each finds being physician.” Wellness includes challenged, building competence, autonomy, achieving personal professional success, strong social relatedness work.3Prins Scholar,11American Preventing residents fellows: 6 keys wellness.https://www.ama-assn.org/residents-students/resident-student-health/preventing-burnout-medical-residents-and-fellows-6-keysGoogle Training pay attention scheduling (section VI.C.1.b), duty-hour adherence, but also consideration workload.12Fletcher K.E. Reed Arora V.M. Doing dirty work: measuring optimizing workload.J Gen 26: 8-9Crossref (9) Workload measured census,13Thanarajasingam U. McDonald Halvorsen A.J. Naessens J.M. Cabanela R.L. M.G. al.Service census caps unit-based admissions: workload, conference attendance, duty hour compliance, safety.Mayo Clin Proc. 2012; 87: 320-327Abstract Full Text PDF (29) complexity,14Ratcliffe T.A. Crabtree Palmer R.F. Pugh Lanham H.J. Leykum L.K. Service education: association complexity, teaching internal medicine inpatient services.J 33: 449-454Crossref (5) or paging data.15Kaushal Katznelson Harrington R.A. Beyond hours: leveraging large-scale data monitor workload.NPJ Digit 2: 87Crossref Work-related stress, activities marginal educational value (phlebotomy transportation), burden documentation increase perception Currently, consensus measurement workload. Nevertheless, responsible providing schedule enhances physician. Requirements workplace safety standards (VI.C.1.c). Safety efforts focused fatigue-related harm like motor vehicle accidents needle sticks.16Blum A.B. Shea Czeisler Landrigan Leape Implementing 2009 Institute recommendations hours, supervision, safety.Nat Sci Sleep. 3: 47-85PubMed hospitals should provide transportation who feel too fatigued safely navigate home.16Blum extend beyond mandate sufficient time away manage including medical, health, dental appointments (VI.C.1.d). AMA ACS suggest foster multifaceted through nutrition, fitness, preventative care, financial mindset/behavior adaptability.11American Scholar,17American SurgeonsSurgeon well-being.https://www.facs.org/member-services/surgeon-wellbeingGoogle ACGME-accredited faculty (VI.C.1.e). definition fatigue, burnout3Prins Scholar,18Raj K.S. Well-being residency: review.J Grad Med 2016; 8: 674-684Crossref (98) harmful sequelae, unprofessionalism, depression, suicide.9Han Faculty receive (symptoms, recognition themselves others, mitigation, treatment).19American Ed HubBurnout well-being.https://edhub.ama-assn.org/steps-forward/pages/professional-well-beingGoogle 20Duke School L.I.F.E. teacher’s guide.https://sites.duke.edu/thelifecurriculum/files/2014/05/Macy-teachersguide1.pdfGoogle 21Mayo Clinic Make Difference: Trainee Suicide.https://www.youtube.com/watch?v=I9GRxF9qEBAGoogle able identify seek abuse,22Hill Breaking stigma—a physician's perspective self-care recovery.N Engl J 2017; 376: 1103-1105Crossref (22) others. specifically members alert director designated personnel about any resident, fellow, member experiencing ideation, potential violence. tools well-being self-screening, access health services 24 day, 7 days week policies may unable perform responsibilities (VI.C.2.). Programs prepare possible short- long-term absences. ensure safe protect those covering absent resident. Developing flexible emergency protocols before absence facilitate decrease stress.23Kalmoe M.C. Chapman M.B. Gold Giedinghagen A.M. suicide: call action.Mo 116: 211-216PubMed core places direct responsibility challenging several reasons. First, traditionally placed surgeons, not individuals our field willing sacrifice achieve goal becoming surgeons. Second, does how wellness. needed education, development, service reorganization addressed. Third, framework To address last barrier, we propose 2 development comprehensive meets new Requirements: (1) Checklist essential components 2). will compliance allow program-specific adaptations based program's local resources, current status implementation. (2) Sample template 3, A-D). customize filling blanks appropriate personnel, dates, resources. links educational, treatment resources.17American Scholar,24Thoracic Surgery Directors AssociationFighting fatigue: residents.https://www.tsranet.org/wp-content/uploads/2013/01/Fighting_Fatigue.pdfGoogle Our hope enhance their wellness.Figure 3A-D, policy. Blank fields program.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure (PPT) One steps developing mission statement defines as it relates program. language level commitment defined environment examples statements organizations.25National MedicineAction Resilience.https://nam.edu/initiatives/clinician-resilience-and-well-being/commitment-statements-clinician-well-being/Google develop founded governing body uphold consist director(s), section chief(s), department chairs, officials, expertise hospital officers, committees, representatives psychiatry give larger existing 4). Most importantly, fellow representative participate governance stakeholders roles outlined As whole, dissemination, facilitation, maintenance curriculum faculty. define required ACGME.3Prins engage residents, encourage discussion namely work, health/safety work. times when fatigue. relationship they place Thoracic Resident content fatigue.17American addition, following: Strategies others.19American Means colleague need list services. (3) Notification if trainee appears fatigued, burned out, patients, themselves, decide vary content, approach, time. Once place, determine delivered, ie, grand rounds, small-group discussions, modules AMA.19American frequently delivered updated. rigor could potentially tested in-service examinations, board site visits. recommend designate oversee delivery content. Another requirement assessment life. some At time, administer screening, screened (residents only vs faculty), optimal interval what do results. May 2019 meeting, directors discussed risks self-assessment. Should results confidential? If so, would then self-navigating help? Alternatively, ask share self-screening cannot conflict trainees' right privacy. advise timing tool used, instruments individual's part distinctly separate overall evaluation. maintenance. adequate sleep facilities, environment, water healthy food, options return home. Residents opportunity attend appointments, adjust workload schedules accordingly. Hopefully, advantage scheduled without feeling guilty leaving plans intervene self needs pregnancy, maternity/paternity leave, family leave. issues and/or alternative person turn, expeditious plan individual. For concerns, contact information 24-hour-a-day (mental counseling, treatment). This confidential affordable. Academic institutions systems available Program coverage requires intermittent, short-term, training. relate Transition Care Policy. times, arrange transition responsibilities; circumstance leadership coverage. It advisable crisis event severe illness, prolonged absence, death. Such events require co-trainees possibly clinical cope stress grief. Having coverage, increased faculty, arrangements particularly trying times. procedures, updating procedures.25National limitations. They response Core physicians. Further study needed. unknown effective generalized procedures setting even mandates leadership. Furthermore, difficult mobilize maintain particular, daunting directors. represent 3 different thoracic needs, stages regard shared barriers encountered Prioritizing done support Finding measures. way improve trainees, making yet another fulfill. directors' implementing programs, delineated requirements, 2) organization assist Requirements, applies adopt hopefully means sharing experiences Potential next curriculum, website listing tools, workshops either national meetings. minimize consistency Hopefully institution cardiac community added promoting optimizes education. incorporates Requirements. structure while incorporating mission,