In my first post in this two-part series, I presented an argument for why physicians and administrators need to work together to develop small-scale interventions to bring meaning to medicine while we continue to push for larger systemic change.
In this post, I will explore some effective (and some less effective) themes for interventions for residents. This list is not exhaustive but was developed based on my own experiences as a resident as well as group projects from the Back to Bedside Initiative, an ACGME funded program to support resident-led projects promoting meaning in medicine. Interventions that foster empowerment, connection and feedback all serve to reduce the impact of the daily moral injury that we face. It is vital that we support these endeavors and count their successes, however small, as short-term wins to fuel us onward to repair our broken health care system.
Empowerment: One way to mitigate the sense of learned helplessness is to promote empowerment.
Streamlining pathways for change: Residents and front-line physicians need to be empowered to make local and systemic changes. There needs to be a direct line for residents to report frustrations in their day-to-day work, from the EMR to work-flow processes, to help improve the efficiency of the entire hospital. Dedicated teams outside of the residency program then need to be responsible for working on low-hanging fruit and taking the onus off of already over-worked residents to fix their own problems. Otherwise, as Jennifer Bernstein warns in her series “Resident Wellness is a Lie,” the function of such committees will be “entirely cosmetic.”
Many Back to Bedside projects employed qualitative improvement methodology in service of increasing efficiency, freeing up time for residents to teach and spend time with patients. One project from Connecticut Children’s Medical Center even supported a resident to go to Epic headquarters to work on tweaks to the EMR to better fit their inpatient service’s workflow.
With institutional support and protected time, residents can and should be the leaders of these changes. However, in the absence of protected time, outside leadership needs to step in to carry these ideas to fruition. As Bernstein writes, “Adding commitments to a resident’s calendar will never be the answer (unless you are reducing their clinical duties to compensate).” If full responsibility for these projects is placed on already under-resourced residents, the projects will either fall apart, which will contribute to a sense of lack of efficacy, or residents will stop bringing up new ideas, knowing that it just will add to their to-do list. However, if outside leadership is able to lift the sole responsibility off of residents while still keeping residents involved, residents can be instrumental in effecting changes that will benefit the entire hospital.
My institution’s house staff counseling service is an example of this working well. In response to resident concerns about counseling service accessibility, the counseling services leadership acquired an institutional grant to build a more robust program and to promote it through a new website. Residents remained on the committee to help guide the project but were not charged with doing the legwork nor were responsible for holding the committee together.
The main barriers that currently hinder this process are lack of transparency and lack of direct communication between residents and administration about current problems and potential solutions. Direct communication is difficult to establish due to resident availability (or lack thereof), so residents often find themselves uninvolved in the decisions that impact them the most. In addition, many residents fear retribution if they voice concerns, and may be hesitant to engage with administrators. Interventions that target these barriers, such as setting up a safe, protected time for house staff to make suggestions directly to administrators, may not only provide residents a much-needed sense of efficacy but can also provide administrators with multiple easy ways to improve the hospital.
Autonomy in clinical decision-making: Teaching services need to allow residents room to learn how to make their own medical decisions. Residents will have more motivation to carry out their work if supervising physicians either follow along with resident plans or offer a compelling reason to diverge. Residents who feel like they are just following someone else’s decisions, and are merely performing the scut-work, paper-pusher role, are not likely to feel empowered. One Back to Bedside project found success using the concept of “Attending for a Day,” allowing residents to gain more autonomy while faculty took a strictly supervisory role.
Advocacy training: Residents need to be trained and encouraged to be effective advocates, not just for their patients, but for themselves. As a NEJM article put it, “to fight burnout, organize.” As Parker Palmer puts it in his call for professionals to include advocacy as part of their training, institutional change needs to come from the inside: “We need professionals who are ‘in but not of’ their institutions, whose allegiance to the core values of their fields calls them to resist the institutional diminishment of those values.” Formal advocacy training and advocacy opportunities need to be built into the already existing curriculum rather than adding additional work and responsibilities for already overburdened residents.
Fostering connection: Most physicians went into medicine because of the connections they hoped to build with their patients. Former US surgeon general Vivek Murthy spoke at the ACGME annual conference about the “loneliness epidemic“ which impacts work environments and health across the nation, not only in the medical profession. If depersonalization is a facet of burnout, we can re-instill meaning in medicine with re-personalization.
Building community: There are many creative interventions focused on building community. The key is fostering connection without impinging on the connections someone may already have outside of work. That’s where social hours often fall short: more time is spent with work colleagues at the expense of time spent at home. In contrast, when Vivek Murthy started his staff meetings with five minutes of a staff member presenting something they cared about through pictures, it added a negligible amount of time to the day and served to bring his staff closer together. Many of the Back to Bedside projects focused on community-building, whether through designing fun resident trading cards, making sure teams and families knew each other’s names or by promoting humanistic rounds. Other interventions, such as peer debriefing, offer a chance to connect with colleagues in a therapeutic way.
Fostering professionalism: As we look to build our communities, there also need to be repercussions for incivility, racism and sexism in the workplace, as residents are a vulnerable population who often fear retribution for speaking up. Some institutions have started tracking anonymous incivility reports in a process similar to patient safety incident reporting, allowing the administration to act on trends without exposing individual residents as reporters. One Back to Bedside project from Duke took a more positive spin, allowing house staff to reward acts of professionalism by their colleagues within an app.
Mindfulness: Mindfulness has become a buzzword in the world of physician wellness. While it is not the end-all solution as it is sometimes marketed, the practice of developing attention can help bring awareness to moments of meaning that already exist in our day. As full disclosure, I am a mindfulness teacher, and my Back to Bedside project was a Mindful Rounding Initiative to integrate mindfulness activities into rounds. In order to avoid extra time commitments to learn and practice mindfulness, my project consisted of a mindfulness foundations training that was built into protected resident conference time followed by brief daily mindfulness interventions during rounds, ‘brief’ being the keyword. I was not expecting residents to take extra time out of their days to attend 20 minute meditations, but rather to pay attention to three breaths. Similar mindfulness interventions that require minimal time commitment and investment can offer significant gains with very little cost.
Feedback: As Daniel Pink, author of Drive: The Surprising Truth About What Motivates Us, said in an interview for the Harvard Business Review, “What’s essentially key to mastery is a sense of feedback.” Feedback is necessary not only for mastery but for deriving meaning on the journey toward mastery and finding purpose through gauging progress.
Addressing imposter syndrome: As trainees, most residents crave a feeling of competence, but we spend most of our time with symptoms of imposter syndrome. It is up to faculty and our fellow residents to promote a culture of honest, clear feedback on what we are doing well and what we need to work on so that we can move toward mastery.
Addressing the hidden curriculum: In our medical education system, there is a large gap between our stated and lived values, known as the hidden curriculum. We are explicitly trained to care for our patients as human beings, but when we actually take the time to do so, we are reprimanded for being inefficient. Our faculty implicitly places value on efficiency over humanism, and these values then become internalized. As a community of providers, we need to reaffirm our true values over and over again and have them exemplified by our faculty.
Measurement of burnout: Another form of feedback is measuring where we are in terms of baseline burnout and how those levels change with interventions. The measurement alone can be therapeutic, as it helps define the scope of the problem and allows individuals to see that they are not alone.
Mental health resources: Residents need access to counseling specific to health care providers to address secondary trauma and moral injury. Access also means time off during workweek for appointments and minimization of mental health stigma.
Blaming the individual: I am tired of hearing how burnout is a generational issue, that millennials are used to getting what they want and that’s why we are whining so much. And as Bernstein points out in her “Resident Wellness is a Lie” series, the answer to reducing burnout in a program is never simply to “recruit better people.” The problem needs to be identified as inarguably outside of the individual for any real change to occur.
Requiring time outside of work: Any interventions that require time outside of work, by adding responsibilities, mindfulness trainings or social hours, will either erode into the relationships that residents have outside of work or sleep time. They will often cause more problems than they fix.
Residents’ basic needs: At the end of the day, enough sleep and access to healthy food would significantly reduce burnout.
Systemic changes to combat moral injury: This is our pie in the sky — an effective health care system with a focus on preventative care and social determinants of health so that our expectations at work are aligned with our values and inner sense of purpose.
I believe that we are a part of this broken health care system, and as a part of it, we can help fix it. We cannot afford to begin and end our efforts by shouting into an echo-chamber of anger and despair, broadly dismissing all attempts at change as offensively small in scale and comically futile, setting ourselves up for defeat before we start. We are up against and inside a behemoth of a system and it is from lovingly taking small steps and fostering connections with each other that we will be able to fuel ourselves on a path to change.