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STRESSED OUT
Why do we find ourselves in this predicament and how might
we see our way clear is a question with no easy answers; but the so-
lutions to this crisis will almost certainly require multiple interven-
tions on a variety of levels. To that end, the Accreditation Council
of Graduate Medical Education (ACGME) recently convened its
second annual Symposium on Physician Well-Being in Chicago this
past December. Over 120 experts from across the nation including
representatives from all the major stakeholders from the House of
Medicine*, researchers and other highly-engaged individuals met
for three days to review the most up to date research, hear directly
from content experts, work together to delineate the causal elements
and propose interventions. From my perspective, four major action
items were identified:
1. Institutions must put into place self-screening programs to iden-
tify individuals at risk for burnout, anxiety, depression and sui-
cidal ideation.
2. Institutions must provide access to comprehensive mental health
resources for those identified available 24 hours a day, 7 days a
week in a convenient, affordable and confidential manner.
3. Hospitals must promote an environment where trainees and fac-
ulty can maintain well-being yet fulfill their professional obliga-
tions.
4. Hospitals and Institutions must develop system-based actions
and tools for preventing, eliminating or mitigating impediments
to that well-being; while understanding the role work intensity
and work compression contribute in today’s outpatient and in-
patient environment.
With these four action items as signposts, how do are we actual-
izing these into the daily operation of our academic institutions and
what is being done to help our wider community of physicians? The
initial approach of UT Health San Antonio to this crisis has required
a dual response: identification and support of those already experi-
encing difficulties, while at the same time working with our hospital
partners to develop programs that enhance the environment, pro-
mote community, a just culture, resilience and wellbeing.
Helping Those at Risk
To help those already experiencing difficulties, the Office of Grad-
uate Medical Education has identified an interactive on-line screen-
ing program or (ISP) that allows biannual, anonymous and
voluntary screening of all the institution’s 750 trainees for depres-
sion, anxiety, burnout and suicidal ideation. This ISP program strat-
ifies respondents into separate risk groups with escalating levels of
response. To operationalize this program, the institution will be
funding two Ph.D. behavioral health providers who will be available
during regular business hours to respond to these surveys.
The behavioral health providers can then develop rapport with
respondents and provide counseling either anonymously through a
secure channel or face to face with referral to higher level psychiatric asking her fellow residents to determine the one activity in their lives
care as needed. Trainees can interact with these counselors apart
from the ISP system if they desire, and in addition, all trainees have
24/7 access to counselors through our Employee Assistance Program
or (EAP). For residents in crisis, immediate care can be obtained
confidentially through our adult emergency center and the Depart-
ment of Psychiatry. At no time can a trainee be required to see a
counselor as a stipulation of employment, and the counselors will
never serve in an evaluatory role for the resident’s departmental pro-
gram. All counseling is strictly confidential.
Promoting Wellbeing
The ability of an institution, department or even division to help
promote wellness and the development of resilience in their physi-
cians is a much greater challenge, since the essential aspects for well-
being are different physician to physician. That said, there are some
things that may be considered essential to the well-being of all physi-
cian providers: a sense of community, a supportive environment and
a culture of respect among all members of the healthcare team that
eliminates aggressive, demeaning or insensitive conduct. For trainees
the availability of adequate, clean work spaces, call rooms and nu-
tritious on-call food is a demonstration of their value and helps them
perform at their best for their patients.
Faculty and trainees must have allowances to attend to important
concerns during working hours, like obstetric appointments or den-
tal care. Updated duty hour rules set to take effect on July 1, 2017
again allow on-call interns to remain beyond their night shifts to
present on morning rounds and gain important insights on their
thought process and management plans from faculty. In the case of
important patient events, e.g. disease progression or end of life care,
residents are allowed to exceed maximum weekly hours. In its revi-
sions to the Common Program Requirements Section VI, the
ACGME rationale for this change was to strengthen the interpro-
fessional team, provide time for faculty to model professionalism
and rebuild the community which had suffered from a “shift work”
mentality. In addition to these fundamentals, programs across the
country are developing “wellness toolboxes” of methods or practices
that promote these ideals. Some examples include team-building re-
treats, nurse-physician collaborative projects, nutrition counseling,
financial planning advice for trainees to manage debt, journaling,
Balint-type groups, faculty-resident sporting events and mindful-
ness, yoga and other stress-reduction techniques.
We are also working closely with our Center for Medical Human-
ities and Ethics to connect with like-mined individuals within the
institution and broader community who share a common vision.
The Center also has helped invite local and national experts to pro-
vide their latest insights and potential solutions. Within the broader
community, participation in local specialty societies allow an outlet
for discussion of these issues directly with peers and a chance to
learn about solutions used by some providers that may benefit oth-
ers. One Chief Resident offered her elegant solution to this issue by
that was most important to their well-being, e.g. running, playing
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