International Approaches to Clinician Wellbeing

Burning out

Dr Caitlin Weston

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DECLARATIONTHEWINSTONCHURCHILLMEMORIALTRUSTOFAUSTRALIAReportbyCaitlinWeston,2016ChurchillFellowToexplorestrategiesthatimprovethewellbeingofclinicians,optimisingtheirmentalhealthandproductivity.IunderstandthattheChurchillTrustmaypublishthisReport,eitherinhardcopyorontheinternetorboth,andconsenttosuchpublication.IindemnifytheChurchillTrustagainstanyloss,costsordamagesitmaysufferarisingoutofanyclaimorproceedingsmadeagainsttheTrustinrespectoforarisingoutofthepublicationofanyReportsubmitted totheTrustandwhichtheTrustplacesonawebsiteforaccessovertheinternet.IalsowarrantthatmyFinalReportisoriginalanddoesnotinfringethecopyrightofanyperson,orcontainanythingwhichis,ortheincorporationofwhichintotheFinalReportis,actionablefordefamation,a breachofanyprivacylaworobligation,breachofconfidence,contemptofcourt,passing-offor contraventionofanyotherprivaterightorofanylaw.

CaitlinWeston27thMay2018

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EXECUTIVESUMMARYDrCaitlinWeston,BLibSt,MBBSChiefWellnessOfficer,MedAppsPtyLtdcaitlin.weston@gmail.comAIMToexplorestrategiesthatimprovethewellbeingofclinicians,optimisingtheirmentalhealthandproductivityMETHODTwenty-eightinterviewswereconductedwith37individualsacrossteninstitutionsintheUnitedStatesofAmerica,Canada,andtheUnitedKingdom.Thefulllistofindividualsinterviewedcanbeseeninthenextsection.Iattendedthetwo-day‘AmericanConferenceonPhysicianHealth’inSanFrancisco,two-day‘EnhancingCaregiverResilience:QualityImprovementandBurnout’courseatDukePatientSafetyCenter,the‘NHSEngland(LondonRegion)ResponsibleOfficerandAppraisalLeadNetworkMeeting’,andthepresentationbyProfessorClareGeradatotheLordandLadyJusticesoftheRoyalCourtsofJustice:‘TheJudiciary:aviewfromtheNHS’.IvisitedtheStanfordWellMDCenter,theCanadianMedicalAssociation,theCanadianMedicalProtectiveAssociation,DukePatientSafetyCenter,JohnsHopkinsHospital,theUniversityofUtah,theNHS(London)PractitionerHealthProgrammeandthePointofCareFoundation.Interviewswerebasedaroundafewkeyquestions,dependingonthetypeofprogramoffered.

• Howisclinicianwellbeingassessed?• Whataretheimportantdriversofadverseclinicianwellbeingineachcontext?• Howareadministratorspersuadedtosupportandfundinterventions,andhowisongoingleadership

supportensured?• Whatinputdoeseachinterventionrequireintermsoffunding,personnelandotherresourcesinthe

stagesofdesign,implementationandongoingoperation?Howissustainabilityensured?• Howareinterventionsevaluated?• Whathavebeenthegreatestchallengesinthedesign,implementationandevaluationofeach

program?RESULTSAfewmajorthemesemergedfrommyinterviews:

• Conceptualframeworksforthedriversandsolutionstoadverseclinicianwellbeing• Theimportanceofmeasurementtobothassessingclinicianwellnessanditsimpacts,anddesigning

andevaluatingsolutions• Thecriticalroleofleadershipsupporttothegrowthandsuccessofprograms,andwaysinwhich

leadershipsupportcanbeobtained• Interventionsaremostsuccessfulwhentheytargetlocallyimportantcausesandharnesslocal

strengthandskills

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DISSEMINATIONANDIMPLEMENTATION

• ThisreportwillbefreelyavailabletothepublicfromtheChurchillTrustwebsite.• IwillpresentmyFellowshipfindingsatlocal,regional,andinternationalmeetings• IhaveinterruptedmyanaesthetictrainingtotakeupthepositionofWellbeingProjectLeadwith

healthtechnologystart-upMedAppsPtyLtd.Thiscompany,foundedbydoctors,makesmobileapplicationsdesignedtoimprovetheworkinglivesandwellbeingofclinicians.Thecompany’sflagshipapplicationResidentGuidehasauserbaseof2,500Australiandoctors-in-trainingthatisrapidlygrowing,providinganincredibleopportunitytoimplementlarge-scalewellbeinginterventionsforanespeciallyvulnerablegroupofdoctors,andofferingapotentialplatformforlongitudinaldatacollection.

• IwillmaintainactivemembershipofcommitteesandworkinggroupswiththeAustralianMedicalAssociation,advocatingfordoctors’welfare.

• Iwillcontinuetocommunicateandcollaboratewithindividualsandteamsfromtheinternationalresearchcommunitytomaintainaglobaldialoguearoundclinicianwelfare

• IwillengagewithAustralianmetalhealthorganisationssuchasEverymindandtheBlackDogInstitutethathavebeenengagedbygovernmentbodiestoresearchandimplementwellbeingsolutionsforclinicians.

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DEDICATIONIdedicatethisreporttomyfriendDrChloeAbbott.Everastaunchadvocatefortherightsofhercolleagues,Chloeherselffellpreytothebrutalcultureofmedicine,takingherownlifeon9thJanuary2017.Chloe,youwillalwaysbemissedandneverforgotten,andwewillneverstopfightingtoenlightenthesystemthatdarkenedyourworld.

ACKNOWLEDGEMENTSThisFellowshipandreportaretheworkofavillageofincrediblepeoplewhohavebeenbehindmethroughout.Myfamily,andinparticularmyparents,SueandPeterWeston,whohaveencouragedandbelievedinmefromthemomentIfirstexcitedlyvoicedmyideatoapply.DrTraceyTay,whohasbeenawonderfulmentorandfriendfromthedaywemetattheChurchillTrustRoadshowinNewcastlein2016.DrBenVeness,alreadyavaluedfriendfrommedicalschool,foralsobecomingagreatmentorandendlessfontofwisdomandgoodadvicethroughoutmyChurchilljourney.CentralCoastLocalHealthDistrict,andinparticularDrFrancesPageandDrScottFortey,forbelievingintheimportanceofthisprojectandsupportingmebyeverymeanspossiblealongeverystepofthejourney.RayO’Donoghueforhisunerringfaithinmyability,andhisinvaluableassistanceinpreparingformyinterviewsandplanningmytrip.BickFultonforhermuch-neededsupportinthelead-uptomydeparture.DrMarionAndrew,DrClairWhelanandDrPeterThomasforbelievinginmeenoughtoactasrefereesonmyinitialapplication.EveryoneImetwithonmytripwhosharedtheirtime,knowledge,expertise,friendshipandhomeswithme!Youmadethisthetripofalifetime;youhavegivenmesomuchinspirationandrenewedpassionandvigourforbothmyresearchandlife.Everyonewhoassistedinthepreparationofthisreport,inparticularSamSeabournforthetypesettingandfinishingofthisdocument,CarmelSealeyforherskilfulediting,DrPriyaRajaendranforspiriteddiscussionandplanningandDrJessicaElmasryforassistancesearchingtheliterature.IamalsogratefultoDrRobPearlmanfortheopportunitytoimplementmyfindingsthroughmyworkatResidentGuide.Lastlyandmostimportantly,IoweahugedebtofthankstotheWinstonChurchillMemorialTrustforgivingmetheopportunityofalifetime.

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PROGRAMMEUNITEDSTATESOFAMERICA2017AMERICANCONFERENCEONPHYSICIANHEALTHSanFrancisco,CaliforniaDrJoSHAPIRODirector,CenterforProfessionalismandPeerSupport,BrighamandWomen’sHospitalDrTinaSHAHWhiteHouseFellow,DepartmentofVeterans’AdministrationMsMary-LouMURPHYAdministrativeDirector,StanfordWellMDCenterMsPattyDEVRIESDirectorofStrategicProjects,StanfordWellMDCenterDirector,StanfordHealthPromotionNetworkDrMickeyTROCKELDirectorofScholarshipandHealthPromotion,StanfordWellMDCenterDrMaryamHAMIDIAssociateDirectorofScholarshipandHealthPromotion,StanfordWellMDCenterDrDavidBURNSAdjunctClinicalProfessorEmeritus,DepartmentofPsychiatryandBehavioralSciences,StanfordUniversityDrBobHOROWITZConsultingProfessor,StanfordPreventionResearchCenterDrMagaliFASSIOTTOAssistantDeanandDirectorofProgramsandResearch,StanfordMedicineOfficeofFacultyDevelopmentandDiversityDrLarryKATZNELSONAssociationDean,MedicalGraduateStudentEducation,StanfordUniversityDrBryanBohmanSeniorAdvisorandFormerInterimDirector,StanfordWellMDCenterENHANCINGCAREGIVERRESILIENCE:BURNOUTANDQUALITYIMPROVEMENTDukePatientSafetyCenter,DukeUniversity,NorthCarolina

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DrJ.BryanSEXTONDirector,DukePatientSafetyCenter,DukeUniversityDrCarrieADAIRResearchAssociate,DukePatientSafetyCenter,DukeUniversityDrJanelSEXTONResearchAssociate,DukePatientSafetyCenter,DukeUniversityDrNnekaSEDERSTROMDirector,OfficeofEthics,Children’sHospitalsofMinnesotaDrAlbertWUDirector,JohnsHopkinsCenterforHealthServicesandOutcomesResearch,JohnsHopkinsHospitalMsCherylCONNORSRISETeamCoordinator,JohnsHopkinsHospitalMsLoriPAINEDirector,ArmstrongInstituteforPatientSafetyandQuality,JohnsHopkinsHospitalDrBarbaraFRIEDRICKSONDirector,PositiveEmotionsandPsychophysiologyLaboratoryProfessor,DepartmentofPsychology&Neuroscience,UniversityofNorthCarolinaatChapelHillDrRobinMARCUSChiefWellnessOfficer,UniversityofUtahHealthProfessorBradPOSSChiefMedicalEducationOfficerandAssociateDeanforGraduateMedicalEducation,UniversityofUtahHealthDrRobDAVIESGraduateMedicalEducationWellnessDirector,UniversityofUtahHealthMsAmyARMSTRONGGraduateMedicalEducationWellnessCoordinator,UniversityofUtahHospitalsandClinicsDrAmyCOWANDepartmentofInternalMedicine,UniversityofUtahSchoolofMedicineDrMeganCALLAssociateDirector,UniversityofUtahHealthResiliencyCenter

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DrAmyLOCKECo-Director,UniversityofUtahHealthResiliencyCenterDrEllenMORROWCo-Director,UniversityofUtahHealthResiliencyCenterDrBrianGOODDepartmentofPaediatrics,PrimaryChildren’sHospitalMsSuzetteGOUCHERDirectorofRiskManagement,UniversityofUtahHealth

CANADADrChristopherSIMONAdvisor,CanadianMedicalAssociationMsTaylorMCFADDENPhDCandidate,UniversityofOttawaResearchAssociate,CanadianMedicalAssociationDrPamelaEISENER-PARSCHEDirectorofPhysicianConsultingServices,CanadianMedicalProtectiveAssociation

UNITEDKINGDOMProfessorClareGERADAMedicalDirector,NHSPractitionerHealthProgrammeMsLucyWARNERCEO,NHSPractitionerHealthProgrammeCEO,NHSGPHealthServiceMsLouisaDALLMEYERCommissioner,NHSPractitionerHealthProgrammeMsJoannaGOODRICHHeadofEvidenceandLearning,ThePointofCareFoundationDrCarolineWALKERCo-Founder,Tea&EmpathySupportNetworkFounder,TheJoyfulDoctor

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BACKGROUNDPoorclinicianwellnessisrapidlygainingrecognitioninAustraliaasasignificantthreattoboththecliniciansthemselvesandtothequalityofcarethehealthcaresystemiscapableofproviding.ThemostcompellingevidenceofthescaleoftheprobleminAustraliacamefromtheNationalMentalHealthSurveyofDoctorsandMedicalStudents,withthisgroupofhealthcareprofessionalsshowingdisconcertinglyhighlevelsofpsychologicaldistressandsuicidalitycomparedtothegeneralpopulationandotherprofessionals,aswellashighlevelsofburnout[1].Groupsmostatriskincludeyoungandearlycareerdoctors,females,thosepracticingrurallyanddoctorsofAboriginalorTorresStraitIslanderorigin.Anotherstudydemonstratedthatfemaledoctors,aswellasnursesofbothgenders,showasubstantiallyhigherriskofsuicidethantheircounterpartsamongthegeneralAustralianpopulation[2].Theproblemofpoormentalhealthamongcliniciansisnotanewone,andnorisitanissuefacedbyAustraliaalone.In1881theriskratioforsuicideamongmalephysiciansinEnglandandWalescomparedtomalesinthegeneralpopulationwas1.5,afigurecomparabletocalculationsofsuicideriskamongmaledoctorstoday[3,4].Femaledoctorsanddoctorsoveralldisplayingstillhigherriskratios[5-8].Internationalinterestinclinicianburnoutandpoormentalhealthhasgrownrapidlyinrecentyears,ashasourunderstandingoftheeffecttheseproblemshaveonpatientcareandontheefficiencyofhealthcaresystems.Cliniciandepressionandburnouthavebeenlinkedtohigherratesofmedicationerrors,surgicalerrors,infectionrates,mortality,patientcomplaints,andhighstaffturnover[9-14].Thegrowingbodyofevidencehasbroughtthoughtleadersinthefieldtoherald“clinicianwellnessandengagement”asthe“fourthqualityindicator”inhealthcare,placingitalongside“improvingpatientexperience”and“reducingthepercapitacostofhealthcare”askeygoalsinsupportingtheoverallaimofimprovingpopulationheath[15,16].

Afteratragicspateofsuicidesin2016–2017byNewSouthWalesdoctorsatarangeofcareerstages,theissueofdoctors’mentalhealthbegantofeatureprominentlyinthemedia,drivenlargelybythefamiliesandcolleaguesofthosewhotooktheirlives.Thisgarneredbothstateandfederalrecognitionoftheproblem,withbothNSWandfederalhealthministers(BradHazzardandGregHunt,respectively)committingtoaddressdoctors’wellbeingasamatterofurgency,andthefederaldepartmentofhealthallocating$1millionspecificallytomentalhealthprogramsfordoctors.ThecurrentlevelofindustrialandpublicengagementwiththeseissuesinAustraliaisunprecedented.

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Box1Frequently-citeddriversofclinicianburnoutandadversewellbeinginAustraliaClinical

• Healthcaresystememphasisonthroughputofpatients• Distressassociatedwithperceivedoractualclinicalerrors• Increasedcomplexityofpathologyandcomorbiditiesinthepatientpopulation• Higherpatientandfamilyexpectationsofhealthcarethanindecades’past• Vicarioustraumafromrepeatedexposuretopatientandfamilydistress• Moraldistressassociatedwithfutilecare

Industrial• Excessiveorunsociableworkhourslimitingcapacityforappropriatemaintenanceofphysical,

psychological,andsocialhealth• Administrativeandclericalbarrierstofindingmeaninginwork• Lackofpsychologically/sociallyergonomicsystemsandworkplaces• Excessiveunclaimedorunpaidovertime• Lackofsupportfromsupervisor• Inabilitytotakeleaveduetochronicstaffingshortages• Concurrentstudyforhigh-stakesprofessionalexaminations• Geographicalisolationfromsocialandothersupportsduringsecondments• Intensecompetitionforjobsdrivingan“educationalarmsrace”• Lackoflong-termjobsecurity• Fearofcomplaints,reportstothemedicalboard,andlitigation• Increasingriskofphysicalviolenceintheworkplace

Cultural• Lackofrecognitionorappreciationfromorganisation/leadership• Healthcare’shypocritical“hiddencurriculum”and“ironman”culture• Systemic,public,andpersonalexpectationsofperfection• Decreasingcollegialityandcamaraderie• Bullyingandharassment• Lackofpreparationfortransitiontoworkforstudents• Lackofpreparationfortransitionbetweencareerstages;forexample:residenttojuniorregistrar,fellow

tojuniorconsultant,transitiontoretirement• Discriminationbyemployers,colleagues,andpatientsonthebasisofrace,gender,sexualorientation,

andreligion

Box2Frequently-citedbarrierstohelp-seekingforAustralianclinicians

• Lackofawarenessofavailableprogramsandresources• Stigmatisationof“weakness”andhelp-seeking• Threatstoconfidentialitywhenbeingtreatedbycolleagues• Concernforpotentialimpactoncareeradvancement• Perceptionsofcurrentmandatoryreportinglawsandpossibleimpactonregistrationandrighttopractice• Difficultyaccessingprimarycarearoundworkhoursandsecondments• Difficultyaccessingleaveentitlementduetochronicstaffingshortages• Lackoftimetoattendtoself-care

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APPROACH

Itisusefultohaveagoodmodelforconceptualisingandapproachinganypublichealthproblem.Thereareanumberofmodelsinusefordiscussionofclinicianwellness,mostofwhicharedividedintoindividualandsystemicinterventionsandseveralofwhichemploythepublichealthprinciplesofstratificationintoprimaryprevention,secondaryscreening,andtertiarytreatment[17,18].Theseapproacheshighlighttheimportanceofearlyinterventionandhealthpromotion,andcanhelptoensureabalancedandcomprehensiveapproachtoprogramdesignintermsofgroupstargeted.

ThemodelconceivedbyDrPattydeVriesfromtheStanfordWellMDCenter,whichhasbeentakenupbymultipleinstitutionsaroundtheUSAandtheworld,focusesonthedriversofburnoutandpoorwellbeing.Itdividesdriversandsolutionsintothreedomains:CultureofWellness,EfficiencyofPractice,andPersonalResilience(seeFigure2,below).Thismodelhighlightsthatthebulkofresponsibilityforreversingthecurrentproblemlieswithhealthcareorganisationsratherthanindividuals(onlyoneofthethreedomainstargetsindividuals),andaidsorganisationsindesigningorselectingprogramsthataddressspecificdriverswithintheircontext.

Figure1A public health prevention framework proposed as an approach to the problem of physician burnout. This model focuses on the level of risk of individuals or groups of clinicians. Reproduced with permission from Chaukos et al 2018..

Figure2StanfordWellMDCenterConceptualFrameworkforphysicianwellness.Thismodelwasdevisedbasedonidentifieddriversofphysicianburnoutandemphasisestheimportantroleofthesystemicinterventionsinpromotingprofessionalfulfilmentforclinicians.ReproducedwithpermissionfromWellMDCenter.

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Myownapproachinthisreportwillbetobeginbydiscussingapproachestomeasurementandareasforfurtherresearch;moveontotheimportanceofleadershipsupportandwaysofattainingit;thendiscussinterventionsatthesystems-levelfollowedbythosetargetedtowardindividuals.IwillthendiscusssystemscurrentlyinuseinAustralia,considerationsforimplementationofnewprograms,areasforfurtherwork,andspecificrecommendationsfortheAustraliancontext.

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MEASUREMENTANDRESEARCHInordertonotonlyassessthescaleofaproblem,butalsooursuccessesandfailuresinremedyingit,reliable,valid,andeasilyappliedmeasuresarevital.Metricsaremadestillmorevaluableiftheyarestandardisedtosomeextentacrossinstitutionsandtheworldtofacilitatebenchmarking,clearcommunicationandresearchcollaborationtoacceleratetheestablishmentofbestpracticeguidelines.Measurementofpatientoutcomesandeconomicimpactrelatedtoclinicianwellbeingarealsocriticaltocompileabusinesscaseforinvestmentinclinicianwellnessandtherebyassistpolicy-makersandadministratorsinallocatingappropriateresourcestotheproblem.WehavesomeknowledgeabouttheextentofpoorclinicianwellbeinginAustralia,andawealthofresearchfromaroundtheworldabouttheeffectthishasonhealthcare[19-24].WemustnowmakemeasurementofclinicianwellnessintheAustraliansystemaprioritycommensuratewithitsimportanceintermsofworkforceproductivity,qualityofcareandcostefficiency.Manyreliable,validatedmetricsareavailablefortheassessmentofthevariousdomainsofclinicianwellnessandinstitutionalculture,withnewinstrumentsconstantlybeingdeveloped.Severalsuchmetricsmaybecombinedinmodularsurveystobuildupacomprehensivepictureofwellnessinhealthcaresystemswhileenablingtheadditionofmeasuresinsubsequentsurveysasnewareasofconcerncometolight[19,22].DrChristopherSimonandTaylorMcFaddenoftheCanadianMedicalAssociation(CMA)discussedwithmethedesignofthe2017CanadianPhysicianHealthandWellnessSurvey,whichfocusedonthecurrentcrisesofphysicianburnoutandworkplaceculture.Onreviewingtheresultsoftheprevioussurveywhichwasconductedin2007,theteamnotedthatmanyofthemetricsusedexaminedissuesnolongerattheforefrontofindustryconcern,limitingitsusefulnessintargetingandrefiningCMApolicies.Theworkinggrouptaskedwiththedesignandimplementationofthe2017surveyhadtoselectwhichmetricsshouldbeincluded,balancingtheconceptof“goldstandard”metricsagainstsurveylength,validationfortheCanadianphysicianpopulation,andtheavailabilityofcomparisonswithotherphysicians,otherhealthcareprofessionals,andthegeneralpopulation.ThisprocessreflectsthecriteriarecommendedbyTaitShanafeltforselectionofmetrics[19].FurtherresearchneedstobeundertakenwithintheAustraliancontexttomoreclearlyestablishtherelationshipbetweenclinicianwellnessandeconomicoutcomes,inordertofacilitateorganisationscompilingbusinesscasesforinvestmentinphysicianwellbeing[13,23,25].Clearbusinesscaseswillnotonlybackupthecompellingmoralandethicalargumentforinvestmentinclinicianwellbeing,butwillalsoassistpolicy-makersandadministratorstoallocatefundingandpersonneltoimprovingthewellbeingoftheworkforcethroughimprovementstosystems,workplaceculture,andrelevantprograms[25].Contextualdifferenceshavealargeimpacthere.Forexample,qualifiedphysiciansinCanada(withtheexceptionofPrinceEdwardIsland)operateassoletraderswithadmittingrightsratherthanasdirectemployeesofthehealthservice,makingthebusinesscaseforphysicianwellnessinthatcountrymuchmorecomplexthanthatintheUSA.Researchisalsoneededtobetterunderstandtheimportanceofvariousdriversofburnoutindifferentareasofourhealthcaresystem.ThiswasanotablepointofdifferenceacrossthethreecountriesIvisitedduringmyChurchilltravels.Forexample,theworkinghoursandpatientloadfordoctors-in-training(DITs)seemsto

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bemodestlylowerinAustraliathanintheUSA,Canada,andtheUK.DoctorsintheUSAgraduatefrommedicalschoolshoulderingamuchlargereducationaldebtthantheircounterpartsinAustralia,Canada,andtheUKexertingfinancialpressurethatmaydriveindividualstoworktothepointofburnout.Australiandoctorsspendbetweentwoandtenyearsaftergraduationtryingtoattainaplaceinatrainingprogramwhichwillthentakethembetweenthreetosevenyearsoffull-timetrainingtocomplete.Duringwhichtimetheymaywellbetryingtostartafamilywhilehavingminimalcontrolovertheirscheduleandmovingcitiesuptoeverythreemonths,exacerbatingwork-lifeconflict.Meanwhile,mostdoctorsinCanadaandtheUSAwillenterspecialtytrainingstraightfrommedicalschoolandattaintheirfellowshipinthreetosevenyearsoffull-timetraining.Thedriversofpoorstaffwellbeinginanyhealthcaresystemalsochangedependingonspecialty,environment,andthroughoutanindividual’sprofessionallifetime.Thisnecessitatesanassessmentofdriversforagivencontextthroughsurveysandfocusgroupspriortoimplementationofprograms[19].ReturnoninvestmentinmeasurementandresearchwillbeincreasedbyadoptingcommonmetricsacrosstheAustralianhealthcaresystemtofacilitatecomparisonandbenchmarking[23].Furthermore,adoptingvalidatedmeasuresalreadyinusebyhealthcareresearchinstitutionsinternationallywillallowustobenefitmorefromresearchundertakenaroundtheworld.Itwillalsoacceleratetheestablishmentofglobalbestpracticeinburnoutinvariouscontextsandcausedbyvariousdrivers[23,26].Therecommendationfroma2016‘JoyinMedicineSummit’toestablishalliancesthataddressphysicianburnouthasresultedinStanfordUniversityfoundingthePhysicianWellnessAcademicConsortium,acollectionofmorethantenlargeacademicorganisationsacrosstheUnitedStatescooperatinginresearchonclinicianwellnessimpactsandinterventions,withplanstoexpandthegroupinternationally.Infrastructureneedstobeestablishedbyhealthcaresystemstofacilitateregulardatacollectionandgoodresponseratesbystaff.Thiswillenablelongitudinalmeasurementofclinicianwellnesstobecomearoutinecomponentoforganisationalperformanceevaluation.Forexample:organisationscouldprovideprotectedtimeforstafftocompletethesurveywithinworkhoursandsetdepartmentaltargetsforstaffresponseratestiedtoafundingbonus.Suchdecisionsalsodemonstrateleadershipinvestmentinstaffwellness.Enablingstafftocompletethesurveyonpersonaldeviceswouldreducetheadministrativeburdenassociatedwithprocessingpaper-basedsurveysandthebottleneckcausedbylimitedaccesstohospitalcomputers.Theadministrativeburdenassociatedwithattemptinglarge-scalesurveyswithoutestablishedinfrastructurehashistoricallybeenabarriertolongitudinalmeasurement.Surveysofdoctors-in-trainingbytheAustralianMedicalAssociation,beyondblueandtheNSWMinistryofHealthhavegenerallybeenstand-alonesurveyswithresponseratesbelow25%despiterepeatedemailandsocialmediareminderstoparticipants[1,27-32].Theten-yeargapbetweeniterationsoftheCanadianPhysicianHealthandWellnessSurveyseverelylimiteditsusefulnessinguidingpolicyandprogramdevelopment,andforthisreasonthecurrentteamarehopingtorepeatthesurveymorefrequentlyinfutureyears.TheMayoClinic,whichhasundertakenregulartestingofclinicianburnoutsince2010,increasedthefrequencyofitsassessmentsfrombiannualtoannualin2016[19].Driversofpoorclinicianwellnessfollowpredictablepatternsthroughouttheyearwithseasonalchangesinworkload,thereforeIwouldadvocateannualsurveystakenatapproximatelythesametimeeachyear.Guidelinesalsoneedtobeestablishedfortheevaluationofwellnessinitiativesforthepurposeofongoingqualityassurance.IntheEnhancingCaregiverResilience:QualityImprovementandBurnoutcourseatDukePatientSafetyCentre,DrJ.BryanSextonadvocatesevaluationnosoonerthan12–18monthsafter

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implementationofaprograminorderforitseffecttobereflectedinthedata.DiscussionbetweenProfessorBarbaraFriedrichsonandmembersoftheJohnsHopkinsHospital(JHH)RISETeamraisedanotherissueforprogramevaluationinthatonemustmaintaintheconfidentialityofserviceusersandnotdisruptserviceprovision.Forthesereasons,evaluationoftheRISEprogramhasformerlybeenrestrictedtocoarseusagedataandirregularqualitativefeedback.RegularwellnesssurveysatJHHprovidelongitudinaldatapre-andpost-intervention,aswellastheopportunitytoaddsurveyitemsonawareness,uptake,andutilityofservices.

Box3Principlesforevaluationofclinicianwellness

• Measurementofclinicianwellnessneedstobecomeapriorityinoursystemcommensuratewithitsimportanceintermsofworkforceproductivityandlongevity,qualityofcareandcostefficiency.

• Individualmetrics:validatedandreliableforselectedpopulationandtimescale;correlatewithpatientandeconomicoutcomes,widelyusedtoprovideexternalbenchmarkingdata.

• Surveys:comprehensive,quickandsimpletocompletetomaximiseresponserate,modulartoallowadditionofmeasuresasnewareasofconcerncometolight.

• Longitudinalmeasurement:repeatregularlytomonitortrendsovertime;ideallytracknon-identifiableindividualresults.

• Establishinfrastructuretofacilitateregulartesting.• Establishguidelinesforprogramevaluation.• Standardisetimingofsurveystoavoidconfoundingeffectofseasonalchangesinworkloadetc.• Repeatingtoofrequentlyrisksdecliningresponseratesduetosurveyfatigue;repeatingtoorarelyprovides

reducedopportunitiestoalterpolicyandadaptprogramsthatarenotworking.Box4PriorityareasforresearchinAustralia

• FurtherestablishthelinksbetweenclinicianwellnessandfinancialandpatientoutcomesintheAustraliancontext.

• FurtherclarifythedriversofadverseclinicianwellnessinAustraliatoenabletargetedintervention.• Furtherresearchoneffectivenessofinterventionsforspecificcontexts,driversand

clinician/patient/financialoutcomes.

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POLICYANDLEADERSHIPThekeytosuccessforanyprogramisthe“toneatthetop”oftheorganisation.Thisfactwasmadeabundantlyclearoverthecourseofmyprogramvisits.Inmanycases,passionateindividualsandgroupshadbeenworkingbehindthescenesforyearsonprogramstopromoteclinicianwellbeing,butitwasonlywhenexecutivestaffwereengagedwiththeproblemthatthingsreallytookoff.Organisationalstructuresdedicatedtoclinicianwelfare,clearchainsofaccountability,andplansformonitoringtrendsovertimesprungupalmostovernightoncethishappened.Theenergyandexpertiseofthoseindividualsalreadyworkingatthegrassrootswereharnessedandutilisedsothat,insteadofthoseprogramsflounderingandtheindividualsburningthemselvesout,theireffortswererecognisedandmademorevisible.Seniormedicalstaffinorganisationswithengagedleadershipwerefarmoreopenandrealisticaboutthehardshipsofclinicalpracticeandshowedrespecttothoseworkingtoamelioratethings,settingoffanimmediateprocessofthawingtheharsh“ironman”cultureofmedicine,withjuniorsvisiblymorecomfortableacknowledgingdifficulties.Whenitcomestoaddressingburnoutandwellbeinginhealthcare,“Commitmentfromexecutiveleadershipistheprerequisite,assessmentthefirststep,andfront-lineleadershipaforcemultiplier”[25].Sohowdoweengageexecutiveleadership?Thisquestionfeaturedprominentlyatthe‘AmericanConferenceonPhysicianHealth’,andhasbeenthemainpriorityoftheStanfordWellMDCenterinitsfoundingyears[33].Thecommonthemeinconferencepresentationsandmyinterviewsonthesubjectwasthatthekeytoengagingleadershipisto“speaktoleadersintheirlanguage”.Manyexecutiveleadersandpolicy-makersaresympathetictothemoralandethicalcaseforimprovingwellbeingbutfeelthattheissueisbeyondtheirpowerandmeanstoaddress.However,thereissubstantialevidencethatthecostoftheproblemgoesbeyondthehuman;thattheeconomicimpactofburnoutissubstantialandcanbequantifiedtoformacompellingbusinesscase[19,25].DifferencesinstructureandfundingbetweenthehealthcaresystemsintheUSAandAustraliameanthatthebusinesscasemodeldevelopedbyProfessorTaitShanafeltmayrequirereworkingandfurtherresearchfortheAustraliancontext.AstheUShealthcaresystemislargelyprivatised,thelanguageusedtodiscusstheeconomiccostsintheUnitedStates’systemfocusesonthecapacityofphysicianstogeneraterevenuefortheorganisation,andcostsassociatedwithstaffturnoverandrecruitment[13,25].CostestimatesfortheAustraliancontext–whereuniversalhealthcaremeansthateventheprivatesystemisheavilyreliantongovernmentfunding–maybemoredependentonthecostofsuboptimaltest-orderingandprescribinghabits,reducedefficiencyofburnedoutcliniciansandreducedqualityofcare;forexample,increasedhealthcare-associatedinfectionsandsurgicalcomplications.ThecostofburnouttotheNHSislikelytobesimilarlydifficulttocalculate,compoundedbythesheerscaleofthesystem.ItmaybeevenmoredifficultintheCanadiansystem,wherenearlyallqualifiedphysiciansactassoletradersratherthandirectemployeesofthehospital.However,asclinicianwellbeingisfundamentallyaqualityandsafetyissue,manyargumentsputforwardinbusinesscasesforthequalityandsafetymovement20yearsagowillbeapplicableinthiscasetoo[34].Anotherconsiderationisthepotentialforinvestmentbycommercialstakeholderswhoarelikelytobenefitfromareductioninclinicianburnout,suchasmedicalindemnityproviders.TheWorldMedicalAssociation’srecentamendmenttotheDeclarationofGenevatoincludethephrase“Iwillattendtomyownhealth,well-being,andabilitiesinordertoprovidecareofthehigheststandard”

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reflectsaninexorableglobalculturalshifttowardrecognitionoftheimportanceofclinicianwellbeing[35].ThenextstepistofortifytheplaceofclinicianhealthinAustraliathroughfederal,state,andprofessionalcollegepolicies,andbyestablishingclearchainsofaccountabilitywithinorganisations.Significantprogresstowardthisgoalcouldbeachievedbymakingkeymetricsofclinicianwellnessacomponentofaccreditationstandardsforpublicandprivatehealthcareorganisations.SettingKeyPerformanceIndicatorswithfinancialincentiveslinkedtolongitudinaltargetswillbeanotherkeystepinassuringchange[19].Organisationscanrecognisetheplaceofclinicianwellbeingasthefourthqualityindicatorbyestablishinganexecutiverolewhoseresponsibilityisthemeasurementandmaintenanceofstaffwellbeing[15,16,19,25].ThisstephasalreadybeentakenatStanfordUniversityHospitalandatUniversityofUtahHealth,wheretheintroductionofaChiefWellnessOfficerreflectsthecurrentculturalshiftinhealthfrom“patient-centredcare”to“person-centredcare”.Boththeseorganisations,aswellastheMayoClinic,aretakingastrategicandstructuredapproachtodeveloping,coordinatingandsurfacingwellnessresourcesforstaff.Shanafeltoutlinesninestrategiesforleadersseekingpracticalmeansofaddressingburnoutandpoorwellbeingintheirinstitutions,anddescribesthetypicalorganisationaltrajectoryinaddressingclinicianwellbeing[19,25].Inthenexttwosections,Iwillfurtheroutlinesomeofthedescribedstrategiesthroughthelensofsystem-targetedandindividually-targetedapproaches.

Box4Principlesofleadershipandpolicy

• “Toneatthetop”iscrucialtoorganisationalchangeandthesuccessofprograms• ThedevelopmentofabusinesscasefortheAustralianhealthcaresystemwillbeimportantinsecuring

leadershipbuy-inandguidingongoingallocationoffunds• TheimportanceofclinicianwellnesstoqualityofcareneedstobereflectedinpolicythroughKPIsand

accreditationstandards• AChiefWellnessOfficerorequivalentshouldbeappointedinlargerorganisationstooverseemeasurement

effortsandcoordinateservices• TheorganisationalstrategiesdescribedbyTaitShanafeltprovideexecutiveleadersattheorganisationlevel

withpracticalguidanceforaddressingburnoutandpoorwellbeing[36],andoutlinetheexpectedtrajectoryofdevelopmentforanorganisation[25]

Box5Advocatingforchangefromthegroundupinyourinstitution:stepsandresources

• Measuretheproblemandcompileabusinesscasetoengageleadership[25]• Identifymaindriversinyourinstitutionorunit(performculturalandneedsassessmentsthroughsurveysof

front-lineclinicians,focusgroups,andworkinggroups)• Identifystrengthsandresourceswithinyourinstitutionorunit(sameprocessasabove:engagefront-line

staff,makethemfeellistened-toanduseful;showleadersthatmanyofthecomponentsnecessaryforchangearealreadythereintheinstitution)

• Coordinateandsurfaceexistingservicesthroughcentraliseddirectoriesandstaffcontacts,empowerindividualstoaccessservices

• Qualityimprovementcycle:establishmechanismsforfeedbackandevaluationofinterventions

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INTERVENTIONS“Resilience”quicklybecomesanemotionallychargedtopicwhenimprovedpersonalresilienceisdiscussedastheprimesolutiontoadverseclinicianwellbeing.Objectiontothetermspringslargelyfromthefactthatcliniciansarealreadyincrediblyresilientpeople.Forexample,despitehighprevalenceofpsychologicaldistress,specificmentalhealthdiagnoses,burnoutandsuicidalityamongAustraliandoctorsandmedicalstudents,itappearstohaveminimalimpactontheirwork[1].Furthermore,astudyofmedicalstudentsintheUSAshowedthattheindividualschoosingtostudymedicineareinfacthealthierandmoreresilientthattheircomparedwithmatchedpeersenteringotherpostgraduatecourses,apatternwhichisoverturnedaftertwoyearsofstudy[37].Placingthebulkofresponsibilityonindividualsnotonlydeniesclinicians’inherentresilience,butmayalsobeseenasanattempttoabsolvepolicy-makers,organisations,andmanagersfromtheresponsibilityofaddressingdysfunctionalsystemsandworkplacecultures[38].Thismaymerelyhavetheeffectofbreedingcynicism,erodingstaffengagement,andunderminingtrustintheinstitution.DespiteconsiderablepoliticalinterestinAustraliandoctors’wellbeingatthestateandfederallevelsonly51%ofNewSouthWalesdoctors-in-trainingfeltthattheiremployersvaluedtheirhealthandwellbeing,andonly24%believedthatanyactionwouldbetakentoimprovetheirsituation[27].Conversely,acknowledgingproblemsandengagingwithfrontlineclinicianstodevelopsolutionsthatspecificallyaddresstheirneedsmayhelpexecutiveleaderstoaddressthehighlevelsofcynicismseeninAustralia.Whilesystems-targetedandindividual-targetedinterventionshavebothprovedtobebeneficialinaddressingclinicianburnoutandpoorwellbeing,twosystematicreviewsandmeta-analyseshavedemonstratedsomesuperiorityintheeffectivenessofsystems-targetedinterventions[39,40].TheStanfordWellMDCenterconceptualframework(Figure2)placesthebulkofresponsibilityforaddressingclinicianwellnessonhealthcareorganisations,withtwoofthethreedomains(cultureofwellnessandefficiencyofpractice)representingsystem-leveldriversandsolutions,andonlyonefocusingontheindividual[41].ThisframeworkprovidesthelensthroughwhichIwilldiscussinterventions,usingtheWellMDCentre’sDomaindefinitions[41].

CULTUREOFWELLNESSOrganisationalworkenvironment,valuesandbehavioursthatpromoteself-care,personalandprofessionalgrowth,andcompassionforourselves,ourcolleaguesandourpatients.

StanfordWellMDCenterDomainDefinitionsApproachestoimprovingthecultureofwellnessobservedintheorganisationsIvisitedincludeleadershipoptimisation,clinicianinvolvementinprogramdesign,programsforpeersupportanddebriefing,andeffortstoimprovecollegialityandprofessionalisminworkplaces.Leadershiphasbeenshowntobeastrongpredictorofwellbeing,professionalsatisfaction,andburnoutatthework-unitlevel[19,24,36].Routineassessmentofwork-unitleadershipcanprovideascreeningtooltodetectdepartmentsathighriskofburnout,andallowtargetededucationofunderperformingmanagersinleadershipandcommunicationskills[36].

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Activeengagementandcollaborationbetweenleadersandfront-lineclinicianstoidentifyandaddressproblemsprovidesanopportunitytotailorprogramstolocalneedandtolocally-availableskillsandresources[19,42].AstrategyusedbytheteamatUniversityofUtahHealthandPattyDeVriesofStanford’sWellMDCenterleveragesgrassrootsskillsandpromotesengagementwithprogramsthrough“WellnessChampions”.Groupsandteamswriteaproposalandmaybeprovidedwithseedfundingorotherresourcestoimplementclinician-designedprogramsatthedepartmentlevel.Theserangefromresourcesforresilience-writinggroupstosubsidisedteamregistrationinlocalsportingcompetitions[43].Thebenefitsarethreefold:byengaginglocalindividualsinthedesignoftheprogramstheyarelikelytoaddresslocaldriversandleveragelocalskillssets,makingthemmoreefficientforagiveninvestment;secondly,individualsfromtheteamaremorelikelytobeengagedwithandinvestedinprogramstheyrequestedanddesignedthemselves,soprogramsaremorelikelytoexperiencesustainedsuccess;thirdly,thisdemonstratesthatleadershipisreceptiveandresponsivetotheneedsofindividualsandteams,combattingcynicism.Peersupportsystemsofallformatsareincreasinglybeingutilisedtoenhanceworkplacecultureandcollegiality,andtoaddresssecondvictimsyndrome[44-47].Trainingprogramsforpeersupporters–vitalinviewofexistingevidenceofharmduetopoorlyconductedortimeddebriefing[48]–havebeendevelopedatJohnsHopkinsandBrighamandWomen’sHospitalstoscaleinterventionsacrossmultiplesites[44,46].“Gatekeepertraining”deliveredinroutineprotectedteachingtimeatUniversityofUtahHealthteachesresidentsandfellowshowtorecogniseandapproachacolleaguetheysuspecttobestruggling;inanefforttopromoteearlyinterventionforindividualswhomaybesufferingfromburnout,distress,orsuicidality.London’sPractitionerHealthProgrammeprovidesremotemultidisciplinarysupervisionandsupporttogeneralpractitionersthroughouttheUKthroughtheNationalGPHealthService.JohnsHopkins’ResilienceinStressfulEvents(RISE)peersupportprogramdemonstratesthepowerofvolunteers[49].TheteambehindRISEdevisedaneducationalprogramtoprovideclinicianswithskillsinpsychologicallysafedebriefingafterdistressingeventsintheworkplace,andholdstheultimategoalofprovidingeveryclinicianatHopkinswiththeseskills.TheRISEtemitselfrunsanon-callrosterofselected,trainedclinicianvolunteerstoprovidea24/7debriefingservice.Theserviceisavailabletoeverystaffmember,clinicalornon-clinical,anddebriefingsessionscanbedeliveredtoteamsorindividuals.Atthetimeofmyvisittherewere34volunteersontheroster,withtheteamreceivingaboutonecallperweek.Inthedayortwofollowingacall,anyoneavailablefromtheteamattendstodebriefthedebriefer.ThepassionandcompassionofvolunteersattheteammeetingIwasluckyenoughtoattendwaselectric.Theirpassionisnotonlyharnessedbutstrengthenedandmultipliedthroughparticipationintheprogramandacommongoaltoimprovelifefortheircolleagues.Formaldebriefingsessionsarelikewisegainingpopularity.TheformatencounteredmostfrequentlywasSchwartzCenterRounds,amultidisciplinaryfacilitateddebriefingsessionheldina‘GrandRounds’-styleformat.Thisinterventionfostersimprovedinterdisciplinaryunderstandingandteamworkthroughdiscussionofcommonandindividualexperiencesofchallengingaspectsofpatientcare.IwasabletoattendoneSchwartzRoundsessionatDukeUniversityHospital,andwitnessedpowerfuldiscussionofissuesofconflictwithfamiliesinpalliativecaresettings.Twocasesweredescribedfromtheperspectiveofdoctor,nurse,socialworker,andhospitalchaplain,andarespectful,thought-provokingandpoignantdiscussionfacilitatedwiththelargeaudience.DesignedintheUSA,SchwartzCenterRoundsareestablishedatmorethan440sitesaroundtheworld,includingfivesitesacrossAustraliaandNewZealand.TheprogramwaspilotedintheUKintwoNHStrustsbythePointofCareFoundationin2009.Theroundshavebeensosuccessfulthatby

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theendof2017theyhadbeensuccessfullyimplementedat180sitesacrosstheUK.Strategiestocultivatecollegialityandprofessionalismarelikewisebeingutilisedtoimproveworkplaceculture.Strong,positiverelationshipspromotebothpsychologicalandphysicalhealth,andfosteringthedevelopmentoftrusting,supportiveprofessionalrelationshipswhileappropriatelyandpromptlyaddressingunprofessionalbehaviourhasbeenusedtogreateffecttoenhanceworkplaceculture[47,50].Addressingbarrierstostaffparticipationisimportanttothesuccessoftheseinterventions.Buildingdebriefingsessionsandinterventionsforcollegialityintowell-establishedstructuresinthehospitalsetting,ideallywithprotectedtimeandfoodprovidedforattendees,maybethebestwayofintroducingsuchinterventions.ManysuchstructuresalreadyexistintheAustraliansetting:GrandRounds,residentteaching,nursingin-services,anddepartmentmeetings;thesecouldbeusedtopilotsystemssimilartoSchwartzortointroduceshortexercisestofostercollegialityandcommunitywithindepartments(seelatersegmentonpositivepsychologytechniquestaughtatDukePatientSafetyCenter).Ifbarrierstoparticipationincludeasenseofdiscomforthavingsuchdiscussionsintheworkplace,ortheworksettingreinforcinghierarchy,off-sitevoluntarymeetingsmaybemoreappropriatehavealsobeenusedsuccessfullyfordebriefinginterventions[51,52]

EFFICIENCYOFPRACTICEWorkplacesystems,processes,andpracticesthatpromotesafety,quality,effectiveness,positivepatientandcolleagueinteractions,andwork-lifebalance.

StanfordWellMDCenterDomainDefinitionsEfficiencyofpracticeiscurrentlyatopicofkeeninterestintheUnitedStates,withfederalincentivesintroducedin2010and2014fordigitisationofhealthrecordsmeaningthatElectronicHealthRecords(EHRs)wererolledoutacrossthenationmorequicklythantheycouldbetailoredtolocalneed[53].AconcurrentincreaseindocumentationrequirementsledDrJamesMadara,CEOoftheAmericanMedicalAssociation,tocommentthat“Physicianshavebecomethemostexpensivedataentryforceonthefaceoftheplanet”[54].Thishasledmanyclinicianstofeeldisconnectedfromtheirsenseofvocationalpurpose,reducingprofessionalsatisfactionandcompoundingmanyoftheotherdriversoftheburnoutepidemic[19,55,56].ConsiderablediscussionattheAmericanConferenceonPhysicianHealthrevolvedaroundwaysofstreamliningEHRdocumentationandbetterutilisingancillarystafftoallowclinicianstodevotetheirtimetoclinicaloverclericaltasks.Manyinterventionsfallingunderthiscategoryareextremelybeneficialtotheefficiencyoftheorganisation.StanfordWellMDCenterusesitsconceptualframeworktodemonstratetocliniciansthatmanyinitiativesofthehealthcareorganisationthatarenotdirectlyrelatedtowellnessinfactaddresssystemsissuestheythemselveshadcitedasproblematicintheirworkinglives.Thishastheeffectofreinforcingtobothleadersandstaffthebenefitsoftwo-wayfeedbackonsystemsimprovements.DrPamelaEisener-Parsche,DirectorofPhysicianConsultingServicesattheCanadianMedicalProtectiveAssociation,spentthefirsttwoyearsofhertermofleadershipfocusingonthewellbeingandefficiencyofherownteam.Alongwithprovidingprotectedtimetoattendwellnessactivities,shefacilitatedagrassrootsgroupsofteammemberstorestructuretheworkflowsoftheunittomakethesystemmoreefficient,

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collegiateandequitable.Thenewincreasedtheabilityofstafftoworkcooperativelyratherthanassiloedindividuals,withtaskshiftingandsharing,increasedworkplaceflexibilityandimprovedcapacitytoallocateschedulesandworkloadaccordingtothechangingdemandonindividualsandteams.Herteamhasexpressedgreatsatisfactionwiththenewsystem.TheinterventionforefficiencyofpracticethatstruckmeasthemostinnovativewastheAcademicBiomedicalCareerCustomisationpilotprogramatStanfordUniversityHospital[57].Thisprogram,initiallyconceivedtoaddresstheobservedgenderimbalanceinacademicmedicine,aimedtomitigatework-lifeandwork-workconflictsforstaffthroughcareercoachingandatimebankingscheme.Thepilotwasimmenselysuccessful,withmeasurableimprovementsonanumberofstaffsatisfactionsscores,areductioninstaffturnover,andanaverage$1.1millionworthofadditionalgrantsperparticipant.Thereturnoninvestmentforthisinterventionisstaggering,with$250,000initialfundingforthetwo-yearpilotprogram,andonly$2,000perparticipantperyeartocontinuethetimebankingcomponentasapermanentprogramforEmergencyPhysicians[58].Unfortunately,theemergencydepartmentwastheonlygroupthatcontinuedtheprogram,withotherdepartmentsawaitingfurtherresultsbeforecommittingfunding.

PERSONALRESILIENCEIndividualskills,behaviours,andattitudesthatcontributetophysical,emotional,andprofessionalwell-being.

StanfordWellMDCenterDomainDefinitionsInterventionsforpersonalresiliencefocusedonthreeareas:traininginskillsofself-compassion,mindfulness,andpositivepsychology;educationaroundoptimalnutrition,sleep,andexerciseforshiftworkers;andprovisionofaccesstotrulyconfidentialmedicaltreatmentandcasemanagement.Self-compassionormindfulness-basedinterventionshavebeenwidelyimplementedwithmuchsuccess,thoughresearchisongoingatmanysites,includingUniversityofUtahHealthandStanfordWellMDCentre,tomaximisetheefficacyofprogramswhileensuringtheyaretime-efficientandsimpleforclinicianstoparticipatein.The‘EnhancingCaregiverResilience:QualityImprovementandBurnout’courseatDukePatientSafetyCenterteachesparticipantspracticalandevidence-basedpositivepsychologytechniques.Thetechniques,whichcapitaliseonthepsychologicalbenefitsofcultivatingsocialconnectionandemotionssuchasaweandgratitude,havemeasurabledose-responserelationships,reliabledurationofeffect,arequicktoimplement,andalmostentirelycost-neutral.Individualsarealsotaughtskillsinresiliencewriting,anauto-debriefingexercisethatacceleratestheprocessingofstressfulevents[59].Thecourseiswellattendedbywork-unitleaders,andattendeesareprovidedwithresources,tools,andsupporttodisseminateandimplementthetechniquesintheirhomeunits.Althoughcliniciansareuniversallyurgedtoattendtotheirownphysicalwellnesswithsufficientsleep,ahealthydiet,andregularexercise,therearebarrierstoachievingthisinherentinmanyclinicalroles.Weunderstandthedetrimentalhealthandcognitiveeffectsofshiftworksleepdisturbanceandyetthereisapaucityofresearchandevenlesseducationaroundoptimalsleephygienepracticesorsaferosteringpatternsforshiftworkers.Happilythereareexpertrecommendationsemergingonthetopic[60,61],thoughtheinformationneedstobeincludedinstandardeducationforcliniciansandrostermanagers,andshouldbeusedtoinformpoliciesforsaferosteringpractices.Asimilarstateofplayexistswithregardstonutritionforoptimalperformanceduringshiftwork,withlittlepublishedonthematter,andaccesstohealthyfoodoptionslackinginhospitals;particularlyovernight[62].IntermountainHealthCarelastyear

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bannedjunkfoodfromitscampuses,drivingwideavailabilityofhealthyfoodoptionsforvisitorsandstafffromhospitalcafeteriasandvendingmachines,andalsoprovidesaccesstoreasonably-pricedonsitegymfacilitiesforstaff[63].InattendingEnhancingCaregiverResilience:QualityImprovementandBurnoutatDukeUniversity,Ihadmyfirstexposuretoformaleducationonthetopicsofsleep,exerciseandnutritionforshiftwork[48].Hopefullyintimeaccesstoeducationandresourcesfacilitatinghealthysleep,nutritionandexerciseforclinicianswillbecomethenorm.Thecareofindividualclinicianscannotbeassuredwithoutaddressingoneoftheprimarybarrierstoseekinghelp:alackofaccesstoconfidentialhealthcare.SeveraloftheorganisationsIvisitedoffercounsellingandcasemanagement,andIwasprivilegedtobeabletotakeacloselookattheservicesavailabletoLondon-baseddoctorsthroughthePractitionerHealthProgramme(PHP).ThePHPoffersclinicianstrulyconfidentialGPaccess;specialisedtrainingandsupervisionfordoctorsoutsideofLondoninterestedintreatingtheirfellowclinicians;casemanagementfordoctorsundergoinginvestigationbyregulatorybodies;referraltootherservices;Balint-stylesupportgroupsandmore.TheorganisationhasbeencondonedbyregulatorybodiestotheextentthatthePHPcliniciansareabletoindependentlyoverseetherehabilitationofindividualswithconditionsimposedontheirlicenses.

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DISCUSSIONThedialoguearoundclinicianwellbeinginAustraliahasneverbeenmoreactivethanitisnow.Althoughmanyofthecultural,industrialandclinicaldriversstillexist,increasedsocietalawarenessofmentalhealthandincreasingeducationinmedicalschoolsisbeginningtoerodethestigmasurroundingmentalhealthandwellbeinginclinicians.Manylongstandingsupportsandprogramsaregainingvisibilityandfinesse,newprogramsareexperiencinglessresistancetotheirdevelopmentandmoreactiveleadershipsupportthanbefore,andindividualswithaninterestintheareaareincreasinglyencouragedtopursueit.Wemustfurtherestablishinfrastructuretosupportorganisationsandindividualstoaddressrootcausesandtobreakdownbarrierstosolutions.Wemustalsofacilitatethesharingofideasandexperiencesofwhatworksindifferentcontextsinordertomaximiseefficiencyofourcollectivelearning.Theestablishmentofinterdisciplinarymeetingsonwellbeinginhealthcareacrossmedical,nursing,alliedhealth,andancillarystaff;inhospitalsandthecommunity,andinpublicandprivatesectorswillfacilitatethis.ProgramsforclinicianwellnessexistatalllevelsoftheAustraliansystem.Forexample,FederalWork,HealthandSafetylegislationhasledthemajorityofhealthcareorganisationssubscribetoEmployeeAssistancePrograms.Theseprogramsareanexcellentresourcebutperhapsunder-utilisedduetoalackofawarenessamongstaffofwhatsupportisavailableorofprotectionsforconfidentiality.Organisationsneedtotakestepstodemystifyanddestigmatisesuchexistingservicestopromotestaffengagement.TheDoctors’HealthServicesprovide24-hourfree,confidentialadvicetodoctorsonmattersofphysicalandpsychologicalhealthineachstateandterritory.InNewSouthWales,aJuniorMedicalOfficerSupportLinehasbeenestablishedinpartnershipwithanEmployeeAssistanceProgramProvidertoofferfree24-hour,confidentialadvicetojuniordoctorsaroundinappropriateworkplacebehaviours.Servicessuchastheselikewiseneedtobemademorevisibleandaccessibletoindividuals.OrganisationssuchastheAustralianNursingandMidwiferyFederation,theAustralianMedicalAssociationandtheAustralianSalariedMedicalOfficers’Associationwillcontinueadvocatingfortheinterestsofcliniciansatfederalandstatepolicylevel.Indoingthis,theymuststrivetoensurethattheirvoiceisrepresentativeofcliniciansworkinginallcontexts:publicandprivate;largeandsmallorganisations;metropolitan,ruralandremote.Federalandstatebodiesaswellaslocalorganisationsmustalsoengagefront-lineclinicianswhereverpossibleindiscussionaroundpolicydecisionstoanticipateandaddressadverseeffectsonstafffromimplementation.Moreattentiveworkforceplanningisneededespeciallyfordoctors-in-trainingandjuniornurses.Alackofjobsecuritycreatesanatmosphereoffearandinsecuritythatwecannotaffordinthefaceofpredictedworkforceshortages.Intensecompetitionforvocationaltrainingpositionsfordoctors-in-trainingputsenormouspressureonindividualstoprioritisetheiremploymentprospectsfaraboveself-care,andamplifiesthealreadyhighstakesplacedontheoutcomeofprofessionalexaminations.Asolutiontotheseproblemswillrequireconsiderablecooperationbetweentheministriesofhealth,professionalassociations,collegesandregulatorybodies.Asmentionedpreviously,withinlargehealthcareorganisationstheappointmentofaChiefWellnessOfficer

23

willcreateachainofaccountabilityforstaffwellness,butwhoisresponsibleforensuringthewellbeingofthemanycliniciansworkingoutsidesuchorganisations?ProfessionalIndemnityInsuranceprovidersareextremelywell-placedtoplayakeyrolehere,havingaclearstakeinthemaintenanceofoptimalperformancebyclinicianswhilealsohavingalmostunparalleledreachtocliniciansoperatingindependentlyfromlargeorganisations.ProfessionalCollegesandUniversitiesarelikewiseinagoodpositiontoreachalargeaudienceofclinicianstoprovideeducation,healthpromotionandscreening.ManymedicalschoolsaroundAustraliaaredevelopingwellbeingcurricula,harnessingtheircapacitytoshapethefuturemedicalworkforcebothinequippingindividualsandineffectingculturalchange.Thismovementshouldbeencouragedinalldisciplines,asshouldthesharingoftechniquesandresourcesbetweeneducationalcentres.ManybutnotallprofessionalcollegeshavesubscribedtotheCanadianMedicalAssociation’sCanMEDSFrameworkthatlistsself-careasacorecomponentofprofessionalism.Allprofessionalcollegesandregulatorybodiesoughttoadoptaformalpositionofclinicianwellbeingandencouragethedevelopmentofskillsinthisareathroughaccreditationofwellness-relatedContinuingProfessionalDevelopmentactivitiesand,importantly,amoreflexibleandhumaneapproachtodealingwithcliniciansindifficulty.SomebutnotallhealthcareorganisationsinAustraliahaveachievedthe“Novice”stageoftheOrganisationalJourneyTowardsExpertiseinPhysicianWell-being(Shanafeltetal2017),offeringprogramstargetedtowardindividualsthatareoftenscheduledduringbusyworkdayswithnoprotectedtimeforattendanceandwithoutanattempttocoordinateacomprehensive,measurableandevidence-basedapproach.Unfortunately,theseprogramsineffectdolittlemorethanpaylipservicetotheissuesathand,andplaceresponsibilityforreversingthispublichealthcrisislargelyontheshouldersofindividualclinicians.Ameta-analysisofphysicianburnoutpreventionprogramsnotedthatsystemicinterventionsaresignificantlymoreeffectiveinreducingclinicianburnoutthanindividual-focusedinterventions[40].Thereisstillalongwaytogoonourcountry’sjourneytoward“Expertise”inthisfield.Encouragingly,RoyalPrinceAlfredHospital’sPilotProgramBPTOKdemonstratesarareexampleofaninstitutiondemonstratingacomprehensive,integratedandseriousinvestmentinthewellbeingofitsdoctorswithacommitmenttoevaluationandongoingdevelopment.Programslikethisneedongoingsupportfortheiroperation,evaluationandupscalingacrossthecountry.Itisimportantthatweasanindustryaddressthebarrierstoindividualsprioritisingself-careandseekinghelpwhenrequired.Thiswillincludeprovidingaccesstoarangeofservicesandresourcestoallowindividualstoassessandaddresstheirownneeds,andmaximisingaccessibilitytoservicesduringworkhours,afterhours,on-siteandoff-site.TheproblemofalackofconfidentialcarefordoctorsiscurrentlybeingaddressedinNSWwithadvocacyfromfederalandstatebranchesoftheAustralianMedicalAssociation,andthesechangeswillneedtobebroadlypublicised.Furthermore,trainingoughttobeofferedtocliniciansseekingtodebriefandtreattheircolleaguessothattheseservicesareprovidedinapsychologicallysafeaswellasconfidentialmanner.Althoughthisreportservesasabasisfordiscussion,Iamnecessarilyrestrictedsomewhatinmyperspectivetothatofamiddleclass,femaleNewSouthWalesdoctor-in-training.IssuesthatIhavenotaddressedinthisreportbutwhicharenonethelessapriorityincludeworkplaceviolence,discrimination,andadeeperdiscussionoftheissuesaffectingnursesandalliedhealthaswellasdoctorsatlatercareerstages.

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RECOMMENDATIONS

1. MeasurementandResearch1.1. Standardised,validatedmetricsneedtobeadoptedtofacilitatebenchmarkingacrosstheAustralian

healthcaresystem.Adoptingmeasuresalreadyinusebyhealthcareresearchinstitutionsinternationallywillallowustobenefitmorefromresearchundertakenaroundtheworldandacceleratetheestablishmentofaglobalbestpracticestandard

1.2. UniversitiesandorganisationswithastrongresearchbaseshouldformthecentreofongoingadvancesinAustralianclinicianwellness,clarifyingdriversandbestpracticeinterventions,andofferingresearchsupporttoorganisationsimplementingnewprograms

1.3. AustralianresearchbodiesshouldpartnerwithinternationalresearchgroupssuchasthePhysicianWellnessAcademicConsortiumtofortifyresearcheffortsandremainuptodatewithbestpracticeintheassessmentandmanagementofclinicianwellness

1.4. Infrastructureneedstobeestablishedtoallowregular,ideallylongitudinalmeasurementofclinicianwellbeingacrossthehealthcaresystem

1.5. PriorityareasforresearchincludethelinksbetweenclinicianwellnessandfinancialandpatientoutcomesintheAustraliancontext,driversofpoorwellbeingindifferentcontextsandpopulations,andtheeffectivenessofdifferentinterventionsforspecificcontexts,driversandclinician/patient/financialoutcomes.

1.6. Guideinesfortheevaluationofclinicianwellnessinitiativesneedtobeestablished,ideallyassessinguptake,engagement,socialreturn-on-investment,clinicianoutcomesandpatientoutcomeswithoutdisruptingserviceprovisionorcompromisingconfidentiality

2. LeadershipandPolicy2.1. Leadershipengagementmaybeachievedmoremeaningfullybysupportingthemoral/ethical

argumentwithabusinesscasepresentingfinancialandpatient-centredoutcomes2.2. Australianregulatorybodiesshouldformallyacknowledgetheplaceofclinicianwellnessasthe

fourthqualityindicatorinhealthcarebylinkingkeymetricsofclinicianwellnesstoaccreditationstandardsforpublicandprivatehealthcareorganisations

2.3. HealthorganisationsneedtoprioritisethemeasurementandimprovementofclinicianwellbeingbymakingstaffwellnessaKeyPerformanceIndicatorfortopexecutives,withfinancialincentivesformeetingtargetslinkedtolongitudinaloutcomes

2.4. Aclearchainofaccountabilityneedstobeestablishedfortacklingclinicianwellnessissues.Assuch,aChiefWellnessOfficerorsimilarshouldbeappointedineveryhealthcareinstitutionatFTEproportionaltothenumberofstaff.Itwillbetheirroletocoordinateandpromoteexistingwellnessprograms,andoverseethemeasurementofstaffwellnessasanessentialcomponentofqualityassurance

2.5. ProfessionalIndemnityInsuranceprovidersarewellplacedtoplayakeyroleinclinicianwellness,clearlyhavingastakeinmaintainingoptimalperformanceofclinicians,andhavingtheadvantageofcontactwithcliniciansoperatinginisolationintheprivatesectorandthroughlocumagencies

2.6. AllAustralianProfessionalCollegesoughttoincludewellnessindefinitionsandassessmentofProfessionalismaspertheCanMEDSframework.

2.7. Institutearegularregionalconferenceonclinicianwellbeingtoencouragecontinuingdialogueandresearchoncurrentissuesandthesharingofbestpracticeinitiativesacrossthecountryandacrossdisciplines

25

2.8. Engagecliniciansinthedesignandimplementationofwellnessprogramsatthelocallevel3. System-LevelInterventions

3.1. Themajorityofinterventionsneedtobesystem-targetedratherthanindividually-targeted3.2. Bulkofinvestmentshouldbeinprimarypreventionandearlyinterventiontoinordertoensurethe

greatestreturnoninvestedtime,personnelandfunding3.3. Educationforculturalchange:universaltraininginpsychologicalfirst-aid,peersupportand

recognitionofwhenyouarethebully[64]3.4. Mandatetheprovisionofdebriefing/peerreview/supervisionsessionswithtrainedfacilitators.The

PeerReviewactivitiesmandatedbytheRoyalAustralianNewZealandCollegeofPsychiatristsareanexampleofoneformatthisprocesscantake,howeverSchwartzCentreRounds,BalintGroupsandremotemultidisciplinarysupervisionhavebeenusedtogoodeffectinvariouscontexts.

4. Individual-levelinterventions4.1. Organisationsshouldaimtoprovideacomprehensiverangeofprogramsinresponsetoidentified

driverstotakeadvantageofmarginalgainsandallowindividualstoselectprogramsaccordingtopersonalneed

4.2. Provideresourcesandinterventionsforindividualsfromallcareerstagesfromstudentsthroughtolate-careerandretiredclinicians

4.3. Organisationsshouldempowerstafftotakecontroloftheirownwellnessthroughrealandmeaningfulsteps:forexample,provisionoftrulyprotectedtimeoratimebankingsystem

4.4. Furtherresearchisneededtoestablishevidence-basedrecommendationsforshiftworkerswithregardstonutrition,sleephygiene,exercise.Establishmentoftargetsfororganisationstofacilitatecliniciancompliancewithbestpracticee.g.availabilityofhealthyfoodoptionsovernight,availabilityofsafeplacetosleeponnightshift,programtoaddressworkplaceviolence

5. Addressbarrierstohelp-seeking5.1. Ensuretrulyconfidentialphysicalandmentalhealthservicesforclinicians,ideallywithafter-hours

optionstosuitshiftworkers5.2. Compileanationaldirectoryofgeneralpractitionersandpsychologistswillingtotreatfellow

clinicians5.3. Developandinstituteatrainingandaccreditationpathwayfordoctorstreatingclinicians;provide

confidentialsupervisiontothoseprovidingtreatment5.4. Ensuretransparencyofprivacyprotectionwhereexistingnon-confidentialservicesareused

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REFERENCES1. beyondblue,Nationalmentalhealthsurveyofdoctorsandmedicalstudents.2013,beyondblue.2. Milner,A.J.,etal.,Suicidebyhealthprofessionals:aretrospectivemortalitystudyinAustralia,2001-

2012.TheMedicalJournalofAustralia,2016.205(6):p.260-265.3. Ogle,W.,StatisticsofMortalityintheMedicalProfession.Medico-ChirurgicalTransactions,1886.69:

p.217-237.4. Aasland,O.G.,Physiciansuicide-why?Generalhospitalpsychiatry,2013.35(1):p.1-2.5. Lindeman,S.,etal.,ASystematicReviewonGender-SpecificSuicideMortalityinMedicalDoctors.

BritishJournalofPsychiatry,1996.168(3):p.274-279.6. Stack,S.,SuicideRiskAmongPhysicians:AMultivariateAnalysis.ArchivesofSuicideResearch,2004.

8(3):p.287-292.7. Schernhammer,E.S.andG.A.Colditz,Suicideratesamongphysicians:aquantitativeandgender

assessment(meta-analysis).AmericanJournalofPsychiatry,2004.161(12):p.2295-2302.8. Hawton,K.,etal.,Suicideindoctors:astudyofriskaccordingtogender,seniorityandspecialtyin

medicalpractitionersinEnglandandWales,1979–1995.JournalofEpidemiologyandCommunityHealth,2001.55(5):p.296.

9. Fahrenkopf,A.M.,etal.,Ratesofmedicationerrorsamongdepressedandburntoutresidents:prospectivecohortstudy.BMJ,2008.336(7642):p.488-491.

10. Shanafelt,T.D.,etal.,BurnoutandmedicalerrorsamongAmericansurgeons.Annalsofsurgery,2010.251(6):p.995-1000.

11. Welp,A.,L.L.Meier,andT.Manser,Emotionalexhaustionandworkloadpredictclinician-ratedandobjectivepatientsafety.Frontiersinpsychology,2015.5:p.1573.

12. Welle,D.,etal.Physicianwellnessmeasuresareassociatedwithunsolicitedpatientcomplaints:Amarkerforincreasedliabilityrisk.inAmericanConferenceonPhysicianHealth.2017.SanFrancisco.

13. Hamidi,M.S.,etal.Theeconomiccostofphysicianturnoverattributabletoburnout.inAmericanConferenceonPhysicianHealth.2017.SanFrancisco,CA.

14. Anagnostopoulos,F.,etal.,PhysicianBurnoutandPatientSatisfactionwithConsultationinPrimaryHealthCareSettings:EvidenceofRelationshipsfromaone-with-manyDesign.JournalofClinicalPsychologyinMedicalSettings,2012.19(4):p.401-410.

15. Bodenheimer,T.andC.Sinsky,Fromtripletoquadrupleaim:careofthepatientrequirescareoftheprovider.TheAnnalsofFamilyMedicine,2014.12(6):p.573-576.

16. Wallace,J.E.,J.B.Lemaire,andW.A.Ghali,Physicianwellness:amissingqualityindicator.TheLancet,2009.374(9702):p.1714-1721.

17. Chaukos,D.,etal.,Anounceofprevention:apublichealthapproachtoimprovingphysicianwell-being.AcademicPsychiatry,2018.42(1):p.150-154.

18. Tay,T.,Discussionregardingdevelopmentofawellbeingframeworkmodelandorganisationaltoolkitfordesignandimplementationofclinicianwellbeingprograms,C.Weston,Editor.2018:NewLambton,NSW,Australia.

19. Shanafelt,T.D.andJ.H.Noseworthy,Executiveleadershipandphysicianwell-being:nineorganizationalstrategiestopromoteengagementandreduceburnout.MayoClinicProceedings,2017.92(1):p.129-146.

20. Dyrbye,L.N.,etal.,UtilityofaBriefScreeningTooltoIdentifyPhysiciansinDistress.JournalofGeneralInternalMedicine,2013.28(3):p.421-427.

21. Trockel,M.,etal.,Abriefinstrumenttoassessbothburnoutandprofessionalfulfillmentinphysicians:reliabilityandvalidity,includingcorrelationwithself-reportedmedicalerrors,inasampleofresidentandpracticingphysicians.AcademicPsychiatry,2017:p.1-14.

22. Simon,C.andT.McFadden.TheCanadianphysicianhealthandwellnesssurvey:buildinganationaldataset.inAmericanConferenceonPhysicianHealth.2017.SanFrancisco.

23. Dyrbye,L.N.,etal.,Developmentofaresearchagendatoidentifyevidence-basedstrategiestoimprovephysicianwellnessandreduceburnout.Annalsofinternalmedicine,2017.166(10):p.743-

27

744.24. Williams,E.S.,etal.,Therelationshipoforganizationalculture,stress,satisfaction,andburnoutwith

physician-reportederrorandsuboptimalpatientcare:resultsfromtheMEMOstudy.HealthCareManageRev,2007.32(3):p.203-12.

25. Shanafelt,T.,J.Goh,andC.Sinsky,Thebusinesscaseforinvestinginphysicianwell-being.JAMAinternalmedicine,2017.177(12):p.1826-1832.

26. Brownson,R.C.,G.A.Colditz,andE.K.Proctor,Disseminationandimplementationresearchinhealth:translatingsciencetopractice.2017:OxfordUniversityPress.

27. NSWHealth,YourTrainingandWellbeingMattersSurveyReport.2017,NSWGovernment.28. AMA,AMAsurveyreportonjuniordoctorhealthandwellbeing,inACT,Australia:AustralianMedical

Association.2008.29. Markwell,A.andZ.Wainer,Thehealthandwellbeingofjuniordoctors:Insightsfromanational

survey.Vol.191.2009.441-4.30. AMA(NSW)andASMOF,AllianceNSWHospitalHealthCheckSurvey2017.2017,AMA(NSW)and

ASMOFSydneyNSWAustralia.31. AMA(QLD),AMAQueensland’sResidentHospitalHealthCheck2017.2017,AMA(QLD):Brisbane,

QLD,Australia.32. AMA(WA),AMA(WA)DoctorsHospitalHealthCheckSurvey2017.2017,AMAWesternAustralia:

Perth,WA,Australia.33. Murphy,M.L.,etal.,WellMDCenterStatusReportMarch2017.2017,StanfordUniversity:Stanford,

California,USA.34. ACSQHC,NationalSafetyandQualityHealthServiceStandards(September2012).2012,Australian

CommissiononSafetyandQualityinHealthCare:Sydney,NSW,Australia.35. WMA,WorldMedicalAssociationDeclarationofGevena.2017,WorldMedicalAssociation.36. Shanafelt,T.D.,etal.Impactoforganizationalleadershiponphysicianburnoutandsatisfaction.in

MayoClinicProceedings.2015.Elsevier.37. Brazeau,C.M.L.R.,etal.,DistressAmongMatriculatingMedicalStudentsRelativetotheGeneral

Population.AcademicMedicine,2014.89(11):p.1520-1525.38. Montgomery,A.,Theinevitabilityofphysicianburnout:Implicationsforinterventions.Burnout

Research,2014.1(1):p.50-56.39. West,C.P.,etal.,Interventionstopreventandreducephysicianburnout:asystematicreviewand

meta-analysis.TheLancet,2016.388(10057):p.2272-2281.40. Panagioti,M.,etal.,ControlledInterventionstoReduceBurnoutinPhysicians:ASystematicReview

andMeta-analysis.Vol.177.2016.41. WellMDCenter,S.,2017WellMDModelDomainDefinitions.2016,StanfordMedicine:Stanford.42. Sexton,J.B.,etal.,ExposuretoLeadershipWalkRoundsinneonatalintensivecareunitsisassociated

withabetterpatientsafetycultureandlesscaregiverburnout.BMJQualSaf,2014.23(10):p.814-822.

43. Morrow,E.,etal.Reachingthetippingpoint:Creatingmomentumformeaningfulchange.inAmericanConferenceonPhysicianHealth.2017.SanFrancisco.

44. Edrees,H.,etal.,ImplementingtheRISEsecondvictimsupportprogrammeattheJohnsHopkinsHospital:acasestudy.BMJOpen,2016.6(9).

45. Dukhanin,V.,etal.,Case:ASecondVictimSupportPrograminPediatrics:SuccessesandChallengestoImplementation.JPediatrNurs,2018.

46. Shapiro,J.andP.Galowitz,PeerSupportforClinicians:AProgrammaticApproach.AcademicMedicine,2016.91(9):p.1200-1204.

47. Shapiro,J.,A.Whittemore,andL.C.Tsen,Institutingacultureofprofessionalism:theestablishmentofacenterforprofessionalismandpeersupport.JointCommissionjournalonqualityandpatientsafety,2014.40(4):p.168-177.

48. Sexton,J.B.,EnhancingCaregiverResilience:QualityImprovementandBurnoutCourse,C.Weston,Editor.2017.

28

49. Paine,L.,ChurchillFellowshipinterviewontheJohnsHopkinsResilienceinStressfulEvents(RISE)program,effectivepolicydesignandaplannedworkplaceviolencepreventioninitiative,C.Weston,Editor.2017:Baltimore,Maryland,USA.

50. Adair,C.,EnhancingCaregiverResilience:QualityImprovementandBurnoutCourse,C.Weston,Editor.2017:DukePatientSafetyCentre,ChapelHill,NorthCaroline,USA.

51. Sederstrom,N.,etal.,MWHCCenterforEthicsTransformingEnd-of-LifeCareProgram(TECP).2015,LownInstituteRightCareAlliance.

52. Sederstrom,N.,ChurchillFellowshipinterviewregardingdevelopmentofprotectedtimedebriefingprogramforcriticalcareresidentsatMassachussetsGeneralHospital,inChurchillFellowship,C.Weston,Editor.2017.

53. Wachter,R.D.HowtheEHRcontributestoburnoutandwhyitmightjustbetheanswer.inAmericanConferenceonPhysicianHealth.2017.SanFrancisco,California,USA.

54. Lesko,J.,TwitterCommunication,11thJune2016.https://twitter.com/joshualesko/status/741723853265637376.2016,Twitter:SanFrancisco,California,USA.

55. Sinsky,C.,etal.,Allocationofphysiciantimeinambulatorypractice:atimeandmotionstudyin4specialties.Annalsofinternalmedicine,2016.165(11):p.753-760.

56. Woolhandler,S.andD.U.Himmelstein,Administrativeworkconsumesone-sixthofUSphysicians'workinghoursandlowerstheircareersatisfaction.InternationalJournalofHealthServices,2014.44(4):p.635-642.

57. Fassiotto,M.,etal.,AnIntegratedCareerCoachingandTimeBankingSystemPromotingFlexibility,Wellness,andSuccess:APilotProgramatStanfordUniversitySchoolofMedicine.Academicmedicine:journaloftheAssociationofAmericanMedicalColleges,2018.

58. Fassiotto,M.,ChurchillFellowshipinterviewregardingthedesign,fundingandimplementationoftheAcademicBiomedicalCareerCustomisationpilotprogramatStanfordUniversityHospital,C.Weston,Editor.2017.

59. Sexton,J.D.,etal.,Careforthecaregiver:benefitsofexpressivewritingfornursesintheUnitedStates.ProgressinPalliativeCare,2009.17(6):p.307-312.

60. Farquhar,M.,Fifteen-minuteconsultation:problemsinthehealthypaediatrician—managingtheeffectsofshiftworkonyourhealth.Archivesofdiseaseinchildhood-Education&practiceedition,2017.102(3):p.127-132.

61. Hamor,P.,Tipsonpreparingfornightshift,inOnthePods,S.Anderson,Editor.2017,onthewards:Sydney,Australia.

62. Hamidi,M.S.,M.K.Boggild,andA.M.Cheung,Runningonempty:areviewofnutritionandphysicians'well-being.PostgraduateMedicalJournal,2016.92(1090):p.478-481.

63. Poss,B.,ChurchillFellowshipinterviewontheoriginofwellbeinginitiativesatUniversityofUtahHealth,C.Weston,Editor.2017.

64. Llewellyn,A.,etal.,BullyingandsexualharassmentofjuniordoctorsinNewSouthWales,Australia:rateandreportingoutcomes.AustralianHealthReview,2018:p.-.