Resident Wellness and Well-being: Lessons Learned from the Integrative Medicine in Residency Program

Patricia Lebensohn, M.D., Sally Dodds, Ph.D., Mary Guerrera, M.D., Dael Waxman, M.D., & Craig Schneider, M.D.

Presentation Objectives

▫ Describe the importance of teaching about wellness and well-being during residency.

▫ Discuss the definitions of wellness and well-being used in the IMR.

▫ Describe the tools used to assess resident wellness and well-being.

▫ Review the preliminary findings about IMR resident wellness and well-being.

▫ Discuss teaching strategies to promote IMR resident wellness & well-being.

Integrative Medicine in Residency (IMR) is…

• Competency-based, online, 200-hour, curriculum.

• In-depth training in Integrative Medicine.

• Incorporated through all 3 years of Family Medicine residency.

• Piloted at 8 residencies nationwide.

• Seamless, online evaluation of the curriculum and the residents.

• Responds to ACGME competency requirements.

• Evaluation developed simultaneously with the curriculum.

University of Arizona

University of Texas Medical Branch

Hennepin County

Carolinas Medical Center

Beth Israel

Maine-Dartmouth

Maine Medical Center

University of Connecticut

IMR Program Locations

Moses H. Cone

Alaska Family Medicine

Univ. of Minn

A. Einstein Montefiore

Control sites

Importance of Teaching About Wellness & Well-being

Residency is a powerful, formative experience in adulthood. Establishing physician identity, schema of patient relationships, work

habits, and self care. Physician Burnout

Estimates of physician burnout: 25% - 70%. Onset linked to residency training.

Distress in Residency Dramatic increases in depression, anxiety, and drug use. Increased cynicism, decreased empathy, poorer overall performance. Consequences

Psychological problems under diagnosed and under treated. Physician stress and burnout linked to lower-quality patient care. Habit of ignoring self care perpetuated in life after residency.

IMR and Wellness & Well-being

IMR uniquely positioned to shift graduate medical education toward physician wellness.

Prevention and wellness are central in course content.

Opportunity to explore and describe resident wellness & well-being longitudinally.

IMR Wellness & Well-being Definitions

Wellness behaviors: Specific behaviors and lifestyles that promote optimal physical, psychological, and spiritual health (Carlson et al., 1997).

Sense of Well-being (multiple dimensions): Satisfaction with Life: Global judgment of quality of life

(Diener et al., 1985).

Sense of Happiness: Pleasant affects (Pavot & Diener, 2008). Psychological well-being: Absence of psychological

distress (Ryff et al., 1995; Keyes et al., 2002).

Positive Personal Characteristics: Qualities of mindfulness, a grateful disposition, and emotional intelligence in the context of interpersonal relationships.

Wellness Behaviors Assessed in the IMR

Behavior

Moderate physical activity (30 min/da)

Fruits & vegetables (5/da)

Vitamins/other dietary supplements

Meditation

Prayer

PMR/other relaxation

Yoga

Tai Chi or Qi Gong

Behavior

Massage

Outdoors in nature

Nurturing relationships

Restful sleep

Alcoholic drinks per week

Smoking (y/n)

Rx for mood, anxiety, stress, sleep (y/n)

Resident Wellness Behaviors (All groups combined)Protective

Phys Act Fruit/Veg Nurt Rels PMR Meditation Prayer0%

10%

20%

30%

40%

50%

60%

70%

None 1-2 3-4 5-6 Daily

Resident Wellness Behaviors (All groups combined)

Risk

Restful sleep

11%

34% 35%

17%

3%

None 1-2 da 3-4 da5-6 da Daily

Alcohol drinks per week

38% 45%

13%

5%0%

0 1-3 4-7 8-14 14+

Yes2%

No98%

SmokeYes14%

No86%

Rx Dep/Anx/Stress

Well-being MeasuresDimension Measure

Global life satisfaction Satisfaction with Life Scale (SWLS; Dierner, 1985)

Affective traits Positive & Negative Affect Schedule (PANAS; Watson, 1988)

Psychological healthPerceived stressMood state distressDepressionBurnout

Perceived Stress Scale (Cohen et al., 1983)CES-D (Radloff, 1977)PHQ-9; (Kroneke et al., 2001)Maslach Burnout Inventory (Maslach et al. 1996)

Personal characteristics

MindfulnessGratitudeEmotional intelligence

Freiburg Mindfulness Inventory (Walach, et al., 2006)Gratitude Questionnaire-6 (McCullough, 2002)Trait Meta Mood Scale (Salovey & Mayer, 1995)Interpersonal Reactivity Index (Davis, 1980)

Series1

15.7 16.9 16.1

2011 2012 Controls

Perceived Stress Scale(e.g., “How often you felt you were on top of things?”)

Mean scores at baseline – 2011, 2012, Controls

ns

Range 1-33 Range 5-27 Range 9-30

Possible scores range from 0 – 40.

Never (<10)

Almost never (11-20)

Sometimes (21-30)

Fairly often /Often (>31)

22%

61%

15%

2%

15%

58%

27%

15%

59%

26%

2011 2012 Controls

Perceived Stress Scale Frequency of stress in the past month (at baseline)

*

*p = .03

Mean Score

15.4 16.9

PGY1 PGY2

Perceived Stress ScaleBaseline and 1st repeated measure

2011 Class (mean scores)

n=44; ns

Nev

er

Almos

t nev

er

(

11-2

0)

Somet

imes

(21-

30)

Fairly

ofte

n /O

ften

(>31

)

23%

61%

14%2%

9%

75%

14%2%

PGY1 PGY2

* p = .002; ** p = .001

Stress Frequency past 30 days

*

**

CES-D (Depression screener) – Mean scores

PGY1 – All groups (baseline)

Series1

12.5

11.411.5

2011 2012 Controls

ns

Range 0-34 Range 0-32 Range 1-34

Cutpoint =/> 16

CES-DSeverity scores in the past month (at baseline)

Non

dep

ress

ed

<15

Mild

dep

ress

ion

16-

20

Mod

erat

e de

pres

sion

21-

30

Very

depr

esse

d

>31

67%

17%10% 5%

74%

16%9%

2%

72%

12% 12%4%

2011 2012 Controls

Mean Score

12.2 10.9

PGY1 PGY2

Range 0-34

Range 0-32

n=46; nsNon

dep

ress

ed

...

Mild

dep

ress

ion

...

Mod

erat

e de

pres

sion.

..

Very de

pres

sed

...

67%

17%11%

4%

76%

9%13%

2%

PGY1 PGY2

Severity scores2011 Class means

*p= <.001

*

CES-DBaseline and 1st repeated measure

PHQ-9 (Depression diagnostic screener)Mean scores at baseline

Series1

3.33.8

4.2

2011 (02) 2012 Controls

ns

Range 0-13

Range 0-14

Range 0-16

None (<4)

Mild (5-9)

Moderate (10-14)

Mod Severe (15-19)

Severe (>20)

71%

25%

4%

64%

28%

8%

65%

27%

4% 4%

2011 (02) 2012 Controls

PHQ-9Severity scores at baseline

ns

CES-D and PHQ-9 Compared2011 PGY2

Non dep/None Mild Moderate Mod severe/ Severe

76%

9%13%

2%

71%

25%

4% 0%

CES-D (02) PHQ-9 (02)

Mean Scores

15.3 16.920.7

2011 2012 Controls

Maslach Burnout Inventory1Emotional Exhaustion Subscale (e.g., “I feel emotionally drained from my work”)

Mean scores at baseline – 2011, 2012, Controls

ns

Range 1-33 Range 5-27 Range 9-30

Possible scores range from 0 – 54.

Low </=18 Moderate 19-26 High >/=27

71%

11%18%

57%

32%

11%

54%

27%19%

2011 2012 Controls

Maslach Burnout Inventory2EE category scores at baseline

*p = .02

*

Mean group scores at baseline

Severity scores t1 – t2

Series1

15.3

22.3

PGY1 PGY2

Maslach Burnout Inventory3

EE Baseline and 1st repeated measure

ns

Low </=18

Moderate 19-26

High >/=27

71%

10%18%

45%

16%

39%

PGY1 PGY2

*p=.032; **p=<.001

**

*

*

*p=<.001

Series1

6 6.5 8

2011 2012 Controls

Maslach Burnout Inventory4

Depersonalization (e.g., “I really don’t care what happens to some patients”)

Mean scores at baseline – 2011, 2012, Controls

ns

Range 0-23 Range 0-18 Range 1-20

Possible scores range from 0 – 30.

Low <=5

Moderate 6-9

High >/=10

61%

9%

30%

43%

33%

24%

38%

27%35%

2011 2012 Controls

Maslach Burnout Inventory5

Dp Score Categories – 2011, 2012, Controls

Baseline Severity scores t1 – t2

Series1

6.210.2

Baseline Time 2

Maslach Burnout Inventory3

Depersonalization (Baseline &1st F/U)

p = <.001 p = <.001

Low

<=5

Moderate

6-9

High

>/=10

59%

8%

33%

20%27%

53%

PGY1 PGY2

*

**

***

*p = <.001; **p=..001; ***p= <.001

References

• De Matteo, MR, Sherbourne, CD, Hays, RD, Ordway, L, Kravitz, RL, McGlynn, EA, et al. (1993). Physicians’ characteristics influence patients’ adherence to medical treatment: Results from the Medical Outcomes Study. Health Psychology, 12, 2, 93-102.

• Eckleberry-Hunt, J, Lick, D, Boura, J, Hunt, R, Balasubramaniam, M, Mulhem, E, & Fisher, C. (2009). An exploratory study of resident burnout and wellness. Academic Medicine, 84, 2, 269-277.

• Eckleberry-Hunt, J, Van Dyke, A, Lick, D, & Tucciarone, J. (2009). Changing the conversation from burnout to wellness: Physician well-being in residency training programs. Journal of Graduate Medical Education, DOI:10-4300/JGME-D-90-00026.1.

• Gunderson, L. (2001). Physician burnout. Annals of Internal Medicine, 135, 2, 145-148.

• Wallace, JE & Lemaire, J. (2009). Physician well being and quality of patient care: An exploratory study of the missing link. Psychology, Health & Medicine, 14, 5, 545-552.

Discussion

AcknowledgementsUniversity of Arizona Pilot Sites

Emily Sherbrooke Ben Kligler, M.D., MPH

Paula Cook Victor Sierpina, M.D.

Rhonda Hallquist Selma Sroka, M.D.

Tieraona Low Dog, M.D. Raymond Teets, M.D.

Victoria Maizes, M.D. John Woytowicz, M.D.