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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. - PowerPoint PPT PresentationTRANSCRIPT
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.