Miller School Launches Pioneering Program for First-Year Residents
In a single week last August in New York City, two first-year residents, in different programs and in separate incidents, jumped to their deaths. What could have happened, just three months after their triumphant graduation from medical school, that would have made them want to take their lives?
We may never know, but a likely contributing factor is a syndrome called burnout.
“Burnout is a serious issue across the entire medical profession,” said Joan St. Onge, M.D., associate professor of clinical medicine and Associate Dean for Graduate Medical Education. “It is typically characterized by depersonalization, emotional exhaustion and a low sense of personal accomplishment. The effects are insidious changes in attitudes, moods and behaviors that have consequences for performance and the quality of work. It has been associated with anxiety and depression, as well as suicidal ideation. First-year residents are at high risk for emotional exhaustion, doubting their abilities and a sense of loss of control over their environment — all characteristics of burnout.
“The results of studies evaluating levels of burnout among residents and medical students are alarming. There are many published surveys of medical students, residents and practicing physicians. The numbers in each group meeting the criteria for burnout are high — as high as 77 percent in some cases. It is not limited to one type of hospital or one specialty; it’s a national problem.” While many studies have described the prevalence of burnout, few have looked at programs that either treat or provide protection against burnout in physicians.
To help prevent burnout and to address other aspects of the clinical learning environment that are part of new accreditation directives, the Miller School’s Office of Graduate Medical Education, in collaboration with the GME Executive Committee and the GME administration at Jackson Memorial Hospital, is spending 11 months testing a new initiative for residents in their first year of training. All 194 interns and six second-year residents who came in from preliminary years at other institutions are enrolled in the program, called Multispecialty Learning Communities (MSLC).
The program is six themed two-hour meetings, and its goals are to educate the interns in the areas of wellness and self-care, to improve communication skills, to address the challenges to professionalism during internship, and to encourage multidisciplinary collaboration in the areas of patient safety and quality.
The residents are divided into 18 groups of 11 or 12 from as many different disciplines as possible, and each group has a faculty facilitator who has no direct supervisory relationship with any of its members. There are 14 facilitators representing 10 medical specialties.
The focus of the first session: avoiding burnout.
“The burnout literature says that some people, once they get burned out, remain burned out,” said St. Onge, who is MSLC’s Director and one of the facilitators. “They don’t have the resilience to snap back. Those are the individuals who are at high risk for depression and suicidal ideation, and that’s the most worrisome group.
“There are others who go through a very stressful time and feel burned out, but they have the resiliency that allows them to bounce back and not have it affect them long term.”
“We are trying to intervene at a very early stage, prior to major burnout,” said Heidi Allespach, Ph.D., Director of Behavioral Medicine, Family Medicine and Internal Medicine Residency and Subspecialty Fellowship Programs, MSLC’s Assistant Director and a facilitator. “We are giving the interns proven tools and techniques that should be included in the medical curriculum, in the same manner in which they learn how to conduct a good physical exam and other basics of medicine.”
For example, MSLC’s initial discussion assigned the interns homework that included setting aside at least 15 to 30 minutes each day for something personal — reading, exercise, a favorite TV program, anything that was focused only on themselves.
“We teach interns that if they don’t take care of themselves first, their patients are going to suffer, they’re going to make more medical errors, they’re going to be miserable and then burn out,” said Allespach.
Another facilitator, Yvonne M. Diaz, M.D., assistant professor of medicine and Assistant Dean for Graduate Medical Education, is also concerned about the negative impact burnout can have on patient care.
“We all know that when we’re under stress, our ability to make decisions is impaired,” she said. “If we can provide interns with strategies to help them stay balanced, and a safe environment in which to interact with others, they will perform better and truly be the professionals they have the potential to be.” Studies looking at the effect of burnout and professionalism show a distinct correlation between the two — the more burned out, the less professional one becomes. Importantly, exposure to unprofessional behavior is also correlated with the development of burnout.
The interns are already reporting feeling positive effects.
“It’s so easy to discover that it’s already 3 p.m. and I haven’t eaten lunch,” said Tiffanie Wong, D.O., a first-year resident in family medicine. “Now I try to take 15 to 30 minutes at the end of the day for myself. I like cooking, so I’ll watch something on the Food Network or try out a new recipe.
“You also have to remind yourself to push away the negatives and tell yourself, ‘I’m doing my best every day, and that’s all that anyone can ask of me. I’m going to get through this.’ You build on a foundation of confidence and remind yourself that you don’t know everything, and that as an intern you’re not expected to know everything, because that’s why we’re all here – to learn.”
“A program like this is so much more important than it was in my day,” said facilitator W. Jarrard Goodwin, M.D., professor of otolaryngology and Chief Medical Officer at Sylvester Comprehensive Cancer Center. “The pressures of multitasking and information overload can be overwhelming today.”
The other 10 facilitators are David M. Andrews, M.D., associate professor of pathology; Michael Barron, M.D., associate professor of anesthesiology; Christine L. Curry, M.D., Ph.D., assistant professor of obstetrics and gynecology; Amar R. Deshpande, M.D., associate professor of medicine and Assistant Dean for Medical Education and Competency Assessment; Richard K. Parrish II, M.D., professor of ophthalmology and Associate Dean for Graduate Medical Education; Rafael Rico, M.D., assistant professor of anesthesiology; Merrell R. Sami, M.D., assistant professor of family medicine and community health; Satinder K. Sandhu, M.D., professor of pediatrics; Kenneth D. Stahl, M.D., associate professor of surgery; and Tanya Liv Zakrison, M.D., M.P.H., assistant professor of surgery.
Halcyon M. Quinn, Senior Manager for Programs in the Office of Graduate Medical Education, provides the administrative support. “Halcyon is the person who holds this all together,” said St. Onge. “She schedules the individual MSLCs, notifies the residents, works with the coordinators, and makes sure we have everything we need for a successful group.”
The second session focuses on difficult conversations that may take place in the doctor-patient relationship, and the interns take turns at role-playing, with assistance from the facilitator. Giving bad news about a patient’s disease prognosis or telling a family that their loved one has died are examples.
“In the second week of my internship, I had to walk in and tell a family whose 17-year-old son was struck by lightning that he was dead,” said St. Onge. “There was no training for me. My resident just looked at me and said, ‘Okay, Joan, go right in.’ It never should have happened that way.
“We also want to give some pointers on how to deal with conflict. How do you handle an angry person or a difficult patient, or an unexpected situation? Sometimes you develop these skills because you’re a natural at communication or have a great attending physician to watch; other times, you aren’t so lucky. Then, to make matters worse, you go home and beat yourself up about it. We tell the interns that we have gone through this ourselves, and we’re here to help them learn how to deal with these situations, and give them communication tools to use before they need them.”
Conflict may stem from communication difficulties between medical specialties, as well.
“The interns in my groups are learning that miscommunication is often due to misunderstanding of the other individual’s approach or priorities,” said Diaz. “I think learning this from their colleagues who are at their level and recognizing different traits among the specialties is useful.”
“That’s why we made these groups multispecialty,” said St. Onge. “Someone who chose to go into surgery is going to think differently about a problem than a person who chose to pursue psychiatry or pediatrics. Hopefully this will be one of the ‘take-home points’ from our learning communities. In the future, they will remember this and hopefully be able to bridge the chasm in their approaches that would otherwise lead to conflict.”
“There are also similarities among the interns,” said Allespach. “They begin to realize that, underneath everything, their problems are not unique. As interns they may have fears. It brings them a lot of comfort to realize that the others feel the same way, no matter what their specialty. In addition, through meeting other interns in their group, they have some cross-specialty bonds now when they go into the hospital.”
Those connections also come in handy when interns need assistance from someone outside their specialty.
“This is when we really have to begin taking on responsibility for treating patients,” said Kate Rooney-Otero, M.D., a first-year resident in pediatrics, after one of the sessions. “In medical school, they try to get you to think like a physician. Now is when it really counts, when your assessment matters. These groups help us get to know people in other services. If we need help, there is someone we can call.”
As far as the MSLC organizers know, no similar program has been tried on this scale anywhere else in the United States.
“We don’t know what the long-term effect will be,” said Allespach. “We’re planning to study that, and we will probably have to follow the participants for several years to see if they remember the content of these groups. Would we like to do this across all 1,000-plus residents? Yes! The data is there, telling us that something needs to be done. The facilitators say they would like an initiative like this for the faculty, too.”
“We are known for taking very good care of our patients, but we also want to be known for taking very good care of our own people,” said Diaz. “A happy workforce is going to lead to better patient care than we already have. If we have one resident come to us and say, ‘You made me a better doctor,’ then we can say we made a difference.”