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    Residency Programs Develop Strategies to Respond to High Burnout Rates


    In March, two internal medicine residents from Massachusetts General Hospital (MGH) died in an avalanche while hiking in Canada. The sad news hit Emmett Kistler, MD, a fellow internal medicine resident, harder than he expected.

    Kistler turned to Kerri Palamara, MD, who founded and developed the MGH Internal Medicine Professional Development Coaching Program. The program, which was rolled out in 2012, is designed to provide emotional and professional support to residents. The program has grown from an initial 26 coaches—all volunteer faculty members—to more than 100 coaches, who are trained to help residents identify the personal strengths that will help them accomplish their goals.

    “We’re a very large residency program, and it started to feel like we just didn’t have a good sense of how people were doing,” said Palamara, also director of the MGH primary care residency program. “We knew people were struggling, but we often found out too late. We were losing the ability to know how residents were doing with their personal, professional, and emotional development.”

    Palamara wanted to turn that dynamic around and make sure every resident was “well known by somebody.” All MGH interns are automatically matched with a nonsupervisory faculty coach when they begin training, ideally staying with the same coach throughout their residency. Up to three-quarters of residents meet with their coaches at least three times a year.

    Kistler said the MGH program was especially helpful when his colleagues died. But it has also provided relief as he has faced other challenges during his residency. “Before, I had a big picture of what I wanted to accomplish,” said Kistler. “But the coaching helps me develop specific steps and timetables for what I want to get done. It helps me frame the year in manageable chunks. Having that amount of specificity is so stress relieving.”

    Fostering resiliency during residency

    The Accreditation Council for Graduate Medical Education (ACGME) considers burnout-related activities as critical to optimal clinical learning environments. Research has shown that depression can increase during residency, with trainees having concerns about work–life balance and the possibility of medical errors, among other issues.

    Fortunately, resiliency building is becoming more common in residency programs. In fact, Palamara said, about 25 U.S. residency programs have already adopted the MGH coaching program.

    Other national initiatives are designed to strengthen resiliency for residents, as well as for medical students and practicing physicians, who also face high rates of burnout. In 2017 the National Academy of Medicine launched the Action Collaborative on Clinician Well-Being and Resilience, led by the National Academy of Medicine, AAMC, and ACGME. The goal of the collaborative is to provide a platform for understanding the causes of burnout and advance collaborative programs that reverse trends in stress, burnout, and suicide among clinicians. More than 30 medical specialty and physician groups, academic health systems, and other groups are participating. The ACGME also launched a physician well-being initiative, with the goal of improving well-being in the clinical learning environment.

    “There’s always going to be stress. One of our goals is to help residents adapt in a way that maintains their excitement for medicine and their own mental health.”

    Paul Griner, MD
    University of Rochester School of Medicine

    A web-based program directed toward residents launched a pilot in January at 23 U.S. programs. Known as Timely Access to Lifetimes of Knowledge for Health Professionals, or Talk4HP.com, the program connects residents with practitioners—often medical faculty experienced in mentoring and advising students—who can offer confidential advice on personal and professional challenges. Residents can use the website to schedule a phone conversation, email a specific advisor, or request a chat session with an on-call advisor. Paul Griner, MD, emeritus professor of medicine at the University of Rochester School of Medicine in New York, codeveloped the program with Donald Bordley, MD, associate chair for education at Rochester.

    “There’s always going to be stress,” Griner said. “One of our goals is to help residents adapt in a way that maintains their excitement for medicine and their own mental health.”

    Griner and Bordley began discussing the idea nearly three years ago. But before diving into development, they surveyed internal medicine and medicine/pediatric residents at the University of Rochester Medical Center. They found that a majority were concerned about burnout and a lack of balance between their personal and professional lives, but relatively few sought advice.

    Talk4HP conversations are confidential, but Griner said advisors would—if needed and with the resident’s permission—reach out to a residency program director about connecting a resident to local mental health services. If Talk4HP is successful, Griner hopes to expand it to serve all U.S. residents, medical students, and other health professionals.

    The high suicide rate among physicians was the impetus for another program, Healer Education Assessment and Referral (HEAR) Program at University of California, San Diego (UCSD), Health Sciences. Launched seven years ago and initially for faculty physicians, the program has expanded to serve residents, as well as students in medicine, nursing, and other health professions, said Sidney Zisook, MD, director of the UCSD Department of Psychiatry residency program and a professor of psychiatry.

    In addition to providing one-on-one help, HEAR conducts outreach and educational campaigns to raise awareness about its services among faculty and learners. HEAR advisors typically meet with residents in every major training program at least once annually, Zisook said. Advisors also educate incoming chief residents on how to recognize the signs of mental illness.

    As resiliency programs continue to catch on in graduate medical education, cultural change will happen “one coach at a time, and one coaching encounter at a time,” Palamara said. “It normalizes that people have feelings, lives, and emotions and gives them a space to talk about it.”