As part of a conceptual shift toward competency-based medical education, the Accreditation Council for Graduate Medical Education (ACGME) fully implemented the Next Accreditation System (NAS) beginning in July of 2014. Although this represents a tremendous step forward in medical education, it has also raised a number of questions regarding the optimal way to teach and assess residents, particularly with skills such as professionalism.
Unique to many of the gradual medical education programs, Emergency Medicine specifies a “wellness” milestone under professionalism. The table above has been excerpted directed from the ACGME milestone for Emergency Medicine. It specifies that residents must be able to demonstrate the following:
- Arrive for work well-rested and ready to deliver patient care as a functional physician (Level 1)
- Identify basic principles of physician wellness, including sleep hygiene (Level 2)
- Knowledge of alertness management and fatigue mitigation principles (Level 2)
- Form a plan to address impairment in one’s self or a colleague, in a professional and confident manner (Level 4)
- Train physicians and educators regarding wellness, fatigue, and physician impairment (Level 5)
Furthermore, in addition to the milestones, each residency program is also required to provide evidence of their institutional support for wellness to maintain accreditation standards. The following provisions are excerpts from the ACGME Program Requirements for Graduate Medical Education in Emergency Medicine:
VI.A.2. The program must be committed to and responsible for promoting … resident well-being in a supportive educational environment
VI.A.6. Residents and faculty members must demonstrate an understanding and acceptance of their personal role in the following … c) assurance of their fitness for duty; d) management of their time before, during, and after clinical duties; e) recognition of impairment, including illness and fatigue, in themselves and in their peers;
Many residency programs have established wellness committees, presumably to address many of these requirements set out by the ACGME. Anecdotally however, the majority of these committees’ primarily responsibility is to organize the social functions for the residency, such as orientation meet-and-greets, holiday parties, the annual residency retreat, and graduation celebrations. While these events certainly promote bonding and foster the development of social networks for residents (particularly important if the resident is far from family and friends), based on the milestones and program accreditation requirements, there is a lot more work to be done.
One notable wellness committee that extends its mission statement beyond organizing social gatherings is the national American College of Emergency Physicians (ACEP) Well-being Committee. This committee operates in conjunction with the Wellness Section and has been tasked to broadly address multiple aspects of physician wellness across a lifetime, including burnout, litigation stress, and other relevant topics. Each year at the ACEP Scientific Assembly, the committee hosts a Wellness Booth that offers burnout surveys, routine health maintenance blood pressure and laboratory screenings, and resources on physician wellness. In previous years, the committee has also hosted a meditation room open to all throughout the duration of the conference. Specifically, the objectives of the Well-being Committee are to:
- Expand and promote the availability of resources on physician wellness throughout the various stages of their career and life.
- Finalize the report on findings from a decade of aggregate data obtained from the burnout survey that members have taken at the Wellness booth.
- Continue to write and submit articles to ACEP News on wellness topics related to the training and practice of emergency physicians.
- Continue to promote the availability of the litigation stress peer-to-peer counseling services.
- Review and update the Wellness book.
- Develop and promote materials on burnout detection and prevention.
- Investigate developing a wellness policy statement or information paper.
- Work with the Medico-Legal Committee as needed to finalize the information paper and talking points for the volunteer litigation stress and burnout peer-to-peer counselors.
Residency wellness committees may do well to incorporate some of these broader objectives into their own mission statements. Possibilities include: creating orientation guides; mentor pairings; inviting visiting professors to speak on wellness topics; publicizing mental health resources and confidential counseling services; and organizing wellness retreats.
In addition to developing a broader approach to residency wellness, programs also need to engage faculty members as well. Many education scholars have discussed the impact of the hidden curriculum–that is, the lessons learned indirectly through the absorption of attitudes, values, and even institutional slang toward patients, colleagues, and even the residency program and hospital policies. Physicians notoriously take terrible care of their own health. I have heard colleagues with severe dehydration secondary to gastroenteritis talk about interviewing patients while hooked up to a bag of IV fluids. Calling out for personal or family illness is mark of shame while working long hours grants bragging rights. If attending physicians devalue wellness, either explicitly in their language or implicitly by their actions, what kind of lessons are they imparting to residents and medical students? Cultural change to promote resident wellness requires promotion among the faculty as well.
Furthermore, when it comes to education, whether at the medical student, resident, or attending level, working together beats out working alone every time. Collaboration among different communities will inevitably lead to greater awareness of wellness issues, integration across disciplines, brainstorming new approaches, and hopefully to happier physicians. National organizations such as the ACGME and ACEP support wellness efforts–why not create similar networks, standards, and resources at the local level?
As part of its educational mission, AKOSMED supports the development of regional and national wellness committee networks. If you’d like to add your program or wish to view the list of current members and their leadership contact information, click here. For more specific educational resources on wellness, including links to MedEdPORTAL and free online classes, click here.