Presentation Objectives

1. 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.

2. 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.

3. 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.

4. Alaska Family Medicine IMR Program Locations Maine-Dartmouth Maine Medical Center Univ. of Minn Hennepin County University of Connecticut Beth Israel • A. Einstein Montefiore Carolinas Medical Center • Moses H. Cone University of Arizona University of Texas Medical Branch • Control sites

5. 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.

6. 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.

7. 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.

8. Wellness Behaviors Assessed in the IMR

9. Resident Wellness Behaviors (All groups combined)Protective

10. Resident Wellness Behaviors (All groups combined)Risk

11. Well-being Measures

12. Perceived Stress Scale(e.g., “How often you felt you were on top of things?”) Mean scores at baseline – 2011, 2012, Controls Range1-33 Range 5-27 Range 9-30 Possible scores range from 0 – 40. ns

13. Perceived Stress Scale Frequency of stress in the past month (at baseline) * *p = .03

14. Perceived Stress ScaleBaseline and 1st repeated measure 2011 Class (mean scores) Stress Frequency past 30 days * ** * p = .002; ** p = .001 n=44; ns

15. CES-D (Depression screener) – Mean scores PGY1 – All groups (baseline) Range 0-34 Range 0-32 Range 1-34 ns Cutpoint =/> 16

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

17. CES-DBaseline and 1st repeated measure 2011 Class means Severity scores * Range 0-32 Range0-34 *p= <.001 n=46; ns

18. PHQ-9 (Depression diagnostic screener)Mean scores at baseline Range 0-13 Range 0-14 Range 0-16 ns

19. PHQ-9Severity scores at baseline ns

20. CES-D and PHQ-9 Compared2011 PGY2

21. Maslach Burnout Inventory1Emotional Exhaustion Subscale (e.g., “I feel emotionally drained from my work”) Mean scores at baseline – 2011, 2012, Controls Range1-33 Range 5-27 Range 9-30 Possible scores range from 0 – 54. ns

22. Maslach Burnout Inventory2EE category scores at baseline * *p = .02

23. Maslach Burnout Inventory3 EE Baseline and 1st repeated measure Mean group scores at baseline Severity scores t1 – t2 ** * * ns *p=<.001 *p=.032; **p=<.001

24. Maslach Burnout Inventory4Depersonalization (e.g., “I really don’t care what happens to some patients”)Mean scores at baseline – 2011, 2012, Controls Range0-23 Range 0-18 Range 1-20 Possible scores range from 0 – 30. ns

25. Maslach Burnout Inventory5Dp Score Categories – 2011, 2012, Controls

26. Maslach Burnout Inventory3Depersonalization (Baseline &1st F/U) Baseline Severity scores t1 – t2 * *** ** p = <.001 p = <.001 *p = <.001; **p=..001; ***p= <.001

27. 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.

28. Discussion