Well Being

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ACGME Requirements Well-Being (VI.C.)

Background and Intent: The ACGME is committed to addressing physician well-being for individuals and as it relates to the learning and working environment. The creation of a learning and working environment with a culture of respect and accountability for physician well-being is crucial to physicians’ ability to deliver the safest, best possible care to patients. The ACGME is leveraging its resources in four key areas to support the ongoing focus on physician well-being: education, influence, research, and collaboration. Information regarding the ACGME’s ongoing efforts in this area is available on the ACGME website. As these efforts evolve, information will be shared with programs seeking to develop and/or strengthen their own well-being initiatives. In addition, there are many activities that programs can utilize now to assess and support physician well-being. These include culture of safety surveys, ensuring the availability of counseling services, and attention to the safety of the entire health care team.

The responsibility of the program, in partnership with the Sponsoring Institution, to address well-being must include:

a) efforts to enhance the meaning that each resident finds in the experience of being a physician, including protecting time with patients, minimizing non-physician obligations, providing administrative support, promoting progressive autonomy and flexibility, and enhancing professional relationships;

b) attention to scheduling, work intensity, and work compression that impacts resident well-being;

c) evaluating workplace safety data and addressing the safety of residents and faculty members; 

Background and Intent: This requirement emphasizes the responsibility shared by the Sponsoring Institution and its programs to gather information and utilize systems that monitor and enhance resident and faculty member safety, including physical safety. Issues to be addressed include, but are not limited to, monitoring of workplace injuries, physical or emotional violence, vehicle collisions, and emotional well-being after adverse events.

d) policies and programs that encourage optimal resident and faculty member well-being; and,

Background and Intent: Well-being includes having time away from work to engage with family and friends, as well as to attend to personal needs and to one’s own health, including adequate rest, healthy diet, and regular exercise.

(1) Residents must be given the opportunity to attend medical, mental health, and dental care appointments, including those scheduled during their working hours.

Background and Intent: The intent of this requirement is to ensure that residents have the opportunity to access medical and dental care, including mental health care, at times that are appropriate to their individual circumstances. Residents must be provided with time away from the program as needed to access care, including appointments scheduled during their working hours.

e) attention to resident and faculty member burnout, depression, and substance abuse. The program, in partnership with its Sponsoring Institution, must educate faculty members and residents in identification of the symptoms of burnout, depression, and substance abuse, including means to assist those who experience these conditions. Residents and faculty members must also be educated to recognize those symptoms in themselves and how to seek appropriate care. The program, in partnership with its Sponsoring Institution, must:

Background and Intent: Programs and Sponsoring Institutions are encouraged to review materials in order to create systems for identification of burnout, depression, and substance abuse. Materials and more information are available on the Physician Wellbeing section of the ACGME website (http://www.acgme.org/What-WeDo/Initiatives/Physician-Well-Being).

(1) encourage residents and faculty members to alert the program director or other designated personnel or programs when they are concerned that another resident, fellow, or faculty member may be displaying signs of burnout, depression, substance abuse, suicidal ideation, or potential for violence;

Background and Intent: Individuals experiencing burnout, depression, substance abuse, and/or suicidal ideation are often reluctant to reach out for help due to the stigma associated with these conditions, and are concerned that seeking help may have a negative impact on their career. Recognizing that physicians are at increased risk in these areas, it is essential that residents and faculty members are able to report their concerns when another resident or faculty member displays signs of any of these conditions, so that the program director or other designated personnel, such as the department chair, may assess the situation and intervene as necessary to facilitate access to appropriate care. Residents and faculty members must know which personnel, in addition to the program director, have been designated with this responsibility; those personnel and the program director should be familiar with the institution’s impaired physician policy and any employee health, employee assistance, and/or wellness programs within the institution. In cases of physician impairment, the program director or designated personnel should follow the policies of their institution for reporting.

(2) provide access to appropriate tools for self-screening; and,

(3) provide access to confidential, affordable mental health assessment, counseling, and treatment, including access to urgent and emergent care 24 hours a day, seven days a week.

Background and Intent: The intent of this requirement is to ensure that residents have immediate access at all times to a mental health professional (psychiatrist, psychologist, Licensed Clinical Social Worker, Primary Mental Health Nurse Practitioner, or Licensed Professional Counselor) for urgent or emergent mental health issues. In-person, telemedicine, or telephonic means may be utilized to satisfy this requirement. Care in the Emergency Department may be necessary in some cases, but not as the primary or sole means to meet the requirement. The reference to affordable counseling is intended to require that financial cost not be a barrier to obtaining care.

There are circumstances in which residents may be unable to attend work, including but not limited to fatigue, illness, family emergencies, and parental leave. Each program must allow an appropriate length of absence for residents unable to perform their patient care responsibilities. 

a) The program must have policies and procedures in place to ensure coverage of patient care.

b) These policies must be implemented without fear of negative consequences for the resident who is or was unable to provide the clinical work. 

Specialty Background and Intent: The Review Committee recognizes circumstances in which residents may need additional/extended time away from the program. Residents may additional leave for medical illness, parental care (all circumstances), or caring for a sick immediate family member. Residents are responsible for communicating with their intended certifying board to ensure their understanding of the board’s leave policies.

Background and Intent: Residents may need to extend their length of training depending on length of absence and specialty board eligibility requirements. Teammates should assist colleagues in need and equitably reintegrate them upon return.

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Fatigue Mitigation

ACGME Requirements on Fatigue Mitigation (VI.D.)

Programs must:

a) educate all faculty members and residents to recognize the signs of fatigue and sleep deprivation;

b) educate all faculty members and residents in alertness management and fatigue mitigation processes; and,

c) encourage residents to use fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning.

Background and Intent: Providing medical care to patients is physically and mentally demanding. Night shifts, even for those who have had enough rest, cause fatigue.  Experiencing fatigue in a supervised environment during training prepares residents for managing fatigue in practice. It is expected that programs adopt fatigue mitigation processes and ensure that there are no negative consequences and/or stigma for using fatigue mitigation strategies. 

This requirement emphasizes the importance of adequate rest before and after clinical responsibilities. Strategies that may be used include, but are not limited to, strategic napping; the judicious use of caffeine; availability of other caregivers; time management to maximize sleep off-duty; learning to recognize the signs of fatigue, and self-monitoring performance and/or asking others to monitor performance; remaining active to promote alertness; maintaining a healthy diet; using relaxation techniques to fall asleep; maintaining a consistent sleep routine; exercising regularly; increasing sleep time before and after call; and ensuring sufficient sleep recovery periods.

Each program must ensure continuity of patient care, consistent with the program’s policies and procedures referenced in VI.C.2–VI.C.2.b), in the event that a resident may be unable to perform their patient care responsibilities due to excessive fatigue.

The program, in partnership with its Sponsoring Institution, must ensure adequate sleep facilities and safe transportation options for residents who may be too fatigued to safely return home.

Below is an example of the Department of Surgery initiatives and/or Institutional Initiatives that may be implemented to address the Well-Being/Fatigue Mitigation requirements as above.  This list is not exhaustive.  

If you have other suggestions or best practices that you would like to share with the APDS website resource, please email mkkimbrough@uams.edu 

Departmental Initiatives	Details
Meetings with residents in peer groups quarterly	With PD or APD, helps keep close check on difficult rotations, duty hour issues, schedule issues, aspects of rotations that are not educational or have excessive non-physician obligations
Appoint Resident Leadership Council1	Peer selected residents from each class meet with PD monthly to discuss curriculum, conferences, upcoming social events, schedule issues *Creates resident buy-in and ownership in resident activities
Assign Resident Wellness Officer/Champion	Resident reports to PD/APD and organizes resident social and wellness events, sits on Resident Leadership Council.  Goal for at least one social event quarterly (ex: sporting events, happy hours, dinners, outdoor activities, holiday parties) *Establishes importance of resident wellness
Conduct Faculty Wellness Panel	Organize panel of wellness-minded, trusted faculty to discuss different wellness aspects with residents (may be done yearly or every other year): Financial wellness (paying/deferring loans, etc.) Physical wellness (attending doctor/dentist appointments, eating well, coping with stress) Professional wellness (dealing with complications/bad patient outcomes, career uncertainty, academic struggles) Personal/family wellness (illness personally or in a family member, emotional or psychological issues) *Demonstrates faculty care and concern for resident well-being *Helps residents identify faculty who are wellness champions *Opens the door for discussion between faculty and residents and resident to resident
Create a Mentoring Program1,2	May be faculty-to-resident or peer-to-peer (resident-to-resident) program, may be helpful for career guidance, identify any well-being issues early on, can help off-load wellness checks from PD/APD to other faculty
Protect resident wellness time2	Give residents protected time for wellness activities such as doctor or dentist appointments or for other important errands such as car maintenance, haircuts, driver’s license renewals, etc. that are difficult to get done outside of regular business hours *Set these dates well in advance so that appointments can be made if necessary
Create an “after-hours” guide1	Information on local hikes, biking trails, restaurants, gyms, as well as local primary care physicians, obstetricians, and dentists who may have weekend or late evening hours
Create stocked refrigerator with healthy snacks and drinks1,2	24-hour access to refrigerator with variety of healthy snacks and drinks to promote regular and healthy eating
Conduct resident meetings with clinical psychologist1,2	Regularly scheduled, confidential meetings with residents in their peer groups and an experienced psychologist (brought/available on-site) who can help the residents discuss concerns and develop appropriate coping mechanisms
Conduct team-building retreats	Example: Escape rooms, outdoor ropes courses, Enneagram/personality workshops to promote team building
Evaluate workplace safety data	Monitor resident usage of patient safety programs when residents enter patient safety issues as they see them arise.  PD should receive on-the-job injury paperwork as the residents’ supervisor, can track and trend can track/trend these as needed to see when they occur (nights, weekends, post-call, etc.)
Utilize Grand Rounds time for Well-Being topics	Invite guest speakers or local experts (from GME office or other disciplines) to speak to residents and faculty on various well-being topics (burnout, physician suicide recognition and awareness, fatigue recognition and mitigation, establishing healthy eating/sleep habits, etc.)
Include Well-Being education in Surgery Resident departmental orientation	Show incoming residents how to review policies, where to find/access contact information for wellness resources; establish program and PD importance and emphasis on wellness to new residents;
Educate residents on workplace safety2	May be done as Grand Rounds or in departmental orientation as above; Ensure residents know patient rights and responsibilities charters that prevent patient abuse of staff and create procedures to intervene when patients are abusive or sexually harass staff, teach residents techniques for de-escalation of violence
Utilize departmental/institutional website for Well-Being education	Utilize departmental or GME website to post links to Well-Being policies, educational videos, brochures Example: https://gme.uams.edu/wp-content/uploads/sites/24/2018/06/FINAL-Fatigue-Brochure-2018.pdf  Example: https://gme.uams.edu/gme-resources/fatigue-recognition-and-mitigation/
Institutional Initiatives	Details
Identify on-campus resources for counseling and psychiatric services2	Will vary by institution.  Look for Employee Assistance Programs, online programs (some are anonymous), psychiatrist contact information, Emergency Department access 24-7
Create a Graduate Medical Education Wellness Week	May be done as department or as institution.  Organize wellness events throughout the week (free food, massage chairs, pet therapy, social events/interdepartmental games, raffles, etc.) Example: https://gme.uams.edu/wellness-week/#schedule
Identify other resources that may be available on-campus for same-day appointments	Example: establish agreement with on-campus dental school/dental hygienist clinic to see 1-2 resident walk-in appointments per day Example: give residents information to access on-campus walk-in clinics for acute illnesses such as sore throats, cold/cough, rashes, aches and pains
Identify on-campus or local gym availability	Will vary by institution.  Residents may get free or less expensive access/membership to nearby or on-campus gym.  Access may be 24-7 by badge or key.
Teach Mindfulness techniques	Mindfulness practices can be a way of reducing stress and developing greater balance, control and fuller participation in your life, finding meaning in your life. Example: https://mindfulness.uams.edu/
Create Schwartz Rounds	Can be done at institutional or departmental level.  Pre-planned sessions designed to bring caregivers together to discuss the human elements of health care. Features a discussion of a recent difficult case in the hospital and the related provider issues. The goal of the program is to support caregivers and enhance their ability to provide compassionate care. For more information: https://www.theschwartzcenter.org/programs/schwartz-rounds
Identify availability of chaplain/pastoral services or other clinical faculty	Can partner with chaplain services or other clinical faculty such as psychiatry, psychology, clinical ethicists, or palliative care for availability to discuss challenging cases, bad outcomes with faculty and residents

1. Salles A, et al. “Perceived Value of a Program to Promote Surgical Resident Well-being.” Journal of Surgical Education. 2017 Nov – Dec;74(6):921-927.
2. Shapiro DE, et al. “Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level.” The American Journal of Medicine. 2019 May; 132(5):556-563.

 

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Resources

Please see below for multiple available resources for Well-Being screening, assistance, education, and implementation of best practices for programs.  This list is not exhaustive.

If you know of other helpful resources that should be included, please email mkkimbrough@uams.edu

Resources	Details
National Suicide Hotline	If you are in crisis, please call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255), or contact the Crisis Text Line by texting TALK to 741741
American College of Surgeons Surgeon Well-Being Resources	Articles, webinars, and other publications on surgeon burnout and well-being Links to ACGME, AAMC, AMA, and National Academy of Medicine resources on Wellness are listed here as well https://www.facs.org/member-services/surgeon-wellbeing/resources
American College of Surgeons Physician Well-Being Index	Anonymous, validated screening tool provides an opportunity to better understand overall well-being and identify areas of risk compared to physicians and residents across the nation. Access codes are free and available online for faculty/fellows and residents. For more information: https://www.facs.org/member-services/surgeon-wellbeing
American College of Surgeons Resident and Associate Society (RAS-ACS)	Webinars on Well-being at https://www.facs.org/member-services/ras/webinars
American Medical Association (AMA)	Educational modules developed by the AMA on preventing burnout offer physicians an opportunity to assess burnout as well as adopt wellness approaches in their practices https://edhub.ama-assn.org/steps-forward/pages/professional-well-being
Accreditation Council for Graduate Medical Education (ACGME)	https://www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being
Association of American Medical Colleges (AAMC)	https://www.aamc.org/news-insights/wellbeing/faculty
National Academy of Medicine (NAM)	https://nam.edu/initiatives/clinician-resilience-and-well-being/