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A mentorship program at Stanford is helping to prevent burnout and promote wellness to neurology residents, fellows, and faculty. Early response from surveys of the participants indicate it may be working.
As she moved through her residency in the department of neurology and neurological sciences at Stanford Medicine, Rebecca Miller-Kuhlmann, MD, put in a lot of long hours.
That was just as she expected. What was disconcerting, though, as she thought about her future were the statistics from a 2016 AAN survey, which showed that six out of 10 neurologists suffer at least one symptom of burnout, and that neurologists in general report higher levels of career dissatisfaction than physicians in other specialties.
“That's a pretty terrifying thing for a trainee,” Dr. Miller-Kuhlmann said. “You are working so hard to become an attending, so the idea that there might not be a light at the end of the tunnel was really concerning.”
That's why she teamed with another resident — Tresa M. McGranahan, MD, PhD, now a neuro-oncologist and assistant professor of neurology and neurological surgery at the University of Washington School of Medicine — to develop a wellness program for residents, fellows, and faculty. Using education, mentorship, and community-building to promote physician well-being, the program has shown measurable success in its first year in reducing burnout levels among participants.
It's still early days for the program. It has not yet tackled some big drivers of burnout, such as the need to continuously measure performance on the job, the demands of maintaining electronic health record technology, and having to work in inefficient practice environments, noted Dr. Miller-Kuhlmann, now a clinical assistant professor in the Stanford neurology department. But she contends it is a step in the right direction.
“You have to attack these problems from multiple perspectives,” Dr. Miller-Kuhlman said. “It's important to get started, and then you can expand as you go.”
Live Well, Lead Well
The Stanford program was developed with support from the AAN's Live Well, Lead Well initiative, which seeks to empower neurologists to mitigate burnout and promote wellness at the individual and organizational level. The first cohort finished its work in 2018, and the application period for the second cohort is planned for early 2019, said Jennifer Rose V. Molano, MD, FAAN, chair of the Live Well, Lead Well program.
“It was applying for this program that helped push our thoughts into action,” Dr. Miller-Kuhlmann said. “Being connected with a community of like-minded individuals doing similar work for brainstorming and troubleshooting was powerful.”
She and the 13 other neurologists in the first Live Well, Lead Well cohort were each paired with a coach to guide development of a project to improve clinician well-being in their own organizations.
“To move a project forward, it's really critical to have that sense of support,” said Dr. Molano, associate professor in the department of neurology and rehabilitation medicine at the University of Cincinnati College of Medicine. “Change is slow and can have its ups and downs, but having a group of people to support you can help you move forward past those challenges.”
Focus on Resident Wellness
Stanford's Neurology Wellness and Mentorship Program, which started in 2017, is designed to educate physicians about self-care strategies, promote well-being as a goal through training and beyond, and build a sense of community within the neurology department. It does so through three activities: creating mentorship teams, holding monthly lunch conferences, and promoting social activities.
Participants are grouped into mentorship teams for the duration of the program year. In the first year, each of 10 teams included an attending, a fellow, and at least three residents at various stages of training. The teams were formed to connect people who had commonalities outside of work: as young parents or people who enjoy running, for example, rather than shared professional interests.
Recognizing that residents may not be comfortable discussing challenges and vulnerabilities with the faculty with whom they work daily and depend on for letters of recommendation, Dr. McGranahan sought to create mentorship relationships between individuals who might never otherwise interact.
“We strategically designed the program so that mentors were paired with both fellows and residents who were not in their subspecialty area, so that made it a bit safer of a space,” she said.
The monthly lunch sessions alternate between team meetings and workshops featuring guest speakers on topics such as sleep, practicing gratitude, and holding difficult conversations. The goal is to teach participants personal resilience skills while creating a culture of wellness within the department.
“We want to make wellness a legitimate concern, something that is okay to talk about,” Dr. Miller-Kuhlmann said. “We want to normalize that burnout is an issue, that we need to support each other, and this is something that we need to be doing.”
Four residents serve as “wellness leads” who help plan the workshops. Amanda Sandoval Karamian, MD, one of the leads, said a nutritionist's presentation was so popular in the program's first year that it was repeated this year.
“Nutrition is a big issue for residents because they are trying to take care of their patients, in addition to other responsibilities that they have, and sometimes they forget to eat,” Dr. Sandoval Karamian said, adding that the nutrition lecture offered suggestions for what they could do to improve their nutrition to help with your cognition.
The program sponsored social activities as well — a happy hour, a potluck, a holiday gift-exchange — all with the goal of getting people together to talk about things other than work. Dr. McGranahan wondered if busy physicians would be willing to use their personal time to socialize with work colleagues, and she was surprised by what she found.
Initially the plan called for quarterly social events sponsored by the department, but people wanted to meet more often. So the quarterly events, like a Saturday picnic at a park near the hospital, were opened to the entire department, allowing faculty members who were unable make a regular commitment to the wellness program to join in.
“And then, based on requests from participants, we added on smaller social events every month, doing things that weren't going to cost [the department] anything, but [which] allowed people to get together to do something a little bit fun,” she said.
Changes Due to Interventions
To assess the program, participants were asked to complete the Professional Fulfillment Index, a 16-item questionnaire, at the beginning of the program, after four months, and again at 10 months. The index has been validated as a way to assess physicians' professional fulfillment and burnout and is designed to detect changes attributable to interventions.
Among the findings from its analysis: Participants experienced a decrease in feelings of interpersonal disengagement after four months and sustained at 10 months; a gradual increase in feeling a sense of professional fulfillment that was significant after 10 months; a decrease in burnout at each time point; and an increase in compassionate self-improvement at each time point. (Self-compassion is measured by using a Likert scale to respond to statements such as “When I made a mistake, I felt more self-condemnation than self-encouragement to learn from the experience” and “I was less compassionate with myself than I was with others.”)
Dr. Miller-Kuhlmann was pleased with the results, which were reported in October 2018 at the International Conference on Physician Health, a meeting held every two years by the Canadian, American, and British Medical Associations.
That said, Dr. Miller-Kuhlmann offered a caveat about the results: “The numbers look great, but I do wonder how much of the change reflects the cycle of the academic year. I don't think we can say our program is solely responsible, because we don't have a control group.”
Numbers aside, Dr. Sandoval Karamian noted how the program influences participants. One resident who went on night duty shortly after attending the nutrition workshop took the nutritionist's advice: Eat protein at the beginning of the shift, avoid snacking, and eat a large meal with protein at the end of the shift.
“She told me that she really felt much better than she had on her previous round of night float,” Dr. Sandoval Karamian said.
Even the doctor herself heeded advice about overcommitting to extracurricular activities Dr. Sandoval Karamian received from a more senior resident in her mentorship group.
“My mentor really helped me focus and pare down the professional commitments that I had made and learn how to find a balance to reduce stress,” she said.
