Resident Evaluation of a Web-based Integrative Medicine Curriculum

Report
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.
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 & wellbeing.
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.
Alaska Family Medicine
IMR Program Locations
Maine-Dartmouth
Univ. of Minn
Hennepin County
Maine Medical Center
University of
Connecticut
A. Einstein Montefiore
Beth Israel
Carolinas Medical Center
Moses H. Cone
University of Arizona
University of Texas
Medical Branch
Control sites
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.
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.
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.
Wellness Behaviors Assessed in the IMR
Behavior
Behavior
Moderate physical activity (30 min/da)
Massage
Fruits & vegetables (5/da)
Outdoors in nature
Vitamins/other dietary supplements
Nurturing relationships
Meditation
Restful sleep
Prayer
Alcoholic drinks per week
PMR/other relaxation
Smoking (y/n)
Yoga
Rx for mood, anxiety, stress, sleep (y/n)
Tai Chi or Qi Gong
Resident Wellness Behaviors
(All groups combined)
Protective
70%
60%
50%
40%
30%
20%
10%
0%
Phys Act
Fruit/Veg
Nurt Rels
None
1-2
PMR
3-4
5-6
Meditation
Daily
Prayer
Resident Wellness Behaviors
(All groups combined)
Risk
34%
38%
35%
45%
17%
13%
11%
5%
3%
Restful sleep
None
1-2 da
3-4 da
Alcohol drinks per week
5-6 da
Daily
0
1-3
4-7
8-14
14+
Rx Dep/Anx/Stress
Smoke
Yes
14%
Yes
2%
No
98%
0%
No
86%
Well-being Measures
Dimension
Measure
Global life satisfaction
Satisfaction with Life Scale (SWLS; Dierner, 1985)
Affective traits
Positive & Negative Affect Schedule (PANAS; Watson,
1988)
Psychological health
Perceived stress
Mood state distress
Depression
Burnout
Personal characteristics
Mindfulness
Gratitude
Emotional intelligence
Perceived Stress Scale (Cohen et al., 1983)
CES-D (Radloff, 1977)
PHQ-9; (Kroneke et al., 2001)
Maslach Burnout Inventory (Maslach et al. 1996)
Freiburg Mindfulness Inventory (Walach, et al., 2006)
Gratitude Questionnaire-6 (McCullough, 2002)
Trait Meta Mood Scale (Salovey & Mayer, 1995)
Interpersonal Reactivity Index (Davis, 1980)
Perceived Stress Scale
(e.g., “How often you felt you were on top of things?”)
Mean scores at baseline – 2011, 2012, Controls
2011
15.7
Range 1-33
ns
2012
Controls
16.9
16.1
Range 5-27
Range 9-30
Possible scores range from 0 – 40.
Perceived Stress Scale
Frequency of stress in the past month (at baseline)
2011
2012
Controls
61% 58% 59% *
27% 26%
22%
15% 15%
15%
2%
Never
(<10)
*p = .03
Almost never
(11-20)
Sometimes
(21-30)
Fairly often /Often
(>31)
Perceived Stress Scale
Baseline and 1st repeated measure
2011 Class (mean scores)
PGY1
Stress Frequency past 30 days
PGY2
PGY1
PGY2
75%
*61%
15.4
16.9
23%
**14% 14%
9%
Never
Mean Score
n=44; ns
2% 2%
Almost
never
(11-20)
* p = .002; ** p = .001
Sometimes Fairly often
(21-30)
/Often
(>31)
CES-D (Depression screener) – Mean scores
PGY1 – All groups (baseline)
2011
2012
Controls
12.5
11.4
Range 0-34
ns
Range 0-32
Cutpoint =/> 16
11.5
Range 1-34
CES-D
Severity scores in the past month (at baseline)
2011
67%
2012
Controls
74% 72%
17% 16%
Non depressed
<15
12%
Mild depression
16-20
10% 9% 12%
Moderate
depression
21-30
5%
2% 4%
Very depressed
>31
CES-D
Baseline and 1st repeated measure
2011 Class means
PGY1
PGY2
Severity scores
76%*
PGY1
PGY2
67%
12.2
10.9
Range 0-34 Range 0-32
n=46; ns
Mean Score
17%
9%
Non
depressed
<15
*p= <.001
11% 13%
Mild
Moderate
depression depression
16-20
21-30
4%2%
Very
depressed
>31
PHQ-9 (Depression diagnostic screener)
Mean scores at baseline
2011 (02)
2012
3.8
Controls
4.2
3.3
Range 0-13
ns
Range 0-14
Range 0-16
PHQ-9
Severity scores at baseline
2011 (02)
71%
Controls
64% 65%
25%
28% 27%
4%
ns
2012
None
(<4)
Mild
(5-9)
8%
4%
Moderate
(10-14)
4%
Mod Severe
(15-19)
Severe
(>20)
CES-D and PHQ-9 Compared
2011 PGY2
CES-D (02)
PHQ-9 (02)
76% 71%
25%
9%
Non dep/None
Mild
13%
4%
Moderate
2% 0%
Mod severe/
Severe
Maslach Burnout Inventory1
Emotional Exhaustion Subscale (e.g., “I feel emotionally drained from my work”)
Mean scores at baseline – 2011, 2012, Controls
2011
15.3
Range 1-33
ns
2012
16.9
Range 5-27
Mean Scores
Controls
20.7
Range 9-30
Possible scores range from 0 – 54.
Maslach Burnout Inventory2
EE category scores at baseline
2011
2012
Controls
71%
57%
54% *
32%
27%
18%
11%
Low
*p = .02
</=18
Moderate 19-26
High
19%
11%
>/=27
Maslach Burnout Inventory3
EE Baseline and 1st repeated measure
Mean group scores at baseline
PGY1
Severity scores t1 – t2
PGY2
PGY1
PGY2
71%
45%
39% **
*
22.3
16% *
10%
15.3
Low
</=18
*p=<.001
ns
*p=.032;
**p=<.001
Moderate
19-26
18%
High
>/=27
Maslach Burnout Inventory4
Depersonalization (e.g., “I really don’t care what happens to some patients”)
Mean scores at baseline – 2011, 2012, Controls
2011
ns
2012
6
6.5
Range 0-23
Range 0-18
Controls
8
Range 1-20
Possible scores range from 0 – 30.
Maslach Burnout Inventory5
Dp Score Categories – 2011, 2012, Controls
2011
2012
Controls
61%
43%
38%
33%
27%
30%
35%
24%
9%
Low
<=5
Moderate
6-9
High
>/=10
Maslach Burnout Inventory3
Depersonalization (Baseline &1st F/U)
Baseline
Severity scores t1 – t2
Baseline
Time 2
PGY1
PGY2
59% *
53%***
27%**
20%
6.2
10.2
8%
Low
<=5
p = <.001
33%
Moderate
6-9
p = <.001
*p = <.001; **p=..001; ***p= <.001
High
>/=10
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-9000026.1.
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.
Discussion
Acknowledgements
University of Arizona
Pilot Sites
Emily Sherbrooke
Ben Kligler, M.D., MPH
Paula Cook
Victor Sierpina, M.D.
Rhonda Hallquist
Selma Sroka, M.D.
Tieraona Low Dog, M.D.
Raymond Teets, M.D.
Victoria Maizes, M.D.
John Woytowicz, M.D.

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