- Email: [email protected]
The Association of Program Directors in Radiology Well-Being 2019 Survey: Identifying Residency Gaps and Offering Solutions
ORIGINAL ARTICLE
The Association of Program Directors in Radiology Well-Being 2019 Survey: Identifying Residency Gaps and Offering Solutions Sheryl G. Jordan, MD a , Jessica B. Robbins, MD b, David Sarkany, MD c, Eric England, MD d, Vivek Kalia, MD, MPH, MS e, Maitray D. Patel, MD f, Kamran Ali, MD g, Carolynn M. DeBenedectis, MD h, Christopher P. Ho, MD i, James M. Milburn, MD j, Seng Ong, MBBS k, Ann K. Jay, MD l, Glenn C. Gaviola, MD m, Darel E. Heitkamp, MD n Abstract Purpose: The Well-Being subcommittee of the Association of Program Directors in Radiology (APDR) Common Program Requirements (CPR) Ad Hoc Committee and the APDR Academic Output Task Force jointly conducted a study of APDR members’ current level of understanding and implementation of the 2017 ACGME CPR regarding well-being. Methods: A survey instrument consisting of 10 multiple-choice and open-ended questions was distributed to the 322 active members of the APDR. The survey focused on three main content areas: APDR member knowledge of the 2017 CPR, composition of department well-being curricula, and residency well-being innovations. Results: In all, 121 members (37.6%) responded to the survey. Of those, 67% rated their knowledge of requirements as incomplete. Responses also indicated that 74% of departments have not implemented a comprehensive well-being curriculum; 53% of programs do not offer the mandated self-screening tool; 15% of respondents do not offer residents protected time for medical, mental health, and dental appointments; and 42% do not offer their trainees access to an institutional mental health clinic. Survey comments offer numerous individual well-being initiatives from across the membership. Conclusions: The results of the APDR Well-Being Survey indicate that many programs have substantial work remaining to achieve ACGME compliance. Well-being innovations were included in an effort to share best practices. Key Words: ACGME, burnout, common program requirements, residency, well-being J Am Coll Radiol 2019;-:---. Copyright 2019 American College of Radiology
INTRODUCTION Burnout among American health care providers has been deemed a public health crisis [1]. The Intersociety Committee of the ACR, a comprehensive coalition of
radiology professional organizations and governing bodies, recently published a road map to fostering wellness and engagement, acknowledging the impact that emotional exhaustion and the sense of reduced
a
j
Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina. b University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. c Staten Island University Hospital, Northwell Health, Staten Island, New York. d University of Cincinnati Medical Center, Cincinnati, Ohio. e University of Michigan Health System Ann Arbor, Michigan. f Mayo Clinic, Phoenix, Arizona. g University of Kansas School of Medicine, Wichita, Kansas. h University of Massachusetts Medical School, Worcester, Massachusetts. i Emory University School of Medicine, Atlanta, Georgia.
ª 2019 American College of Radiology 1546-1440/19/$36.00 n https://doi.org/10.1016/j.jacr.2019.06.017
Ochsner Clinic Foundation, New Orleans, Louisiana. University of Chicago Medical Center, Chicago, Illinois. l MedStar Georgetown University Hospital, Washington, DC. m Brigham and Women’s Hospital, Boston, Massachusetts. n AdventHealth Imaging, Orlando, Florida. Corresponding author and reprints: Sheryl G. Jordan, MD, University of North Carolina School of Medicine, Department of Radiology, 101 Manning Drive Campus Box #7510, Chapel Hill, NC 27514; e-mail: [email protected]. The authors state that they have no conflict of interest related to the material discussed in this article. k
1
personal accomplishment has on radiologists [2]. As cited in the Intersociety Committee’s paper, 78% of radiologists, midlevel providers, and physicists reported burnout as a significant workplace issue in the 2018 ACR HR Commission Workforce Survey. Furthermore, only 19% of respondents reported having access to selfassessment tools, and only 21% reported having effective available means to address burnout [2]. Resident physicians are especially prone to burnout during training when they are called upon to care for patients and devote considerable additional time to selfstudy. In surveys of radiology residents, a high degree of burnout has been reported in more than one-third of radiology residents, stemming particularly from feelings of low personal accomplishment [3-5]. With the implementation of the Next Accreditation System in 2013, the ACGME substantially revised program requirements [6]. During a second major revision to the Common Program Requirements (CPR) in 2017, the ACGME added new emphasis on physician well-being [7,8]. At the same time, the ACGME’s Clinical Learning Environment Review (CLER) Program released the CLER Pathways to Excellence Version 1.1, underscoring the important role of clinical learning environments in implementing systems that support physician well-being [9]. Specifically, training programs are now required to recognize that psychological, emotional, and physical well-being is critical in the development of the competent physician [10]. As a result, all radiology residency programs and sponsoring institutions must turn their attention intently toward physician well-being, with a final implementation deadline of July 1, 2019, to meet the mandates outlined in the CLER Pathways to Excellence goals [11]. After July 1, 2019, programs may be cited for failure to comply with the 2017 CPR well-being revisions, because the 2-year grace period will have lapsed. Programs must demonstrate that they are achieving the following detailed goals of a well-being curriculum, as stated in the CPR: (1) enhancing the meaning that each resident finds in the experience of being a physician, including protecting time with patients, minimizing nonphysician obligations, providing administrative support, promoting progressive autonomy and flexibility, and enhancing professional relationships; (2) giving attention to resident scheduling, work intensity, and work compression; (3) evaluating workplace safety data and addressing resident and faculty safety; (4) implementing policies and programs to optimize resident and faculty well-being; (5) assuring residents are able to attend 2
medical, mental health, and dental care appointments; (6) identifying symptoms of burnout, depression, and substance abuse; (7) facilitating reporting of peer resident and faculty signs of burnout, depression, substance abuse, suicidal ideation, or potential for violence; (8) providing self-screening tools; (9) providing residents with mental health care; and, (10) assuring appropriate leaves of absences and transitions of care when needed [12]. The ACGME has required that all programs adapt to meet the needs of its residents and faculty. Educational leaders must, at a minimum, possess a thorough working knowledge of the requirements. Program directors and department leadership should show strong progress toward ensuring that their programs cultivate a culture of respect, accountability, and safety for patients and health providers, as well as offering counseling services. The Well-Being Subcommittee of the Association of Program Directors in Radiology (APDR) CPR Ad Hoc Committee and the APDR Academic Output Task Force jointly conducted a study of APDR members’ current level of understanding and implementation of the 2017 ACGME well-being requirements. Well-being solutions and innovations were solicited and presented in an effort to share ideas and best practices.
MATERIALS AND METHODS Compliant with the HIPAA, this study was exempted from further review and monitoring by the Institutional Review Board of the lead author’s institution. A survey instrument was created consisting of 10 multiple-choice and open-ended questions aligning with the ACGME revised CPR. The survey focused on three main areas of content: knowledge of the 2017 CPR, composition of departmental well-being curricula, and residency wellbeing innovations. The first survey question gauged APDR members’ overall level of familiarity with the new requirements. Another question asked APDR members to categorize the state of their departments’ well-being curricula with regard to efforts to improve engagement and reduce burnout. These vital issues address new CPR requirements for programs to optimize resident and faculty well-being. Another question sought to understand the primary components of members’ departmental wellbeing curricula, including many key elements of the CPR requirements such as providing residents with mental health care and minimizing nonphysician obligations. One question specifically asked whether departments provide residents and faculty with selfJournal of the American College of Radiology Volume - n Number - n Month 2019
screening tools, a key element of the new requirements. Another inquired about efforts to collaborate with host institutions or local graduate medical education offices. The full survey instrument can be viewed as an appendix to this article (Appendix A). The anonymous survey was approved for distribution to members of the APDR via an online, cloud-based survey development software with built-in analytics (SurveyMonkey, San Mateo, California). The survey was sent electronically via e-mail to all registered APDR members on March 4, 2019, followed by one reminder email 14 days later. A total of 4 weeks was allowed to complete the online survey.
RESULTS Of the 322 APDR members who received the survey, 121 responded, yielding an overall response rate of 37.6%. Respondents rated their knowledge of the 2017 ACGME CPR Clinical Learning Environment: Well-Being parameters: only one-third (33%, n ¼ 40) rated their knowledge highly, and two-thirds (67%, n ¼ 81) scored their knowledge as incomplete (Fig. 1). Only one-quarter (26%, n ¼ 32) of departments had implemented a comprehensive well-being curriculum, defined as containing all of the elements outlined by the 2017 CPR requirements, and the majority (60%, n ¼ 72) had only managed to host wellness events and social gatherings. Of the respondents, 14% (n ¼ 17) reported no well-being curriculum of import (Fig. 2). Over half (53%, n ¼ 64) of programs did not offer the ACGME-mandated self-screening tool. Regarding formal well-being (wellness) committee structure: a low percentage (34%, n ¼ 41) of respondents had a department well-being committee, with a strong majority of respondents reporting institutional GME
Fig 1. Survey question 1. Program directors’ self-rated knowledge of the 2017 ACGME Well-Being Common Program Requirements. Journal of the American College of Radiology Jordan et al n APDR Well-Being 2019 Survey
(80%, n ¼ 96) and institutional resident (64%, n ¼ 77) committees. The majority of programs (78%) indicated collaboration with their GME offices on well-being resources (78%, n ¼ 93). Interrogating the programs’ finer details of the CPR well-being parameters produced more heterogeneous results. Although most programs currently give residents time during work hours for medical, mental health, and dental appointments (85%, n ¼ 97) and schedule social events for residents outside of work hours (85%, n ¼ 97), far fewer have access to an institutional mental health clinic for house staff (58%, n ¼ 66). Fewer yet provide regular interdepartmental wellness experiences (32%, n ¼ 37) or actively minimize nonphysician tasks (32%, n ¼ 36). Based on the survey comments, numerous well-being initiatives have been implemented successfully across the membership, tabulated as a list of suggestions (Table 1). Some of the themes that emerged include: (1) affording trainees increased personal time by way of flex time, flexible vacation, less call, and shorter daily didactic conferences; (2) improving communication and relationship-building via departmental mentorship programs, “kudos” newsletters, and wellness events; and (3) fostering collaboration with institutional GME resources to leverage interdepartmental social activities, house staff wellness spaces, and periodic house staff retreats.
DISCUSSION The results of this APDR Well-Being survey indicate substantial gaps in program compliance with the previously referenced 2017 ACGME CPR revisions. Perhaps most surprising, two-thirds (67%) of APDR members rated their knowledge of the requirements as incomplete. More than half (52%) of respondents currently do not
Fig 2. Survey question 2. Describe official departmental wellbeing curriculum efforts.
3
Table 1. Well-being initiatives listed by survey respondents Initiative Increasing personal time n Limit noon conferences to 45 min, followed by 30-min resident break. n Offer flex time or flexible vacation. n Have fouth-year volunteers take random call for junior residents. n Schedule days without noon conference. n Give fellows academic or wellness days postcall (float rotation to cover fellows next day). Improving communication n Start a departmental mentorship program. n Form a residency or departmental wellness committee. n Start an online newsletter or blog and highlight accomplishments. n Schedule departmental wellness events. Fostering collaboration with institutional GME resources n Utilize institutional wellness centers and resources. n Establish access to campus mental health facilities. n Plan interdepartmental social and fitness activities. n Encourage trainee participation in institutional or GME retreats. Improving interpersonal connections n Schedule quarterly resident-staff events: socials, breakfasts, team-building events. n Apply for departmental and resident social funds. n Schedule group yoga, meditation, fitness events. n Hire a well-being specialist or self-care coach.
offer self-screening tools to their trainees and faculty to evaluate for burnout. More than two-thirds (68%) of respondents had not minimized nonphysician responsibilities or offered administrative support (eg, reading room assistants) to reduce undue trainee burden. Of the respondents, 74% did not have a comprehensive well-being curriculum that includes all of the required 2017 CPR elements; 15% did not offer residents protected time for medical, mental health, and dental appointments; and 42% did not offer their trainees access to an institutional mental health clinic. Although most educators agree that the mental and physical well-being of our trainees should be made a priority to ensure the development of competent and resilient physicians, the results of the APDR Well-Being 2019 Survey indicate that many programs have substantial work remaining to achieve ACGME well-being compliance. As a part of its Physician Well-Being Initiative, the ACGME has developed and published resources available for use by all training programs [10]. Additionally, 4
programs may utilize resources from the newly developed 2019 ACR Well-Being Program [13], whose aim is to provide members with a self-screening tool and other well-being toolkit resources. We hope that this well-being publication offers both education and ideas for best practices that educators could utilize in their own departments. To this end, Table 1 lists well-being initiatives that have been successfully implemented by survey respondents and that can be adopted or modified by other programs to best fit their needs. These ACGME, ACR, and, now, APDR resources join prior publications to equip educational leaders in developing a culture of wellness to ensure residents thrive [2,14-16]. Prioritizing residents’ and faculty members’ psychological, emotional, and physical health protects well-being and lays the foundation for nurturing competent, compassionate, and resilient physicians. Many important issues are dovetailing to underscore the relevance and timeliness of this topic: mounting ACGME program requirements; program directors’ evolving roles in their residencies; department financial pressures that potentially place educational budgets at risk; heightened understanding of the risk and toll of burnout, depression, substance abuse, and suicide; and competing budgetary educational needs.
Limitations This study has several limitations related primarily to the irregularities and retrospective nature of survey data. Multiple responses may be from the same institution with more than one APDR member. As with any survey study, the response rate directly affects the survey’s generalizability of findings. The 37.6% response rate is in line with other APDR surveys [17]. It is also possible that the authors overlooked an important program well-being component, although we feel this is unlikely given that the breadth of authors and respondents from institutions with programs of multiple sizes in multiple geographic locations. TAKE-HOME POINTS -
-
Beginning July 2019, radiology training programs can be cited for being out of compliance with the 2017 ACGME CPR well-being revisions, because the 2-year grace period will have expired. This survey of APDR members identifies substantial curricular gaps in current programs: threequarters of respondents indicated the absence of a Journal of the American College of Radiology Volume - n Number - n Month 2019
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comprehensive well-being curriculum in their programs; half did not offer self-screening tools to their trainees and faculty to evaluate for burnout; more than two-thirds did not minimize nonphysician responsibilities. Two-thirds of survey respondents rated their current knowledge of the 2017 CPR revisions as incomplete.
ACKNOWLEDGMENTS We deeply appreciate our dedicated program director colleagues whose keen focus on resident education assure our future is bright for radiology. ADDITIONAL RESOURCES Additional resources can be found online at: https://doi. org/10.1016/j.jacr.2019.06.017. REFERENCES 1. Noseworthy J, Madara J, Cosgrove D, et al. Physician burnout is a public health crisis: message to our fellow health care CEOs. Health Affairs Blog. March. Available at: https://www.healthaffairs.org/do/ 10.1377/hblog20170328.059397/full/. Accessed March 15, 2019. 2. Kruskal JB, Shanafelt T, Eby P, et al. A road map to foster wellness and engagement in our workplace—a report of the 2018 Summer Intersociety Meeting. J Am Coll Radiol 2019;16:869-77. 3. Guenette JP, Smith SE. Burnout: prevalence and associated factors among radiology residents in New England with comparison against resident physicians in other specialties. AJR Am J Roentgenol 2017;209:136-41. 4. Guenette JP, Smith SE. Burnout: job resources and job demands associated with low personal accomplishment in United States radiology residents. Acad Radiol 2018;25:739-43.
Journal of the American College of Radiology Jordan et al n APDR Well-Being 2019 Survey
5. McNeeley MF, Perez FA, Chew FS. The emotional wellness of radiology trainees: prevalence and predictors of burnout. Acad Radiol 2013;20:647-55. 6. Nasca T, Philibert I, Flynn T. The Next GME Accreditation System—rationale and benefits. N Engl J Med 2012;366:1051-6. 7. ACGME. Common program requirements. Available at: https:// www.acgme.org/What-We-Do/Accreditation/Common-ProgramRequirements. Accessed December 1, 2018. 8. ACGME. Program requirements for graduate medical education in diagnostic radiology. Available at: https://www.acgme.org/Portals/0/ PFAssets/ProgramRequirements/420_DiagnosticRadiology_2019.pdf? ver=2019-06-19-092522-943. Accessed August 1, 2019. 9. ACGME. CLER pathways to excellence version 1.1. Available at: https://www.acgme.org/Portals/0/PDFs/CLER/CLER_Pathways_V1.1_ Digital_Final.pdf. Accessed March 1, 2019. 10. ACGME. Improving physician well-being, restoring meaning in medicine Available at: https://www.acgme.org/What-We-Do/ Initiatives/Physician-Well-Being. Accessed March 1, 2019. 11. ACGME. Common program requirements section VI table of implementation dates. Available at: https://www.acgme.org/Portals/0/ PFAssets/ProgramRequirements/2017CPRSectionVIImplementation Table.pdf. Accessed November 1, 2018. 12. ACGME. Common program requirements (residency). Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPR Residency2019.pdf. Accessed December 1, 2018. 13. ACR. Radiologist well-being program Available at: https://www.acr. org/Member-Resources/benefits/Well-Being. Accessed June 15, 2019. 14. Holmes EG, Connolly A, Putnam KT. Taking care of our own: a multispecialty study of resident and program director perspectives on contributors to burnout and potential interventions. Acad Psychiatry 2017;41:159-66. 15. Harolds JA, Parikh JR, Bluth EI, Dutton SC, Recht MP. Burnout of radiologists: frequency, risk factors, and remedies: a report of the ACR commission on human resources. J Am Coll Radiol 2016;13: 411-6. 16. Slanetz PJ, Reede D, Ruchman RB, et al. Strengthening the radiology learning environment. J Am Coll Radiol 2018;15: 1016-8. 17. Rozenshtein A, Heitkamp D, Muhammed TL, et al. “What program directors think” III: Results of the 2014/2015 annual surveys of the Association of Program Directors in Radiology (APDR). Acad Radiol 2016;23:861-9.
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The Association of Program Directors in Radiology Well-Being 2019 Survey: Identifying Residency Gaps and Offering Solutions Sheryl G. Jordan, MD a , Jessica B. Robbins, MD b, David Sarkany, MD c, Eric England, MD d, Vivek Kalia, MD, MPH, MS e, Maitray D. Patel, MD f, Kamran Ali, MD g, Carolynn M. DeBenedectis, MD h, Christopher P. Ho, MD i, James M. Milburn, MD j, Seng Ong, MBBS k, Ann K. Jay, MD l, Glenn C. Gaviola, MD m, Darel E. Heitkamp, MD n Abstract Purpose: The Well-Being subcommittee of the Association of Program Directors in Radiology (APDR) Common Program Requirements (CPR) Ad Hoc Committee and the APDR Academic Output Task Force jointly conducted a study of APDR members’ current level of understanding and implementation of the 2017 ACGME CPR regarding well-being. Methods: A survey instrument consisting of 10 multiple-choice and open-ended questions was distributed to the 322 active members of the APDR. The survey focused on three main content areas: APDR member knowledge of the 2017 CPR, composition of department well-being curricula, and residency well-being innovations. Results: In all, 121 members (37.6%) responded to the survey. Of those, 67% rated their knowledge of requirements as incomplete. Responses also indicated that 74% of departments have not implemented a comprehensive well-being curriculum; 53% of programs do not offer the mandated self-screening tool; 15% of respondents do not offer residents protected time for medical, mental health, and dental appointments; and 42% do not offer their trainees access to an institutional mental health clinic. Survey comments offer numerous individual well-being initiatives from across the membership. Conclusions: The results of the APDR Well-Being Survey indicate that many programs have substantial work remaining to achieve ACGME compliance. Well-being innovations were included in an effort to share best practices. Key Words: ACGME, burnout, common program requirements, residency, well-being J Am Coll Radiol 2019;-:---. Copyright 2019 American College of Radiology
INTRODUCTION Burnout among American health care providers has been deemed a public health crisis [1]. The Intersociety Committee of the ACR, a comprehensive coalition of
radiology professional organizations and governing bodies, recently published a road map to fostering wellness and engagement, acknowledging the impact that emotional exhaustion and the sense of reduced
a
j
Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina. b University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. c Staten Island University Hospital, Northwell Health, Staten Island, New York. d University of Cincinnati Medical Center, Cincinnati, Ohio. e University of Michigan Health System Ann Arbor, Michigan. f Mayo Clinic, Phoenix, Arizona. g University of Kansas School of Medicine, Wichita, Kansas. h University of Massachusetts Medical School, Worcester, Massachusetts. i Emory University School of Medicine, Atlanta, Georgia.
ª 2019 American College of Radiology 1546-1440/19/$36.00 n https://doi.org/10.1016/j.jacr.2019.06.017
Ochsner Clinic Foundation, New Orleans, Louisiana. University of Chicago Medical Center, Chicago, Illinois. l MedStar Georgetown University Hospital, Washington, DC. m Brigham and Women’s Hospital, Boston, Massachusetts. n AdventHealth Imaging, Orlando, Florida. Corresponding author and reprints: Sheryl G. Jordan, MD, University of North Carolina School of Medicine, Department of Radiology, 101 Manning Drive Campus Box #7510, Chapel Hill, NC 27514; e-mail: [email protected]. The authors state that they have no conflict of interest related to the material discussed in this article. k
1
personal accomplishment has on radiologists [2]. As cited in the Intersociety Committee’s paper, 78% of radiologists, midlevel providers, and physicists reported burnout as a significant workplace issue in the 2018 ACR HR Commission Workforce Survey. Furthermore, only 19% of respondents reported having access to selfassessment tools, and only 21% reported having effective available means to address burnout [2]. Resident physicians are especially prone to burnout during training when they are called upon to care for patients and devote considerable additional time to selfstudy. In surveys of radiology residents, a high degree of burnout has been reported in more than one-third of radiology residents, stemming particularly from feelings of low personal accomplishment [3-5]. With the implementation of the Next Accreditation System in 2013, the ACGME substantially revised program requirements [6]. During a second major revision to the Common Program Requirements (CPR) in 2017, the ACGME added new emphasis on physician well-being [7,8]. At the same time, the ACGME’s Clinical Learning Environment Review (CLER) Program released the CLER Pathways to Excellence Version 1.1, underscoring the important role of clinical learning environments in implementing systems that support physician well-being [9]. Specifically, training programs are now required to recognize that psychological, emotional, and physical well-being is critical in the development of the competent physician [10]. As a result, all radiology residency programs and sponsoring institutions must turn their attention intently toward physician well-being, with a final implementation deadline of July 1, 2019, to meet the mandates outlined in the CLER Pathways to Excellence goals [11]. After July 1, 2019, programs may be cited for failure to comply with the 2017 CPR well-being revisions, because the 2-year grace period will have lapsed. Programs must demonstrate that they are achieving the following detailed goals of a well-being curriculum, as stated in the CPR: (1) enhancing the meaning that each resident finds in the experience of being a physician, including protecting time with patients, minimizing nonphysician obligations, providing administrative support, promoting progressive autonomy and flexibility, and enhancing professional relationships; (2) giving attention to resident scheduling, work intensity, and work compression; (3) evaluating workplace safety data and addressing resident and faculty safety; (4) implementing policies and programs to optimize resident and faculty well-being; (5) assuring residents are able to attend 2
medical, mental health, and dental care appointments; (6) identifying symptoms of burnout, depression, and substance abuse; (7) facilitating reporting of peer resident and faculty signs of burnout, depression, substance abuse, suicidal ideation, or potential for violence; (8) providing self-screening tools; (9) providing residents with mental health care; and, (10) assuring appropriate leaves of absences and transitions of care when needed [12]. The ACGME has required that all programs adapt to meet the needs of its residents and faculty. Educational leaders must, at a minimum, possess a thorough working knowledge of the requirements. Program directors and department leadership should show strong progress toward ensuring that their programs cultivate a culture of respect, accountability, and safety for patients and health providers, as well as offering counseling services. The Well-Being Subcommittee of the Association of Program Directors in Radiology (APDR) CPR Ad Hoc Committee and the APDR Academic Output Task Force jointly conducted a study of APDR members’ current level of understanding and implementation of the 2017 ACGME well-being requirements. Well-being solutions and innovations were solicited and presented in an effort to share ideas and best practices.
MATERIALS AND METHODS Compliant with the HIPAA, this study was exempted from further review and monitoring by the Institutional Review Board of the lead author’s institution. A survey instrument was created consisting of 10 multiple-choice and open-ended questions aligning with the ACGME revised CPR. The survey focused on three main areas of content: knowledge of the 2017 CPR, composition of departmental well-being curricula, and residency wellbeing innovations. The first survey question gauged APDR members’ overall level of familiarity with the new requirements. Another question asked APDR members to categorize the state of their departments’ well-being curricula with regard to efforts to improve engagement and reduce burnout. These vital issues address new CPR requirements for programs to optimize resident and faculty well-being. Another question sought to understand the primary components of members’ departmental wellbeing curricula, including many key elements of the CPR requirements such as providing residents with mental health care and minimizing nonphysician obligations. One question specifically asked whether departments provide residents and faculty with selfJournal of the American College of Radiology Volume - n Number - n Month 2019
screening tools, a key element of the new requirements. Another inquired about efforts to collaborate with host institutions or local graduate medical education offices. The full survey instrument can be viewed as an appendix to this article (Appendix A). The anonymous survey was approved for distribution to members of the APDR via an online, cloud-based survey development software with built-in analytics (SurveyMonkey, San Mateo, California). The survey was sent electronically via e-mail to all registered APDR members on March 4, 2019, followed by one reminder email 14 days later. A total of 4 weeks was allowed to complete the online survey.
RESULTS Of the 322 APDR members who received the survey, 121 responded, yielding an overall response rate of 37.6%. Respondents rated their knowledge of the 2017 ACGME CPR Clinical Learning Environment: Well-Being parameters: only one-third (33%, n ¼ 40) rated their knowledge highly, and two-thirds (67%, n ¼ 81) scored their knowledge as incomplete (Fig. 1). Only one-quarter (26%, n ¼ 32) of departments had implemented a comprehensive well-being curriculum, defined as containing all of the elements outlined by the 2017 CPR requirements, and the majority (60%, n ¼ 72) had only managed to host wellness events and social gatherings. Of the respondents, 14% (n ¼ 17) reported no well-being curriculum of import (Fig. 2). Over half (53%, n ¼ 64) of programs did not offer the ACGME-mandated self-screening tool. Regarding formal well-being (wellness) committee structure: a low percentage (34%, n ¼ 41) of respondents had a department well-being committee, with a strong majority of respondents reporting institutional GME
Fig 1. Survey question 1. Program directors’ self-rated knowledge of the 2017 ACGME Well-Being Common Program Requirements. Journal of the American College of Radiology Jordan et al n APDR Well-Being 2019 Survey
(80%, n ¼ 96) and institutional resident (64%, n ¼ 77) committees. The majority of programs (78%) indicated collaboration with their GME offices on well-being resources (78%, n ¼ 93). Interrogating the programs’ finer details of the CPR well-being parameters produced more heterogeneous results. Although most programs currently give residents time during work hours for medical, mental health, and dental appointments (85%, n ¼ 97) and schedule social events for residents outside of work hours (85%, n ¼ 97), far fewer have access to an institutional mental health clinic for house staff (58%, n ¼ 66). Fewer yet provide regular interdepartmental wellness experiences (32%, n ¼ 37) or actively minimize nonphysician tasks (32%, n ¼ 36). Based on the survey comments, numerous well-being initiatives have been implemented successfully across the membership, tabulated as a list of suggestions (Table 1). Some of the themes that emerged include: (1) affording trainees increased personal time by way of flex time, flexible vacation, less call, and shorter daily didactic conferences; (2) improving communication and relationship-building via departmental mentorship programs, “kudos” newsletters, and wellness events; and (3) fostering collaboration with institutional GME resources to leverage interdepartmental social activities, house staff wellness spaces, and periodic house staff retreats.
DISCUSSION The results of this APDR Well-Being survey indicate substantial gaps in program compliance with the previously referenced 2017 ACGME CPR revisions. Perhaps most surprising, two-thirds (67%) of APDR members rated their knowledge of the requirements as incomplete. More than half (52%) of respondents currently do not
Fig 2. Survey question 2. Describe official departmental wellbeing curriculum efforts.
3
Table 1. Well-being initiatives listed by survey respondents Initiative Increasing personal time n Limit noon conferences to 45 min, followed by 30-min resident break. n Offer flex time or flexible vacation. n Have fouth-year volunteers take random call for junior residents. n Schedule days without noon conference. n Give fellows academic or wellness days postcall (float rotation to cover fellows next day). Improving communication n Start a departmental mentorship program. n Form a residency or departmental wellness committee. n Start an online newsletter or blog and highlight accomplishments. n Schedule departmental wellness events. Fostering collaboration with institutional GME resources n Utilize institutional wellness centers and resources. n Establish access to campus mental health facilities. n Plan interdepartmental social and fitness activities. n Encourage trainee participation in institutional or GME retreats. Improving interpersonal connections n Schedule quarterly resident-staff events: socials, breakfasts, team-building events. n Apply for departmental and resident social funds. n Schedule group yoga, meditation, fitness events. n Hire a well-being specialist or self-care coach.
offer self-screening tools to their trainees and faculty to evaluate for burnout. More than two-thirds (68%) of respondents had not minimized nonphysician responsibilities or offered administrative support (eg, reading room assistants) to reduce undue trainee burden. Of the respondents, 74% did not have a comprehensive well-being curriculum that includes all of the required 2017 CPR elements; 15% did not offer residents protected time for medical, mental health, and dental appointments; and 42% did not offer their trainees access to an institutional mental health clinic. Although most educators agree that the mental and physical well-being of our trainees should be made a priority to ensure the development of competent and resilient physicians, the results of the APDR Well-Being 2019 Survey indicate that many programs have substantial work remaining to achieve ACGME well-being compliance. As a part of its Physician Well-Being Initiative, the ACGME has developed and published resources available for use by all training programs [10]. Additionally, 4
programs may utilize resources from the newly developed 2019 ACR Well-Being Program [13], whose aim is to provide members with a self-screening tool and other well-being toolkit resources. We hope that this well-being publication offers both education and ideas for best practices that educators could utilize in their own departments. To this end, Table 1 lists well-being initiatives that have been successfully implemented by survey respondents and that can be adopted or modified by other programs to best fit their needs. These ACGME, ACR, and, now, APDR resources join prior publications to equip educational leaders in developing a culture of wellness to ensure residents thrive [2,14-16]. Prioritizing residents’ and faculty members’ psychological, emotional, and physical health protects well-being and lays the foundation for nurturing competent, compassionate, and resilient physicians. Many important issues are dovetailing to underscore the relevance and timeliness of this topic: mounting ACGME program requirements; program directors’ evolving roles in their residencies; department financial pressures that potentially place educational budgets at risk; heightened understanding of the risk and toll of burnout, depression, substance abuse, and suicide; and competing budgetary educational needs.
Limitations This study has several limitations related primarily to the irregularities and retrospective nature of survey data. Multiple responses may be from the same institution with more than one APDR member. As with any survey study, the response rate directly affects the survey’s generalizability of findings. The 37.6% response rate is in line with other APDR surveys [17]. It is also possible that the authors overlooked an important program well-being component, although we feel this is unlikely given that the breadth of authors and respondents from institutions with programs of multiple sizes in multiple geographic locations. TAKE-HOME POINTS -
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Beginning July 2019, radiology training programs can be cited for being out of compliance with the 2017 ACGME CPR well-being revisions, because the 2-year grace period will have expired. This survey of APDR members identifies substantial curricular gaps in current programs: threequarters of respondents indicated the absence of a Journal of the American College of Radiology Volume - n Number - n Month 2019
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comprehensive well-being curriculum in their programs; half did not offer self-screening tools to their trainees and faculty to evaluate for burnout; more than two-thirds did not minimize nonphysician responsibilities. Two-thirds of survey respondents rated their current knowledge of the 2017 CPR revisions as incomplete.
ACKNOWLEDGMENTS We deeply appreciate our dedicated program director colleagues whose keen focus on resident education assure our future is bright for radiology. ADDITIONAL RESOURCES Additional resources can be found online at: https://doi. org/10.1016/j.jacr.2019.06.017. REFERENCES 1. Noseworthy J, Madara J, Cosgrove D, et al. Physician burnout is a public health crisis: message to our fellow health care CEOs. Health Affairs Blog. March. Available at: https://www.healthaffairs.org/do/ 10.1377/hblog20170328.059397/full/. Accessed March 15, 2019. 2. Kruskal JB, Shanafelt T, Eby P, et al. A road map to foster wellness and engagement in our workplace—a report of the 2018 Summer Intersociety Meeting. J Am Coll Radiol 2019;16:869-77. 3. Guenette JP, Smith SE. Burnout: prevalence and associated factors among radiology residents in New England with comparison against resident physicians in other specialties. AJR Am J Roentgenol 2017;209:136-41. 4. Guenette JP, Smith SE. Burnout: job resources and job demands associated with low personal accomplishment in United States radiology residents. Acad Radiol 2018;25:739-43.
Journal of the American College of Radiology Jordan et al n APDR Well-Being 2019 Survey
5. McNeeley MF, Perez FA, Chew FS. The emotional wellness of radiology trainees: prevalence and predictors of burnout. Acad Radiol 2013;20:647-55. 6. Nasca T, Philibert I, Flynn T. The Next GME Accreditation System—rationale and benefits. N Engl J Med 2012;366:1051-6. 7. ACGME. Common program requirements. Available at: https:// www.acgme.org/What-We-Do/Accreditation/Common-ProgramRequirements. Accessed December 1, 2018. 8. ACGME. Program requirements for graduate medical education in diagnostic radiology. Available at: https://www.acgme.org/Portals/0/ PFAssets/ProgramRequirements/420_DiagnosticRadiology_2019.pdf? ver=2019-06-19-092522-943. Accessed August 1, 2019. 9. ACGME. CLER pathways to excellence version 1.1. Available at: https://www.acgme.org/Portals/0/PDFs/CLER/CLER_Pathways_V1.1_ Digital_Final.pdf. Accessed March 1, 2019. 10. ACGME. Improving physician well-being, restoring meaning in medicine Available at: https://www.acgme.org/What-We-Do/ Initiatives/Physician-Well-Being. Accessed March 1, 2019. 11. ACGME. Common program requirements section VI table of implementation dates. Available at: https://www.acgme.org/Portals/0/ PFAssets/ProgramRequirements/2017CPRSectionVIImplementation Table.pdf. Accessed November 1, 2018. 12. ACGME. Common program requirements (residency). Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPR Residency2019.pdf. Accessed December 1, 2018. 13. ACR. Radiologist well-being program Available at: https://www.acr. org/Member-Resources/benefits/Well-Being. Accessed June 15, 2019. 14. Holmes EG, Connolly A, Putnam KT. Taking care of our own: a multispecialty study of resident and program director perspectives on contributors to burnout and potential interventions. Acad Psychiatry 2017;41:159-66. 15. Harolds JA, Parikh JR, Bluth EI, Dutton SC, Recht MP. Burnout of radiologists: frequency, risk factors, and remedies: a report of the ACR commission on human resources. J Am Coll Radiol 2016;13: 411-6. 16. Slanetz PJ, Reede D, Ruchman RB, et al. Strengthening the radiology learning environment. J Am Coll Radiol 2018;15: 1016-8. 17. Rozenshtein A, Heitkamp D, Muhammed TL, et al. “What program directors think” III: Results of the 2014/2015 annual surveys of the Association of Program Directors in Radiology (APDR). Acad Radiol 2016;23:861-9.
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