A program matrix is a visual depiction used by stakeholders as a tool for planning, implementing, and evaluating a program that comprises resources, outputs, and outcomes. We developed an ARWP matrix to describe the structure of the program, including its goals, target populations, assumptions of support, and required inputs. From these components, we developed the outputs that define the structure of the ARWP and its short-term, intermediate, and long-term outcomes (Figure 1).
The ARWP modules provide a foundation on which to cover various topics that were identified by the RCPSC,6,7 the anesthesiology program directors (PDs),4 and the residents themselves.4 Additional details are available in the accompanying article, “Concept and Development,” appearing elsewhere in this issue.4 The list of module topics (with the details for each presented in the corresponding appendices) is as follows:
Module 1: Physician Wellness (Appendix 1)
Module 2: Physician Resilience (Appendix 2)
Module 3: Professionalism (Appendix 3)
Module 4: Occupational Wellness (Appendix 4)
Module 5: Emotional Wellness (Appendix 5)
Module 6: Financial Wellness and Career Management (Appendix 6)
Module 7: Social Wellness and Team Building (Appendix 7)
Module 8: Situational Awareness and Mindfulness (Appendix 8)
Each module is co-facilitated by a faculty member with an interest in physician wellness and a resident (usually one who is a member of the Resident Wellness Committee). Each module has a title, topics, learning objectives, suggestions for preparation and pre-reading, delivery methods (e.g., didactic, small group, role play, simulation), and a list of associated resources.
The ARWP curriculum seminars run on a two-year cycle, with two of eight modules usually offered per term (i.e., four sessions per academic year). Because of the overall compact residency training curriculum, however, we are sometimes unable to offer the full four sessions per year. In these circumstances, we have combined two modules, if needed, and have also presented a topic at one of our departmental Grand Rounds each term or in our separate visiting guest lecturer series. We have also used the Resident Wellness Night and Transition to Practice Night to discuss specific topics that lend themselves well to those situations. Additional details can be found later in the article in the sections that address the Peer Support Curriculum, Self-Directed Learning Activities, and Department Wellness Program.
Because of the often sensitive nature of the topics and discussions, it is crucial to create a sense of safety that can be supported by discussions of trust, respect, and “double confidentiality” prior to each session. “Double confidentiality” assumes that not only will one not repeat anything discussed in the session but that participants will not approach each other outside of this space to discuss or advise further.8 This format allows a deeper discussion and openness and allows faculty and residents to share the experiences as well as challenges and rewards of trying to maintain a balanced work life in the context of a demanding career. It is crucial to have specific information (e.g., Saskatchewan Medical Association Physician Health Program, University of Saskatchewan Student Health Services, University of Saskatchewan Resident Resource Office) about personnel and resources for support available at all times.
There are many other relevant topics (a substantial list of which is available in the RCPSC Physician Health Guide)6 that may be substituted at the discretion of the Resident Wellness Committee and the Residency Program Director. We found it easiest to introduce the modular curriculum first, after which we added the Peer Support Curriculum and Self-Directed Learning Activities as time and capacity permitted.
Peer support curriculum
The Peer Support Curriculum encompasses the Resident Wellness Committee, Mentorship, and Resident Wellness/ Transition to Practice Evening Events.
Resident wellness committee
The first curricular seminar presented at the start of each new residency year (July) introduces the ARWP. At the end of the session, the first-year residents are invited to join the Resident Wellness Committee (RWC) by senior members of the RWC, who themselves speak to the time and energy commitments of involvement and the benefits of participating. They then answer any questions. It is important to emphasize that the RWC is made up of residents and is explicitly for the benefit of residents. In our program of 32 residents, we request that two members per each resident class year participate. The ARWP has faculty advisors/mentors who are leading participants in a Department Wellness Program Peer2Peer (P2P) support group. This arrangement allows cohesiveness in planning, clarity of messaging, and opportunities for collaboration between residents, faculty, and other healthcare team members in the department. The current RWC is comprised of one staff physician, two junior faculty members, two resident representatives per class year, and one administrative support staff member who works with the P2P group. It is the responsibility of all RWC members to collaborate to co-create a culture of resilience, peer support, and collegiality to enhance personal wellness and a healthy workplace, which positively affects the quality of patient care and patient safety. The RWC faculty and residents are responsible for organizing the wellness curriculum seminars and professionalism rounds as well as collaborate with the P2P group.
The resident mentorship programming begins with the initial Canadian Resident Matching Service interview processes, where the applicants are made to feel comfortable and safe during what is often a stressful time during the matching process. As soon as the match results are announced, each of the incoming first-year residents (R1) are connected with a second-year resident (R2), who makes contact with, assists, and supports the new resident’s transition into this new phase of the residency life cycle. This mentorship continues throughout the first year and beyond. Informal feedback from residents has been positive about this arrangement.
Upon entering the residency program, a formal individualized mentorship is also established between R1 and R5 residents. Each R1 resident is assigned to work in the operating room with a R5 resident for one- to two-week periods. This enables the development of personal and professional bonds at a much needed time of transition. The feedback from residents has been positive about this particular mentorship model.
Resident wellness night
On one evening per year, residents and their significant others attend the Resident Wellness Night, which is considered a mandatory part of the curriculum. Attendance by a significant other is not mandatory but is strongly encouraged. Residents and their significant others, other faculty invited by the residents, and the faculty advisors of the RWC have a dinner, usually at the home of one of the faculty members. Prior to this resident wellness night dinner, the topics to be discussed are shared. After dinner, all attendees seat themselves, and a short introduction is made – again emphasizing confidentiality and respect. Residents and their significant others are reminded that it is often the person at home who recognizes that things may not be going well with the resident. They are also reminded that our Saskatchewan Medical Association Physician Health Program can anonymously provide options to the family member in regard to approaching the resident and for issues they themselves or immediate family members may be having. The evening begins with a few faculty narratives and then opens up to the question/answer portion of the evening. If a safe, supportive environment has been created, the residents often speak about their own challenges and issues. It is important to acknowledge that physicians at all stages of life may have challenges, need support, and must stay resilient. The topics we have covered are substance use disorders and addictions (with powerful faculty narratives), the impact and recovery from significant adverse events, and various mental health narratives (e.g., depression, suicide, anxiety). There is often an expressed need for discussion about the challenge of spousal relationships in medicine. Although spousal challenges are often raised, it is still difficult to find individuals who are willing to talk about such personal subjects.
Transition to practice night
In the second term of the ARWP, there is a Transition to Practice Night, with all residents and selected faculty (both junior and senior) members invited to attend. The purpose of the Transition to Practice Night is to recognize the challenges associated with residency training, especially at points of transition to different stages of training. This range includes, but is not limited to, the final transition to practice. Such focussed discussion of these transitions in a collegial and confidential manner is intended to prepare the residents to better adapt to these changes. Professional licensing, contractual obligations, financial aspects of practice, and fellowship training are some of the other topics that come up regularly in these discussions. “What do you wish you had known?” is a common question that explores these and other themes.
A regular resident “check-in” component of ARWP takes both group and individual forms. The group encounter is called the “bear pit” and takes place once a month with 30- to 60-min confidential discussions about all aspects of the program between the residents and the PD. This check-in allows problems to be detected before they become significant. Individual check-ins take the form of quarterly meetings (usually lasting 5-15 min) with the PD. A standardized format is utilized for these check-ins, with a Microsoft Excel spreadsheet used to collect and maintain longitudinal data. These data are used for the purpose of this check-in, and each resident’s records are available only to that resident and the PD. The standardized questions relate to personal and family health, financial well-being, and the learning environment (specifically as it relates to issues of intimidation and harassment).
Following department educational sessions regarding the impact of adverse events, discussion with our local simulation faculty led to the development of a scenario of an unanticipated death in the operating room that required disclosure and/or apology. Although this simulation might ideally be positioned more appropriately in Module 2 (physician resilience), its use is not always possible, and it does stand well on its own. It has been an extremely powerful tool to educate our residents on how negatively an adverse event may affect them. It also gives them some practice with these difficult disclosures to the patient’s relatives and care-givers.
A standardized set of simulation scenarios has been developed at a national level by the Canadian National Anesthesiology Simulation Curriculum (CanNASC). Our program uses these standardized scenarios to discuss adverse event disclosure, physician resilience, stress mitigation or physician wellness in general.