The Royal College of Physicians and Surgeons of Canada (RCPSC) recognized Physician Health as “one of the cornerstone ideas to improving the delivery of healthcare.”1 Resident and physician health are also integral to the CanMEDS 2015 framework, in which the professional role requires competence in demonstrating commitment to patients, society, our profession, and physician health if we are to optimize patient care.2 The Future of Medical Education in Canada Postgraduate Project commissioned an environmental scan in 2011 that emphasized the dire need to promote resident and physician health from the perspectives of patient safety, physician sustainability, and resident academic performance.3

Resident physicians experience high levels of stress, emotional exhaustion, burnout, and depression.4,5 Fatigue, stressful work situations, high financial debt loads, and conflict between work and home life contribute to psychological distress and resident burnout.5,6 Resident burnout and depression have been associated with self-reported suboptimal patient care and increased medication errors, respectively.7,8

Formal wellness curricula during residency training have been proposed to promote resident wellness and resilience.9 In conjunction with a national needs assessment, we have developed an Anesthesiology Resident Wellness Program (ARWP) at the University of Saskatchewan (U of S). The purpose of the present article was to describe the need for such a program (as outlined in a national environmental scan), along with the challenges associated with its development and implementation. We also describe the results of a preliminary evaluation of this program.

Methods

Environmental scan

The need for a formal ARWP was assessed through an environmental scan of Canadian anesthesiology residency programs. The scan involved a sequential, mixed-methods study, including a cross-sectional survey and a focus group of anesthesiology residency training program directors (PDs) across Canada. Ethics approval was obtained from the University of Saskatchewan Behavioral Research Ethics Board (BEH#14-48, February 2014).

The survey tool (Appendix 1) was developed by the research team using published guidelines.10 We generated items through informal e-mail and personal discussions with all Canadian anesthesiology PDs regarding wellness initiatives in their programs. Three themes were deemed important: attitudes toward residents’ health and wellness; current wellness initiatives; opinions about a module-based wellness curriculum. The research team developed questions to elaborate on these themes and then pretested the survey with three U of S Department of Anesthesiology faculty members. After we revised questions based on the pretesting results, we pilot-tested the survey with two PDs from other departments at the U of S College of Medicine to ensure the relevance of questions and to improve the flow of the survey.

We distributed the survey in May 2014 via e-mail to the 17 Canadian anesthesiology residency training program PDs. We excluded the PD involved in the present study. One program was in transition and had the incoming and outgoing PDs involved. Both were invited to participate. Consent to participate was implied by completing the survey. We sent e-mail reminders to non-responders at two and four weeks.

The survey was conducted and distributed using Fluid Surveys, a free survey tool available through the U of S. Data were anonymized and then exported to a Microsoft Excel file for quantitative statistical analysis. The survey responses were analyzed both qualitatively and quantitatively.

We held a focus group to discuss the results of the survey with all of the PDs at a regularly scheduled Association of Canadian University Departments of Anesthesia (ACUDA) meeting in June 2014. The focus group was conducted by one of the authors (M.R.) using a semi-structured interview guide (Appendix 2) with concurrent note taking. Participants were informed that their participation was voluntary, and they were free to decline answering any questions if they so chose. The researchers conducted a thematic analysis of the focus group notes. Agreement was achieved through an iterative discussion among authors. To establish rigor, the authors held extensive discussions to challenge the focus group facilitator on his interpretation of the results, as he was also a Canadian PD whose perspective may have biased his understanding and interpretation of the participants’ responses.

Anesthesiology Resident Wellness Program development and implementation

Some of the key developments and time lines that influenced ARWP development included one of the author’s (A.C.) attendance at the inaugural Canadian Conference on Physician Health (CCPH) in the fall of 2009 and her subsequent proposal to the PD, Department Head, Executive, and Residency Program Committee (RPC) for a Resident Wellness Curriculum in January 2010. Initial module development was based on topics presented at the CCPH and formal and informal discussions with residents and staff. The CanMEDS Train-the-Trainer session on Physician Health11 further informed modular development.

To increase awareness of, and engagement with, physician wellness throughout a physician’s life cycle, the primary author made presentations to the Student Medical Society of Saskatchewan (SMSS) and the Provincial Association of Interns and Residents of Saskatchewan (PAIRS). This step directly facilitated the development of the Physician Wellness Initiative of the SMSS (2009) and the PAIRS Wellness Committee (2010). Concurrent development of health promotion initiatives occurred in the Saskatchewan Medical Association Physician Health Program, Saskatoon Health Region Healthy Workplace Committee, and U of S Healthy CampUS Committee and Health Sciences Students’ Association.

The ARWP was informed by eight domains of wellness (physical, emotional, intellectual, social, spiritual, occupational, environmental, financial),12 and the four pillars of a healthy workplace (healthy lifestyle, physical environment, mental health and workplace culture, corporate social responsibility).13

Anesthesiology Resident Wellness Program evaluation

We conducted an internal evaluation to gather feedback on the ARWP developed at the U of S. This program evaluation received (January 2015) an ethics exemption from the U of S Behavioral Research Ethics Board (Beh#15-09), as per Article 2.5 of the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans. The questionnaire was pretested with two anesthesiology residents and two anesthesiology faculty members. Following pretesting, the Research Coordinator (J.O.) circulated an e-mail invitation to complete an anonymous electronic questionnaire through Fluid Surveys to all 31 current anesthesiology residents at the U of S (Appendix 3). Reminders were sent one, two, and five weeks after the initial invitation. Completion and submission of the survey constituted consent to participate and permission for the researchers to use the data gathered. Responses were exported for analysis in Microsoft Excel 2010. Quantitative data are reported using descriptive statistics. Common themes were generated from qualitative data through an iterative process among three authors (A.C., M.R., J.O.).

Results

Environmental scan

Despite the fact that only ten of the 18 (56%) invited PDs completed the survey, we received responses from PDs across Canada, representing western, central, and eastern Canada, including Quebec. The results of the three major themes of the environmental scan follow.

Part I: attitudes toward residents’ health and wellness

All of the PDs (n = 10, 100%) who responded agreed that resident and physician wellness directly affects patient health and well-being. All respondents (n = 10, 100%) also agreed that educating residents about physician well-being is an important part of a postgraduate training program. Nine respondents (90%) agreed that faculty/staff in their anesthesiology departments value residents’ well-being. One responding PD (10%) disagreed with this statement. Most respondents (n = 8, 80%) agreed that residents’ wellness is encouraged in their anesthesiology department. Two responding PDs (20%) were neutral on this statement. All responding PDs (n = 10, 100%) agreed that their anesthesiology program supports resident work/life balance.

Part II: current wellness initiatives

Only three responding PDs (n = 3, 30%) said that resident wellness is already a well-defined part of their formal academic curriculum. Those who said that their programs included resident wellness specified that it was included in the core program (n = 2, 20%), grand rounds (n = 1, 10%), visiting professors or lecture series on physician health topics (n = 3, 30%), and “other” (n = 2, 20%). “Other” included a conference put on by the postgraduate medical education office and an annual residents’ retreat. Two responding PDs (20%) said that their wellness curriculum had objectives, but none (0%) said that they had an assessment tool for this curriculum.

All respondents (n = 10, 100%) thought that they had informal wellness initiatives in their department. Six respondents (60%) said that they promote awareness of mental health services. All respondents (n = 10, 100%) said that they have residents’ social events. None (0%) had a physical activity group. Only one respondent (10%) said that residents have access to healthy nutrition 24 hours per day. All respondents (100%) said their programs had peer support. Eight respondents (80%) hold a residents’ retreat. Nine respondents (90%) include mentorship in their educational program. Six responding PDs (60%) have reduced resident on-call duty hours to 16 hours or less per day.

With regard to resources for resident wellness initiatives, four respondents (40%) said that their department provides funding for resident wellness. Six (60%) said that they provide staff and mentors, and four (40%) said that they provide protected academic time for resident wellness initiatives.

Part III: module-based wellness curriculum

Among those who responded to the survey, most (n = 9, 90%) believe that it is important to demonstrate that they are including all of the CanMEDS roles in their curriculum. One (10%) respondent was neutral on this statement. Most respondents (n = 8, 80%) agreed that they would include a series of modules as part of a resident wellness curriculum in their academic curriculum if they were developed by the research team. Respondents were asked to rank resident wellness topics in the order of most important to least important for inclusion in a module-based wellness curriculum. Their choices were compiled in a rank-sum fashion, where the lowest summed score was the highest-ranked topic (Table 1).

Table 1 Order of importance of residents’ wellness topics
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Focus group

The qualitative component of the environmental scan was a focus group comprising all PDs at a regular ACUDA meeting in June of 2014. In all, 16 of the 17 (94%) possible PDs participated in this focus group, representing most Canadian anesthesiology residency programs. The general consensus from the PDs was that they agreed with the results of the survey but would like more details regarding its content prior to adopting it into their training programs. PDs had questions regarding the format and function of the module-based curriculum.

Anesthesiology Resident Wellness Program development and implementation

The first formal Resident Curriculum Seminar on Physician Wellness was delivered in July 2010 to the residents in the U of S Department of Anesthesiology. Over the next two years, the ARWP developed into its current form, comprising a Modular Curriculum, a Peer Support Curriculum, Self-Directed Learning Activities, and a Department Wellness Program. These components are described in further detail in the description of the curriculum (this issue).14

Anesthesiology Resident Wellness Program evaluation

Among the 31 (90%) anesthesiology residents, 28 completed the online survey between January 23 and March 7, 2015. Twenty respondents (71%) were in their postgraduate training years 1-3 (PGY1-3), and eight (29%) respondents were in years 4 or 5 (PGY4 or r5). Twenty-one (75%) respondents were partnered, and seven (25%) were single.

Respondents reported high levels of satisfaction with the ARWP, relevance of the topics, applicability of skills and information to both work and daily life, and facilitators’ knowledge of each subject (Table 2).

Table 2 Satisfaction with the Residents’ Wellness Program
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Respondents identified the following as the most valuable components of the Anesthesiology Resident Wellness Program: team-building activities (86%), mentorship and orientation for residents in their first and second year of residency (R2s-R1s) (64%), resident wellness nights (64%), and physicians’ life cycle and transitions (50%) (Table 3).

Table 3 Anesthesiology residents’ wellness program components selected as most important to respondents
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Qualitative comments

Qualitative analysis of the residents’ responses to specific questions revealed the following themes.

  • Examples of how residents have applied the ARWP to their work included a heightened awareness of the need for an optimal work/life balance, self-care as an essential prerequisite to optimal patient care, better recognition of stress-reduction strategies, and recognition of the importance of nurturing team relationships.

  • Examples of how residents have applied the ARWP to their daily life included prioritizing exercise and nutrition, nurturing family and social connections, and practicing mindfulness.

  • Suggestions for improving delivery of the ARWP included increasing the number of interactive and small-group discussions and facilitating further team-building activities.

  • Suggestions for enhancing the content of the ARWP revealed a high level of satisfaction with the topics being covered.

Discussion

The majority of Canadian anesthesiology residency training programs do not include resident wellness in their formal academic curriculum. A small number of those that do include resident wellness in their curriculum have formal objectives, but none has an assessment tool. PDs agreed that educating residents about physician well-being is an important part of a postgraduate training program. Although few programs have formal wellness curricula, most do have informal wellness initiatives. In general, the PDs agreed that it is important to demonstrate that they are including each CanMEDS role in their curriculum. They would also include a module-based wellness curriculum if it were available to them.

A major strength of the environmental scan is that the results accurately portrayed the current state of wellness curricula in Canadian anesthesiology departments. PDs agreed that the results accurately represent them as a group. This was the first survey that assessed residents’ wellness curricula in Canadian anesthesiology residency training programs.

A limitation inherent to survey methodology, which indeed affected this study, includes the self-reporting nature of responses, which were not verified by such other sources as resident surveys or curricular documents. The research team developed the survey tool, pretested it with the teaching faculty, and pilot-tested it with non-anesthesiology PDs at the U of S to increase face validity of the questions. Two methods (survey, focus group) were used to elucidate responses from PDs. An additional limitation is that we did not formally survey residents, teaching faculty, or other stakeholders to determine if they thought that their anesthesiology program supported resident work/life balance.

Implementation of the ARWP at the U of S was greatly facilitated by support and encouragement from our Department Head, PD, RPC, and our Departmental Executive. Adequate financial and logistical support for the ARWP physician lead in the Department took time to establish. Once established, however, it greatly facilitated implementation and sustainability. Challenges to the development and implementation of the ARWP included eliciting engagement from residents and staff, who had to “fit it into” an already overburdened schedule, and engagement from the busy postgraduate medical education office. Although a physician lead was instrumental in getting the ARWP off the ground, having a formal Resident Wellness Committee and a Department Wellness Committee was critical. The collaborative work of these committees enabled a gradual shift toward a culture of self-care and peer support within our program. Establishing the Wellness Committees with appropriate representation and resources were challenges that had to be met.

Although evaluation of the ARWP has served our needs while developing the ARWP, it could have been more robust if each curriculum seminar and peer support session had undergone its own evaluation.

Future research should assess the ARWP’s impact on resident well-being and patient safety. We have begun to export the ARWP collaboratively to other anesthesiology residency training programs, including a one-year pilot ARWP at the University of Manitoba. We propose a nationally distributed ARWP of a blended format that utilizes online and face-to-face components. At the U of S, we have an ARWP with a modular curriculum that addresses specific, important topics about residents’ wellness. We believe that distributing an ARWP with clear objectives to all anesthesiology residency programs will be beneficial. The PDs responding to the environmental scan ranked the topics that we currently include in our modular curriculum, thereby ensuring that we have addressed topics that PDs believe are important and applicable across Canada.

This present report is relevant and timely for medical educators because the RCPSC has underscored the importance of physician health in CanMEDS 2015. It will be important for the RCPSC accreditation process for programs to demonstrate that they are including resident wellness in their academic curricula. Developing an ARWP is time consuming and labor intensive. We hope that this article will facilitate the process elsewhere.