Introduction: The National Academy of Medicine recently published “A Multifaceted Systems Approach to Addressing Stress Within Health Professions Education and Beyond,” which calls for greater attention to the wellness of health care providers, students, and educators. Suggested actions include “creating and training positive role models.” In order for faculty to role-model behaviors of wellness, they need to understand what this means and how to incorporate it into their lives. At present, there is only one other MedEdPORTAL resource on wellness and resilience that includes faculty as audience members. Methods: This 60-minute workshop is designed to provide faculty with a basic framework for wellness, with an emphasis on the emotional process aspect of resilience. Strategies for stress and anxiety management are reviewed. The workshop is interactive, with large- and small-group discussions, as well as a guided meditation. Results: This workshop was given at the 2017 Council of Faculties Business Meeting at the American Dental Education Association Annual Session, with 40 participants. Workshop evaluations, completed by 34 (85%) attendees, showed an overall rating of 4.0 on a 5-point Likert scale, with 5 = excellent. The workshop was repeated at the School of Dentistry at the University of California, San Francisco, with 11 attendees; there, the overall rating was 4.7. Discussion: In order to contribute to a culture of wellness and resilience in their organization, faculty need training on the concepts, as well as practical skills for implementation. This workshop provides introductory-level knowledge and skills.
- Define resilience.
- Discuss resilience in the context of personal, professional, and organizational well-being.
- Demonstrate techniques to employ resilience in the face of adversity.
- Identify one habit/behavior that they will stop and one habit/behavior they will start to improve their resilience.
In January 2017, the National Academy of Medicine (NAM) published a paper titled “A Multifaceted Systems Approach to Addressing Stress Within Health Professions Education and Beyond” that brought to light the increase in burnout, depression, suicide, and other stress-related sequelae experienced by health care providers and health professions educators.1 Physician well-being is one of the major initiatives of the ACGME, with symposia on this topic being held in 2015 and 2016.2 The AAMC dedicated its 2016 Leadership Forum to this topic,3 and the National Center for Interprofessional Practice and Education held a Nexus Summit on the topic in March 2017.4 With an increase in burnout, physicians have called for the Institute for Healthcare Improvement’s triple aim to be expanded to include “improving work life of health care providers.”5 The Commission on Dental Accreditation requires institutions to “have a stated commitment to a humanistic culture and learning environment,” which is defined as a culture that includes “respect, tolerance, understanding, and concern for others."6 Assessment of humanistic teaching practices has shown that they measure a domain distinct from traditional teaching effectiveness.6 Humanistic teaching practices include “listens carefully to connect with others,” “serves as outstanding role model for how to build strong relationships with learners as well as patients,” and “skillfully recognizes and supports emotions of patient, team, and self in difficult situations.”7 These qualities are more likely to be exhibited if instructors themselves have a sense of well-being and emotional intelligence.
An extensive study conducted by Gallup scientists explained that there are “five universal elements of wellbeing:” career, social, financial, physical, and community.8 “People with high Career Wellbeing are more than twice as likely to be thriving in their lives overall.”8 Conversely, the U.S. spends an estimated $125 to $190 billion on health care—5%-8% of national health care spending9—on conditions from work-related stress because of multiple new pressures, including a new expectation to be always on. Half of people working in medicine report that their job is bad for their stress level,10,11 which is attributed to factors including heavy workload, staffing issues, lack of time, faculty demands, uncertain/tight funding, debt, low salaries, and bureaucracy.1 Similar results have been cited in dentistry, with the additional stressor of occupational hazards from regular exposure to sharps and blood-borne pathogens.12 The American Medical Association (AMA) reported that implementation of the electronic health record has contributed significantly to physician dissatisfaction and that “70% to 80% of physician work output could be considered waste.”11
Resilience is a personal characteristic that allows a person to persist when there is an imbalance in any of the five elements of well-being, including in the workplace. Newly emerging leadership frameworks emphasize the importance of resilience. Resilient leadership offers a new way of seeing, thinking, and leading.13 It suggests that people’s behaviors and relationships at work are part of a complex system and that these reactions have profound impacts on other people in that system.13,14 This underscores the importance of leading with calmness, clarity, and conviction through self-awareness and self-management.
A search of wellness, wellbeing, and resilience on MedEdPORTAL produced resources for trainees such as “‘Time to Talk About It: Physician Depression and Suicide’ Video/Discussion Session for Interns, Residents, and Fellows,”15 “A Curriculum to Foster Resident Resilience,”16 and “Positive Learning Environment and Mistreatment Prevention Module.”17 Recently, a resource called “Building Team Resilience and Debriefing After Difficult Clinical Events: A Resilience Curriculum for Team Leaders”18 was published, aimed at physician learners who are team leaders, including senior residents, fellows, and faculty.
Our resource is novel in that it is aimed only at faculty members and is designed in a way that can be used across health professions. It serves as an introduction to the five elements of well-being and to the importance of resilience in achieving well-being. Specifically, this workshop provides strategies for in-the-moment self-management during workplace challenges, an important aspect of the resilient leadership framework. The presentation also provides short- and long-term strategies for overall well-being. This resource thus addresses a key initiative of the NAM, ACGME, AAMC, AMA, and American Dental Education Association (ADEA).
This workshop was first envisioned after the ADEA Joint Council Administrative Board meeting in January 2017. The Council of Faculties (COF) Administrative Board members (the authors) decided that awareness of this topic needed to reach a broader audience, including their constituents. The board members drafted an outline on the topic and its importance in an academic health care setting. They decided to create a workshop that would be given to members at the COF Business Meeting during the March 2017 ADEA Annual Session.
The authors created a 60-minute interactive workshop drawing on a broad body of literature. Not including the five presenters, 40 attendees were present, and all participated. Feedback was obtained, prompting minor changes. The updated workshop was given at the University of California, San Francisco (UCSF), School of Dentistry in April 2017 as a lunchtime faculty development offering. Eleven faculty members attended.
The target audience was faculty and administration. No prerequisite training was required.
For the first workshop with 40 attendees, participants were seated at round tables in groups of six. For the workshop with 11 attendees, a classroom-style setup was used, and participants clustered into groups of two to three for breakout sessions. The presenter used a computer with Microsoft PowerPoint. An overhead projector was connected to the computer.
Each participant was given: (1) one notecard with an envelope, (2) a copy of the Session Evaluation (Appendix B), and (3) a color copy of the Resilient Leadership Self Assessment19 (Appendix C).
- 40 minutes: interactive presentation.
- 3 minutes: guided meditation.
- 5 minutes: Resilient Leadership Self-Assessment.
- 5 minutes: goal setting.
- 2 minutes: session evaluation.
The material for this presentation largely echoed the NAM paper from January 20171 but also drew on the broader literature on well-being and resilience. When given at the 2017 ADEA COF Business Meeting, the workshop was presented by the five members of the administrative board, with each person presenting some of the slides. When given at UCSF, it was presented solely by the first author. The presentation was scripted by the primary author, and other presenters had not previously read all of the references. The suggested script for each slide was included in the speaker notes of the PowerPoint presentation (Appendix A).
As the audience members entered the room, each was instructed to pick up one notecard and envelope. The presentation began by creating a frame of reference for why wellness and resilience are becoming increasingly important topics to discuss in academic health care institutions. This was followed by a statement of the intended learning objectives. Next, audience members were asked to consider the definition of resilience, first to themselves, then with small groups. The small groups were then asked to report back to the larger group. The definition of resilience from various sources was presented, with its importance being linked to attaining well-being in the five universal elements described by the Gallup scientists.8
Resilient leadership, which suggests that the modern workplace is a complex system and that each person’s interactions have a ripple effect in that system, was then described. Leaders have an important role in their own self-management, as well as being role-models of positive behavior for those around them. The specific aspect of resilience that this presentation focused on was self-management of anxiety and stress.
The group watched a video of a professor who had an outburst in front of learners. The audience was given two questions to ponder in the small groups: “How resilient do you think this professor is?” and “What impact do you think her reaction is having on the rest of the room?” After small-group discussion, there was a report back to the large group.
These questions transitioned to a discussion on how people function in complex systems and how their behaviors impact those systems. The presenter talked about how self-management is important not only in health providers’ professional worlds with their colleagues but also with their patients, as well as in both their personal lives and relationships.
The presenter then talked about the importance of provider wellness in patient health outcomes and satisfaction. There was an explanation of the triple aim, which has evolved into the quadruple aim to overtly acknowledge the importance of provider wellness. Details from the NAM paper1 then outlined some of the specific stressors in health professions education and the effect these stressors have on providers and educators. Some natural reactionary behaviors were discussed. Audience members were asked to self-reflect on the past year to see if they had experienced any effects of burnout or reactionary behaviors. A brief reference to mirror neurons followed, showing the biological impact individuals have on people in their surroundings when they react positively or negatively. Audience members were then asked to reflect back to the video of the professor who had an outburst.
The presentation returned to the NAM paper,1 which offered recommendations to address the problem of provider wellness. An image from the paper was projected, prompting a discussion on the aspects of the system that people can impact and the aspects of the system that they cannot impact as acutely. The presenter discussed the specific actions outlined in the diagram, as well as the positive impacts that these actions could have.
Finally, practical strategies for anxiety control and well-being were discussed in three main areas: in the moment, short-term, and long-term. The presenter led the group through a short guided meditation.20 Immediately after this, the presenter passed out copies of the Resilient Leadership Self Assessment (Appendix C), which the audience was asked to complete. Audience members were then asked to look at their score for the category called “Non-Anxious Presence” to determine how well they were doing with anxiety management. Each participant was asked to set personal goals to improve in this area. They were to select one reactionary behavior or bad habit they would like to stop, as well as one positive habit or behavior they would commit to start doing. The participants were asked to write these commitments on their notecard, place the notecard in the envelope, seal the envelope, and self-address it. The presenter promised not to view the contents of the envelopes but to store them for 1-2 months, then mail them to the attendees. This allowed the attendees to be accountable to themselves based on the goals they had set for themselves.
A summary slide captured the essence of why it is important for anyone in a role of leadership to be resilient. Session Evaluations (Appendix B) were then distributed to audience members. Participants were given 2 minutes to complete the evaluations. They were then instructed to leave their envelopes and Session Evaluations at the table, to be collected by the presenter. The presenter then had the responsibility of storing the envelopes, stamping them, and sending them out to the participants in 1-2 months.
The event at UCSF was advertised via the existing process for faculty development sessions. This gave the presenter and topic credibility and allowed the event to be widely advertised.
This workshop was attended by 40 faculty from across the U.S. at the 2017 ADEA Annual Session COF Business Meeting. Thirty-four attendees (85%) completed the session evaluation. The workshop was subsequently given to 11 faculty members at the UCSF School of Dentistry, including two full-time faculty, eight part-time faculty, and one volunteer part-time faculty.
When asked to rate the overall workshop on a 5-point Likert scale (1 = poor, 5 = excellent), the ADEA attendees gave the presentation a 4.0, and the UCSF attendees gave it a 4.7. Using the same scale, attendees were asked to rate how well each objective was met. For “define resilience,” the ADEA audience gave a 4.5, and the UCSF audience gave a 4.9. For “discuss resilience in the context of personal, professional, and organizational wellbeing,” the ADEA audience gave a 4.1, and the UCSF audience gave a 4.7. For “demonstrate techniques to employ resilience in the face of adversity,” the ADEA audience gave a rating of 3.9, and the UCSF audience gave a 4.5. For the final objective, “identify one habit/behavior s/he will stop and one habit/behavior s/he will start to improve his/her resilience,” the ADEA audience gave a 4.1, and the UCSF audience gave a 4.8.
Attendees at both sessions were asked to rate the question “How well do you understand resilience in the context of well-being now compared to before the workshop?” on a 5-point Likert scale (1 = understand it much less, 5 = understand it much better). At the first workshop, this question received an average rating of 3.7, and at the second workshop, it received a 4.5. Respondents at the first session were also asked whether they would consider giving this session at their home institutions if it was available on MedEdPORTAL, and 22 out of 34 (65%) answered yes. In the first workshop, the most common suggestion was to increase the length of time, followed by more discussion and less use of the audience response system.
For the second presentation at UCSF, the workshop length could not be extended, simply due to lack of time availability. However, the segments using an audience response system were all replaced with small-group discussion. The UCSF attendees also suggested that the workshop length be extended.
This resource addresses a current topic that is prioritized by multiple organizations across health professions education. There are currently no other resources available on MedEdPORTAL to train faculty in this topic; therefore, this resource fills a gap.
Deployment and Lessons Learned
In the first iteration of this workshop with the ADEA audience, the small-group exercises were individual exercises using an audience response system called PollEv. This was intended to allow educators to utilize contemporary methods for active learning; however, some technical glitches arose. Additionally, feedback from this session suggested that small-group discussions would be more effective. In the second iteration at UCSF, the small-group discussion followed by large-group report-back was well received.
Also, in the first workshop, 4×6 index cards were used instead of notecards with envelopes. There was concern from attendees that personal goals would be seen by the individual responsible for collecting and sending the cards back to the attendees in 1-2 months. In the second workshop, notecards with envelopes were used, and attendees were asked to seal the envelopes before turning them in.
While given only to dental educators, the presentation was intentionally created so that it could be generalizable to all health professions educators. As outlined above, many of the stressors for medicine and dentistry have been shown to be similar.
This workshop is a small step in the direction of raising awareness of provider burnout and suicide and of the specific actions faculty can take in their own lives for well-being and resilience. These actions, in turn, can be role-modeled to their trainees. Session evaluations suggested that a longer workshop would allow people to discuss more workplace challenges and solutions together; however, there is also the realistic challenge of finding time for faculty to come together for such training. UCSF attendees engaged in email discussions for a few weeks after the presentation and started sharing articles and book suggestions about wellness with each other.
This training is an introduction to the topic and its importance in the context of stressors in health professions education. There is a need for additional resources that build on this introduction. The NAM paper suggesting a multifaceted approach illustrates the need for abundant and robust resources to be created.1 Because this issue affects all health disciplines, any subsequent material that builds on this work can also be created to be generalizable to all health professions educators.
None to report.
None to report.
All identifiable persons in this resource have granted their permission.
Presented at: Council of Faculties Business Meeting, American Dental Education Association Annual Session; March 18-21, 2017; Long Beach, CA.
Presented at: University of California, San Francisco, School of Dentistry Faculty Development Series; April 2017; San Francisco, CA.
Reported as not applicable.
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- Blanding M. National health costs could decrease if managers reduce work stress. Harvard Business School Working Knowledge website. http://hbswk.hbs.edu/item/national-health-costs-could-decrease-if-managers-reduce-work-stress. Published January 26, 2015. Accessed March 5, 2017.
- The workplace and health. Robert Wood Johnson Foundation website. http://www.rwjf.org/en/library/research/2016/07/the-workplace-and-health.html. Published July 2016.
- Beresford L. AMA official highlights: EHR’s contribution to physician burnout. Medscape website. http://www.medscape.com/viewarticle/856009. Published December 1, 2015. Accessed March 5, 2017.
- Basson RA. Management and prevention of burnout in the dental practitioner [letter to the editor]. Dentistry. 2013;3(2):168. https://doi.org/10.4172/2161-1122.1000168
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Received: May 5, 2017
Accepted: August 7, 2017