The Resident Wellbeing Program: A Prescription for Embedding Nurture and Empowerment into Graduate Medical Education

Abstract

As student affairs professionals in a medical school setting, we are keenly aware of how easy it is to overlook the health, mental health, and wellness needs of learners in professional schools who are no longer among the undergraduate constituencies that are so often our primary focus. But

Our cohorts, from first-year medical students to interns through advanced residents all bring their own compelling needs to today's medical education.

our cohorts, from first-year medical students to interns through advanced residents all bring their own compelling needs to today's medical education. For instance, they arrive with some of the same dispositional barriers that adult-learning expert Jeanette Passmore (2015) says are familiar to other less traditionally aged learners, including problems with self-efficacy, ability to deal with competing role demands, varying levels of social or family support, and prior academic experiences; they sometimes confront familiar non-traditionally aged learner situational barriers in the form of financial, family or other competing civic responsibilities. Further, they must negotiate institutional barriers like the level of welcome they find in the graduate medical education world or level of navigability they encounter when entering this new academic universe. Additionally, as Shaun Prentice (2020) and colleagues reported in a recent meta-analysis, the high-pressure graduate medical education environment can exacerbate these challenges, leading to significant stress and burnout if not adequately addressed. According to the Journal of Graduate Medicine Education, the complex interplay of these barriers underscores the need for a holistic approach to student support, one that is responsive to the evolving landscape of graduate medical education and the diverse needs of its learners (Vasquez et al., 2021).

Embedding Nurture and Empowerment into Graduate Medical Education

At the core of Eastern Virginia Medical School at Old Dominion University (EVMS at ODU) is a deep commitment to nurturing its medical residents’ professional skills and overall well-being. The Graduate Medical Education (GME) program at EVMS is central to this commitment and is renowned for its rigorous academic and clinical training. This program thoughtfully acknowledges the diverse challenges that residents face today at a critical developmental crossroads. Residents occupy a unique space in the medical landscape because they have earned their Medical Doctorate (MD) and simultaneously occupy the role of both trainees and employees. As such, they must balance the demands of delivering high-quality patient care, navigating the complexities of an evolving healthcare system, and pursuing personal and professional growth.

This program thoughtfully acknowledges the diverse challenges that residents face today at a critical developmental crossroads.

Under the leadership of one of us, Cory Gerwe, who is a Licensed Professional Counselor (LPC), I’ve designed our GME Wellness program to holistically address the multifaceted challenges our medical residents face. My unique perspective, informed by years of working with marginalized populations and fostering interprofessional collaboration, guides my approach and provides a particular set of communication skills not taught in medical education. My vision for the program is to create a supportive ecosystem that enhances clinical proficiency and bolsters our residents’ emotional and mental resilience. This holistic approach is vital in preparing a new generation of physicians who are well-equipped to manage their profession's stresses and demands. Through targeted initiatives that promote well-being, leadership, and communication, I aim to empower residents to excel both in their careers and personal lives. This leadership endeavor has echoed throughout our campus and provides a platform for a supportive and nurturing environment.

The program reflects a broader commitment to cultivating a healthcare workforce that values empathy, collaboration, and personal wellbeing.

For his part, our other author, Daniel St John, the Director of Academic Development in Student Affairs, highlighted the impact of the GME wellness program during a quarterly meeting with other medical education leaders at EVMS. As a former Ph.D.-level intern coach and long-time supporter of the program, Dan emphasized its significance and far-reaching benefits beyond the residency program. He stated that the program reflects a broader commitment to cultivating a healthcare workforce that values empathy, collaboration, and personal wellbeing. By prioritizing these values, EVMS is advancing GME and setting a new standard for training medical professionals, ultimately aiming to improve patient care and healthcare outcomes.

Resident Challenges

The medical residency, a journey fraught with high demands and intense pressure, serves as a crucible for developing healthcare professionals. Echoing the sentiments of Cory Gerwe and colleagues (2017) in their 2017 journal article, “Promoting the Wellness of Physician-Residents: Counselor-Delivered Coaching,” it is imperative to delve deeper than the commonly addressed issue of burnout, exploring the severe psychological and physical tolls, including depression, anxiety, substance misuse, and the troubling presence of suicidal ideation within this population. The construct of burnout, which typically presents as emotional exhaustion, physical fatigue, and a diminished sense of personal accomplishment, only scratches the surface of the challenges faced by physician residents. Research paints a stark portrait of their daily reality, highlighting a significant encounter with mental health issues (Seo et al., 2021). Reports found in journals ranging from BMC Medical Education to JAMA to Perspectives in Medical Education concur that depression and anxiety emerge not as anomalies but as common elements in the collective experience of these medical practitioners (Hategan & Riddell, 2020; Nituica et al., 2021; Zhou et al., 2020). Although the American Council for Graduate Medical Education (ACGME) mandates a maximum of 80 work hours per week for residents, the relentless stress from arduous work hours and significant responsibilities fosters an environment ripe for burnout. This often manifests in physical and emotional strain and a disconcerting depersonalization towards patients – a defensive yet detrimental response indicating a profound decline in the resident's well-being and ability to provide quality care.

A longitudinal perspective found across specialty journals – including Academic Radiology, The American Journal of Emergency Medicine, Academic Medicine, and Journal of Pediatric Urology – reveals the progressive unraveling of residents’ mental health from their medical school transition to the rigorous demands of residency (Prentice et al., 2020). Their transition from medical school to residency is not merely a professional leap but a plunge into an ocean of anxiety about the future, workload, and the herculean task of assimilating vast amounts of medical knowledge. Such fears portend the impending exhaustion that marks their postgraduate journey, maintaining its presence throughout their residency period as outlined by recent studies (Batheja & Lalwani, 2024; Iserson, 2024; Prentice et al., 2020; Reeson et al., 2024; Seo et al., 2021).

Mitigating resident burnout necessitates a multi-pronged strategy, embracing personal, educational, and institutional interventions.

These observations not only serve as sobering data but also as a call to action for systemic reform. They underscore the necessity for comprehensive, well-structured wellness programs specifically designed for the medical community. Such initiatives must provide robust support and actively strive to amend the training elements that perpetuate stress and burnout cycles within medical education. Thus, mitigating resident burnout necessitates a multi-pronged strategy, embracing personal, educational, and institutional interventions. This involves nurturing resilience, building supportive communities, and championing policy changes that prioritize the mental health of those dedicated to healing others. The challenges are formidable, but the stakes — the well-being of our future physicians and the caliber of care they render — are too critical to overlook. Amid these myriad stressors and the high-stakes milieu they navigate, the necessity for structured support systems is unequivocal. Within this framework, the GME Wellbeing Program stands out as pivotal in addressing these comprehensive challenges through a robust array of wellness initiatives.

GME Wellbeing Program

Recognizing these challenges, EVMS's GME Wellbeing Program aims to provide a supportive environment that nurtures the overall health of its residents. This program is built on a foundation of proactive mental health support, wellness initiatives, and leadership development. Central to the program's philosophy is that well-being occurs holistically and includes a combination of factors, including awareness, perception of autonomy, support, and systemic changes when applicable. This approach acknowledges the complex interplay of factors affecting resident doctors, aiming to provide a scaffold that nurtures their ability to thrive under the pressures of the medical profession. Our scaffold is built on the following:

In developing its comprehensive wellbeing curriculum, GME has significantly emphasized its intrepid coaching program.

Coaching. In developing its comprehensive wellbeing curriculum, GME has significantly emphasized its intrepid coaching program. Meticulously crafted to foster personal and professional growth among residents, this initiative enhances their ability to manage the rigors of medical training and the challenges inherent to patient care. The coaching program, led by seasoned LPCs, offers one-on-one and group sessions that focus on a wide range of skills, from stress management and resilience building to effective communication and leadership. The focus of coaching is to help residents reach their full potential and can often include subjects such as wellness skills, leadership, confidence, anxiety reduction, and communication. Such personalized attention ensures that residents receive support tailored to their individual needs and can develop sustainable strategies throughout their careers. This proactive approach in the coaching program reflects EVMS's commitment to not merely educate but also to empower its residents, ensuring they are well-prepared to thrive in their personal lives and professional environments.

Innovative Communication and Leadership Initiatives. At the forefront of these initiatives is the introduction of structured leadership training sessions, including Breaking Bad News training and Chief Resident Leadership training. These educational programs are hallmarked by the use of simulated patients (SP), who are trained to create realistic scenarios where residents can practice their communication and leadership skills. For instance, in Breaking Bad News, the SP would portray a scenario where the resident needed to break bad news to the patient's family, thereby requiring the use of direct yet compassionate communication skills. These sessions are designed to empower residents by enhancing their decision-making abilities, promoting ethical practices, and improving their capability to lead teams effectively in high-pressure situations. This is consistent with Richard Deci and Edward Ryan's (2012) self-determination theory, which posits that individuals increase their well-being when they experience a sense of autonomy over their situation. These educational experiences are complemented by workshops on effective communication, aiming to refine the residents’ abilities to navigate complex conversations with patients, families, and healthcare teams, thus improving the quality of patient care and interprofessional relationships.

Support U Training Program (SUTP). Cory has also spearheaded the SUTP, a targeted program that focuses on addressing and mitigating vicarious trauma, which is a common yet often overlooked consequence of continual exposure to high-stress medical environments. Specifically, it features sessions on empathic expression, active listening, and reflecting compassion, all of which help residents provide peer support for vicarious trauma. This program includes Socratic questions, group discussions, interactive videos, evidence-based research, and role-play.

Residents confirmed that they frequently applied the communication skills learned, using them 3-4 times per week to support their peers.

Similar to the leadership initiatives, the SUTP has shown considerable success in enhancing the knowledge and skills of physician residents regarding vicarious trauma, peer support, and communication, as demonstrated by the results of the evaluation surveys conducted following the training sessions. Cory also conducted a focus group to gather qualitative data on the program's effectiveness and long-term impact. Residents confirmed that they frequently applied the communication skills learned, using them 3–4 times per week to support their peers. They provided compelling testimony on how the SUTP skills have been crucial in their roles. The training facilitated meaningful conversations with co-residents, both during challenging patient encounters and in managing daily stresses like fatigue and scheduling difficulties.

Holistic Approach and Systemic Improvement. The Wellbeing Index and RAFA (Resident and Fellowship Association) initiatives further exemplify the Wellbeing Program's systemic approach. The Wellbeing Index is a nationwide self-assessment tool developed by the Mayo Clinic that allows residents to consistently monitor and evaluate their mental health and wellbeing. By identifying stressors and potential mental health issues early, the program enables timely interventions to prevent burnout and promote long-term wellness.

The RAFA initiative provides a platform for residents and GME to advocate effectively for the needs of residents and fellows. RAFA organizes regular meetings that facilitate a meaningful exchange among residents, fostering a supportive network where concerns are addressed and collaborative solutions are developed. Additionally, RAFA hosts biannual social events at local restaurants, which are key to enhancing wellness among residents. These gatherings provide a relaxed environment away from the clinical setting, allowing residents to unwind and foster personal connections with peers from various programs. Outside of their orientation meetings and clinical work, this is the only other planned occasion that residents have to engage with colleagues outside of their program. These social interactions are essential, as they boost morale and reinforce a supportive network crucial for mitigating the stresses of medical training.

Case Studies

To illustrate the tangible impact of the Wellbeing Program, we can think of several case studies that easily highlight how the office's work has impacted residents effectively. One example involves a resident who, after consistently scoring low on the Wellbeing Index, engaged in the program's coaching sessions. Another case study showcases the effectiveness of the SUTP initiatives, where a resident experiencing signs of burnout received peer support, resulting in significant improvements in their mental health and work-life balance. These cases, among others, exemplify how the Wellbeing Program at EVMS has been instrumental in transforming the residency experience, demonstrating that residents can survive and thrive in their demanding roles with the proper support.

A co-resident who has been through the SUTP training recognized the signs of Vicarious Trauma and empathically engaged in dialogue with Brian.

“Emily,” a third-year OBGYN resident at a busy urban hospital with many underserved patients, recognized the beginning stages of burnout after consistently scoring low on the well-being index. Her burnout resulted from a series of stressful 80-h workweeks, leading to physical exhaustion and social isolation. Her schedule was analyzed and slightly reorganized through wellness coaching, allowing for two 30-min weekly exercise sessions, introducing 5-min daily deep breathing and mindfulness exercises, and enhancing socialization with peers during work breaks and weekly events. These small yet strategic adjustments led to significant improvements in Emily's physical health, mental wellbeing, and social connections. Emily's situation illustrates the effectiveness of targeted, holistic wellness initiatives in managing the intense demands of residency.

“Brian,” a second-year internal medicine resident at EVMS, found himself grappling with emotional exhaustion from handling critical care situations and end-of-life scenarios. Brian was especially bothered when he had to break bad news about a patient who had passed. This patient reminded Brian of his grandfather who recently passed away when he experienced a stroke while in inpatient treatment at the hospital. A co-resident who has been through the SUTP training recognized the signs of Vicarious Trauma and empathically engaged in dialogue with Brian, emphasizing active listening and expressing compassion. One session turned into five sessions, which positively impacted Brian's ability to effectively process his loss while still engaging in his job without absorbing the emotional distress. Brian reported that this engagement “likely prevented me from experiencing emotional burnout.” Brian's experience highlights the effectiveness of SUTP in fostering emotional resilience among residents.

Reflections

Programs like ours, which operate in the context of the structural and systemic challenges that medical residents face, must, of course, continue to evolve, be further strengthened, and seek improvements when needed. For instance, structural strategies we think could complement and augment our work might include increasing institutional support for organized mentorship programs, expanding access to mental health services tailored to residents’ unique stressors, and integrating resilience training into residency curricula from the outset. Additionally, leveraging data from the Wellbeing Index to inform policy decisions could help shape institutional priorities that proactively address resident wellness.

At the same time, the impact of our current program is clear. Medical residents who have engaged in our embedded nurture and empowerment programming report increased satisfaction with their work-life balance, improved mental health, and a stronger sense of community and belonging within the residency program. These outcomes enhance the individual resident's experience and quality of life and significantly contribute to the overall effectiveness and empathy within patient care practices. As an outside program evaluator, Daniel St John stated, “The wellness program is pivotal in cultivating a new era of healthcare professionals who are as committed to maintaining their health as they are to healing others.”

By providing a holistic and inclusive approach to resident wellbeing, EVMS's GME Wellbeing Program stands as a testament to the potential of well-rounded medical education programs. It not only addresses immediate concerns regarding mental health but also prepares a new generation of physicians who are well-equipped to lead, inspire, and care within the dynamic landscapes of modern healthcare systems.

Footnotes

ORCID iD

Cory Gerwe

CORY GERWE, PhD, LPC, is Director of Leadership, Coaching, and Wellness at Eastern Virginia Medical School and Assistant Professor of Psychiatry. His work centers on wellbeing, inclusive education, and leadership development in graduate medical education. He is President-Elect of the Virginia Counseling Association and was named one of Old Dominion University's “40 Under 40” in 2024. His scholarship explores LGBTQ+ inclusion, trauma-informed care, clinician wellness, and the integration of counseling practices in medical education.

DANIEL ST JOHN, PhD, is Director of Academic Development and Associate Professor of Psychiatry and Behavioral Sciences at Eastern Virginia Medical School. His work focuses on advancing student success, academic resilience, and wellbeing in medical education. His scholarship and leadership center on academic coaching, inclusive learning environments, and educational innovation to support future healthcare leaders.

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