Dedicated Wellness Time for Residents

What?

The goals of this intervention are to:

• Develop a mechanism for protecting time for resident wellness for their personal lives/health maintenance.
• Write a policy for resident wellness time.
• Assemble a local health maintenance resource guide for residents.

Why?

In surgical training, many residents’ personal lives and health can fall by the wayside. The ACGME Common Program Requirements mandate that programs allow residents to attend medical, mental health, and dental care appointments without restriction. [1] Although 26% to 43% of American residents reported having health-related problems that required medical attention in the past year and 66% reported self-reported depression, most residents neglect seeking medical care. [2,3] Surgery residents in particular tend to be less likely than other specialties to lack consistent, routine healthcare. [3] 83% of practicing physicians report working while sick, even though 95% acknowledge that they are putting patients at risk.[4] Beyond providing residents with adequate time for health maintenance appointments, many residency programs are not giving residents the opportunity to take time off for activities that may be personally meaningful to them (e.g., taking a child to school, spending time with a loved one). Barriers to health maintenance, household/life maintenance, and other self-care include inadequate time and limited flexibility in work schedules. [4,5] To promote health and well-being in residents, programs have instituted protected wellness time, in which residents are given protected time off to schedule appointments for personal time, health maintenance, household/life maintenance, and/or other self-care.

Organizational Culture and Values	Dedicating time for wellness communicates that the department prioritizes resident wellness and work-life integration.
Work-Life Integration	Protected time removes a major barrier for residents to take care of their health/personal lives.

How?

Step 1. Determine and schedule the resident wellness time

1. Determine the number of wellness days per resident that you will protect/guarantee. Remember that multiple appointments are needed for routine health maintenance; for most adults in their 30s, primary care visits are recommended annually, dental care twice/year, ob/gyn visits annually, and eye exams every two years (with optical prescriptions generally expiring after one year). [6,7] Obviously, more may be needed for those with chronic issues.

1. Emory General Surgery protects one half-day per rotation (i.e., once per month) for each resident. These half-days are designated for personal time (e.g., taking a child to school, sleeping in, spending time with a loved one), and are in addition to (and in exclusion of) residents’ protected time for doctors’ appointments.
2. The University of California, San Francisco (UCSF) General Surgery program protects two half-days per year for each resident for wellness/health maintenance.
3. Northwestern General Surgery protects one half day for each resident about quarterly for wellness/health maintenance.
4. The Icahn School of Medicine at Mount Sinai has a GME-wide policy that protects one full wellness day per quarter for each resident, totaling 4 wellness days per academic year Programs are given the option to allow residents to use wellness days in 2 half-day increments (totaling 8 half-days per year) to allow residents to perform their normal duties before/after their health-maintenance appointments.
5. Northwell offers a half-day quarterly for wellness time, residents must request in advance and the days do not carry over if not used.  
6. New York Medical College allows for 12 sick days per calendar year that carry over if not used, with the only restriction being that the resident should notify as early as possible so arrangements can be made to accommodate. 
7. Residents at the University of Utah get the morning of every 3rd Wednesday off where they round, sign out, and then are off until noon. They can sign out with either an APC if there is one covering the service or faculty (this has been met with a huge boost in morale!).

2. Determine the amount of time to protect per day. A broader window of time is more realistic for allowing your residents to schedule appointments within the designated protected time (i.e., it’s more likely that they’ll be able to find a provider to see them within a half or whole day off, compared to a single hour). Keep in mind that multiple appointments may be needed for routine health and life maintenance.

1. At Emory, the half-days are 4-5 hours long. The scheduled wellness time is between 7am-11am (with the expectation that residents are in and ready to work by 12pm).
2. At UCSF, wellness half-days are 6 hours long.
3. At Northwestern, protected wellness time alternates with didactics/simulation during protected educational time; therefore, scheduled wellness time is always 5 hours long (7am-12pm on selected Thursday morning).
4. At Mt. Sinai, the half-days are 4 hours long.

3. Work with those who create the resident schedule for the program (e.g., PD, APD, administrative chiefs, chief residents on each service) to coordinate scheduling/coverage for those days. Oftentimes, it can be useful to schedule wellness days during times where residents have protected educational time.

1. At Emory, each resident works with his or her chief of service to schedule their half day off for each rotation. This tends to be a good educational opportunity for the chief residents to learn lessons about scheduling (e.g., taking notice of the calendar and being thoughtful about which days may work better or worse for scheduling a half day off – e.g., not when the faculty typically has a busy day in clinic). The rules for scheduling the half-days are as follows:
   1. The half days off are required to be in the mornings, between 7am-11am, with residents being asked not to come in. The residents have to be in and ready to work by noon.
   2. The half-days cannot be scheduled or switched to the afternoons. If the protected time is in the morning and residents are asked not to come in, they will be more likely to actually take the time off. If the half days are in the afternoon and residents are asked to leave work after they already started working, they will be much less likely to leave.
   3. The half day off is scheduled the month before the service starts (before the last week of the month at the latest, ideally earlier).
   4. There are 2 exceptions for these half days off:
      1. No half-days off on services where residents already have extra days off
      2. No rule for nights
2. At UCSF, wellness half-days occur on the months in which there is a fifth week in the month. For example, there are 4 months in the year where there is a 5th Wednesday, so Wellness Wednesdays are allocated such that 50% of the residency is given one “Wellness Wednesday” off at each time and the other 50% is responsible for coverage. In total, each resident gets 2 Wellness Wednesdays per year.
3. At Northwestern, protected educational time occurs on Thursday mornings. The curricular schedule is made and released to residents and faculty several months in advance. Residents may use days in which there are no scheduled didactics or simulation for protected wellness time. As with all protected educational time, all teams are covered by APNs/fellows/attendings, except the trauma team, which remains responsible for responding to level 1 traumas.
4. At Mt. Sinai, each resident is responsible for scheduling their wellness half-day (or full day). Residents should provide their Program Director with at least 7 days advance notice prior to requesting their wellness time off, to ensure adequate coverage. Residents are also encouraged to ensure that their supervising attending on the service is made aware as well. Program coordinators are responsible for tracking wellness days internally, as they are responsible for sick, vacation, and other leave.

Step 2. Consider writing a policy for resident wellness days

1. Include the following details:

1. Number of days per resident.
2. Amount of time per day.
3. Coverage plan.
4. If you are going to require advance notification and approval, delineate this process here. We caution programs that this requirement may discourage use, as residents may not feel comfortable disclosing that they are seeking care (and particularly what they are seeking it for).

2. You can use this fillable policy template as a guide. See the example provided by the Icahn School of Medicine at Mount Sinai.

3. Decide how you want to circulate the policy. If you decide to circulate among faculty, visible leadership support is critical.

1. At Northwestern, the curricular schedule is published months in advance. A weekly email is sent to all residents and faculty that delineates the conferences for that Thursday, including protected wellness time.
2. The PD at Emory was intentional about the decision not to write a formal policy or to widely advertise the intervention among faculty. Originally, the PD only told the residents, the chair, and 2 APDs, but did not tell the faculty about the policy. The rationale for this was that the residents were already being pulled off services for various reasons (e.g., to fulfill the 1 in 7 days off ACGME requirement, to attend fellowship interviews) and therefore, it was likely that no faculty would notice if any particular resident took an additional half-day off per month. The PD reasoned that the intervention would be more likely to be successful if the half-days were introduced subtly and organically, so that the faculty could see firsthand that they wouldn’t notice the change and it wouldn’t disrupt patient care or training. It took 1.5 to 2 months before the half-days became public at Emory, and the PD attributes the success of the intervention to the subtle and casual rollout of the intervention. When faculty asked why the PD didn’t inform them, one of the explanations that the PD gave was, “What is there to inform you about?This is no big deal, the residents are coming in late one morning during their rotation.You won’t even know unless they tell you—you would just assume they’re on vacation or at an interview, right?”

Step 3. Consider assembling a local resource guide for residents

1.Some residency programs (e.g., UCSF, Stanford) provide their residents with resource guides in order to remove the barrier of identifying providers. University of Rochester General Surgery holds an annual wellness fair their residents to which these local businesses come to interact with the residents and/or schedule them for future appointments [see Wellness Fair intervention].

2.Consider including the following local businesses:

1. Physicians
2. Dentists
3. Psychologists/psychiatrists/counselors
4. Gyms and fitness centers
5. Food delivery services
6. Laundry services
7. Cleaning services

3. For a-c providers, it is helpful to delineate (1) those who accept the residents’ insurance and (2) those who have extended or flexible hours.

4.For d-g, you may be able to organize a group discount.

5. This local resource guide may be a living document that is created by the program coordinator(s) and/or GME and updated by the residents in the program (e.g., a Google spreadsheet/document).

Step 4. Set these wellness days as an expectation in the residency program

1.If you rely on senior residents to schedule their junior residents’ wellness time, make sure you have a mechanism for ensuring that they are doing it (1) without discouraging juniors from taking it, and (2) with enough notice that juniors may meaningfully use it.

1. At Emory, the PD ensures that each resident is taking their half-day off per rotation by checking in with the chief residents regularly (at their weekly chief breakfast) to make sure that the residents on each service are getting their half days off. The PD also checks in with the junior residents regularly to ensure that they are taking their half-days off.

2. If your wellness time is scheduled into the year, it is recommended that leadership check in with residents to ensure they are attending regular health maintenance appointments, e.g., at their bi-annual meetings. This communicates that it is an expectation of their program that residents take their regular health maintenance seriously. Be careful not to pry; you need only to know that your residents are taking the opportunities you have created to attend to their health, not specifically what that entails for each resident.

Step 5. Addressing barriers.

1.Administrative burden on those who create/amend the resident schedules. Solutions for reducing the burden for scheduling include:

1. Offer half-days instead of full days off for wellness.
2. Select days that are typically allocated for education/didactics.
3. Rather than allocating those days to the full program, assign half of the program certain wellness days and the other half the remaining (e.g., seniors have wellness days during junior simulation time and vice versa).

2.Pushback from faculty. We have drafted the following responses to common gripes:

1. “Why do residents need this? We never had wellness time when I was a resident.”
   1. Response 1: The PD from Emory would use the following response: “What do you mean why do we do this?Did you think residency when you did it was humane and appropriate?You get to schedule time off whenever you need it, and frequently just when you want it.They’re not excused from doing their job, they just have the opportunity to get some other things done - I can guarantee you they will do their job better if we keep this policy in place.
   2. Response 2: “The ACGME now mandates that programs give residents time for health maintenance appointments.”
2. “Why can’t they go to their appointments on their post-call days?”
   1. Response: “The ACGME specifically states that resident health appointments cannot be restricted based upon their work schedules.”
3. "What if they aren’t even going to the doctor or dentist?”
   1. Response: “While we strongly encourage residents to attend health maintenance, we recognize that they are adults with many responsibilities. Given our [night float system or other structural barriers], they are virtually never free during normal business hours. We would argue that it is acceptable for residents to choose to attend to other non-health needs during this protected time. Accompanying a parent or a child to a particular doctor’s appointment may be more important than a single dental cleaning. Even fixing brakes and changing the oil are safety issues.”

3. Pushback from residents.

1. “We can’t do it. It’s impossible to incorporate these wellness half-days into the schedule.”
   1. Response: The PD from Emory would use the following response: “It is possible, it just requires a bit of thought and intentionality. Consider using this as an educational opportunity for you to learn important lessons about scheduling.”

Helpful Resources

Webinars

Webinar recording available here

Coaches/Successful Implementations

Emory University

Coach: Keith Delman, MD Program Director

University of California, San Francisco

Coach: Linda Reilly, MD Program Director

Icahn School of Medicine at Mount Sinai

Coach: David Lee, MD Faculty Wellness Champion in Department of Surgery

Collaboration Networking/Implementations in Process

Northwestern University

Coach: Yue-Yung Hu, MD, APD Wellness

References

1. Common Program Requirements. ACGME. Available from: https://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements

2. Baiu I, Titan A, Kin C, Spain DA. Caring for Caregivers–Resident Physician Health and Wellbeing. Journal of surgical education. 2019 Sep 4

3. Rangel EL, Castillo-Angeles M, Kisat M, Kamine TH, Askari R. Lack of Routine Health Care Among Resident Physicians in New England. Journal of the American College of Surgeons. 2019 Nov 23.

4. Dunn LB, Green Hammond KA, Roberts LW. Delaying care, avoiding stigma: residents’ attitudes toward obtaining personal health care. Acad Med. 2009;84:242–250.

5. Szymczak JE, Smathers S, Hoegg C, et al. Reasons why physicians and advanced practice clinicians work while sick: a mixed-methods analysis. JAMA Pediatr. 2015;169:815–821.

6. Health screenings for women ages 18 to 39: MedlinePlus Medical Encyclopedia. MedlinePlus. U.S. National Library of Medicine. Available from: https://medlineplus.gov/ency/article/007462.htm

7. Health screenings for men ages 18 to 39: MedlinePlus Medical Encyclopedia. MedlinePlus. U.S. National Library of Medicine. Available from: https://medlineplus.gov/ency/article/007464.htm