Pebbles in Their Shoes: Addressing Hassles & Inefficiencies

WHAT?                                                                                                                                                               

 The goals of this intervention are to:󠄀

•  Describe strategies for identifying and removing hassles and inefficiencies in residency 
  

WHY?                                                                                                                                                               

Residents often feel overextended and underappreciated. Hassles and inefficiencies in the work environment prevent residents from doing the work they find meaningful, and may cause residents to feel deprioritized by the program or institution; addressing these problems can greatly improve the resident work experience. [1] This protocol describes some low effort, inexpensive ways to remove some of these “pebbles in their shoes” and therefore build morale and engagement in the program.

Efficiency & Resources	Many opportunities exist for improving efficiency and/or resources, allowing residents to spend more time on their primary goals: patient care and education. Such solutions help residents function at their highest level.
Meaning in Work	Removing the hassles and inefficiencies in the workplace enables residents to spend a larger proportion of their time on the work they find meaningful.
Organizational Culture and Values	Taking the time to identify and address inefficiencies communicates to residents that the program values their time and effort.
Control & Flexibility	By listening to and addressing resident feedback on system inefficiencies, you grant them the voice and agency to improve their own learning and work environments.
Work-Life Balance	Removing some of the hassles in residents’ home lives enables them to spend a larger proportion of their free time on things that they find meaningful or educational (e.g., being present with family, reading).

How?                                                                                                                                                               

Step 1: Identify the hassles and inefficiencies that impede residents’ experience.

1. Leadership should initiate this conversation/effort to convey their belief in its importance.
2. The effort can be coordinated by leadership (including coordinators) or by a resident work group.
3. Methods to consider:
   1. A focus group (see Appendix B in the Getting Started Guide for a Focus Group Guide). This is ideally accomplished with smaller groups comprised of residents at similar PGY levels.
   2. A Town Hall. Some may be too intimidated in this large group setting to speak up.
   3. Electronic survey. This is less ideal as engagement tends to be lower, and the data will be less granular. We would recommend including multiple choice as well as free-text questions, recognizing that people often do not want to take the time to write out free-text responses. Your multiple choice questions should be driven by what you and/or a focus group of your residents suspect to be true; a survey may be more useful for confirming the findings of focus group than for gathering de novo data.
   4. See our Keeping Your Ear to the Ground as a Program Director intervention for additional ideas including site visits, regular resident-leadership meetings, and informal conversations.
4. The conversation should be led by someone the residents believes to be invested in making changes to improve their experience and with whom they feel safe speaking openly (e.g., faculty Wellness Champion and/or the Resident Wellness Committee). Otherwise, they may feel that speaking up is a risk that is unlikely to produce any meaningful change
5. Open-ended prompts:
   1. What are the impediments to residents’ work and wellness in this program?
   2. What gets in the way of your work? What makes you crazy (the “pebbles in your shoes”)?
   3. Of all of the issues suggested, what are the most important ones? What should we prioritize first?
   4. Is there something we can do to address these issues right away? Any suggestions for solutions that are quick wins?
   5. What do you see as the major barriers to implementing these changes?
6. If participants are not forthcoming, suggest some of the ideas from Step 2 and ask if they resonate.
   1. Of all of the solutions (initiatives, policies, interventions) suggested, which solutions do you think are most meaningful?
   2. Of all of the solutions suggested, which ones are you most willing to test? 
   3. What do you see as the major barriers to implementing these changes? 
      

Step 2: Select a few of the ideas to enact.

Examples from other programs include:

Work Hassles & Inefficiencies

1. See our Keeping Your Ear to the Ground as a Program Director protocol for ideas including:
   1. Ensure that residents have enough resources (e.g., phones, computers, chairs, space) to do their work efficiently (UCSF, Northwestern, University of Wisconsin-Madison).
   2. Ensure that workrooms and call rooms are located near patient spaces (i.e., ORs, surgical floors, ICUs, Emergency Department) (UCSF).
   3. Ensure that process for obtaining call rooms is not prohibitive (UCSF).
   4. Ensure that post-call transportation options are prohibitively cumbersome (UCSF).
   5. Advocate for decreasing resident documentation requirements (UCSF).
   6. Eliminate duplicative work (Northwestern).
2. Install lockers for the residents so they have somewhere safe to put their belongings(Penn).
3. Ensure that the resident work spaces and call rooms are maintained(e.g., clean linens in the call room, trash removal).
4. Pager-Free Educational Time (University of Rochester, UCLA).
5. Clearly define division of labor by defining APP Expectations (Mayo Clinic).
6. Training Nurses to Work with Residents [COMING SOON] (e.g., don’t page during resident sign out unless absolutely necessary) (Penn, Brigham & Women’s, OHSU).
7. Employ pre-medical students to act as scribes to help within patient and outpatient notes (OHSU). OHSU’s Medical Scribe program collaborates with Portland State to hire area pre-med students to work part-time ($15/hr) as scribes on their inpatient services and in their clinics (~$10,000-15,000/year). Professional scribes had been previously utilized and deemed to be cost prohibitive at $60,000-80,000/year. Pre-medical student scribe work is mutually beneficial: students gain clinical and practical skills that make them more competitive applicants, and EMR/documentation burden is substantially alleviated as notes are more rapidly complete. Scribes are assigned to specific clinics and/or services so the knowledge/skill acquisition is summative and consistent. OHSU subsidizes some costs; the Medical Scribe program centrally manages recruitment, training, and evaluations/competency assessments.
8. See our Time Banking intervention (Stanford) for additional ideas, including research support and career coaching.
9. See our Being a Supportive Program Coordinator protocol for additional ideas, including
   1. Offload as much paperwork as possible to program coordinators
   2. Ask coordinators to administratively support resident wellness activities
   3. Have a coordinator become a notary
   4. 
      
10. See our Food & Snacks (Stanford, Northwestern) intervention.
11. Beth Israel Deaconess Medical Center installed rows of hooks outside of patient rooms on the surgical floors so that providers could hang their white coats up before initiating bedside procedures.

Home Hassles & Inefficiencies

1. Provide dry cleaning pick-up service for residents (Emory). Emory University’s Department of Surgery coordinates a weekly pick-up service with a local dry cleaning service. Each resident creates their own account with the service, linked to their own credit card for automated billing, and is given their own bag. Residents leave their dry cleaning bags in a designated spot in the call room. Recommendations for national dry cleaning pick-up services include:
   1. https://www.rinse.com/
   2. https://www.1-800-dryclean.com/
2. See our Time Banking Intervention (Stanford) for additional ideas, including housecleaning and meal delivery.
3. Host a Parents’ Night Out (Indiana University Internal Medicine)in which residents and/or faculty babysit for residents’ children to give them a break/date night.

Step 3: Publicize to the department to communicate the department’s willingness to make meaningful changes and celebrate the progress

1. In the communication, be sure to link these wins to your department’s wellness program, so that residents and faculty understand that these initiatives are all intentional changes that are part of the department’s overall mission to improve wellness. This is particularly important when there is skepticism about wellness (e.g., when wellness is conceptualized as yoga, crystals, or something that may seem similarly peripheral to surgeons). Removing these pebbles from their shoes may create and sustain enthusiasm in the Wellness Program, providing the necessary context to implement longer term, higher impact initiatives.
2. The Wellness Champion and the Wellness Committee should continually query and update the residency program on new issues that arise, the issues they are working on, and the progress they’ve made on each. Often the most important piece of an initiative is the mere demonstration that the department cares for its residents.
   

Helpful Resources for Implementation                                                                                                            

Coaches/Successful Implementations

                                                                                                                                                                                                     Medical College of Georgia                                                                                                                                                                                                                                                          

•  Coach: Assistant Dean for Operative Skills Assessment (also Former Program Director at University of Wisconsin-Madison): Jacob Greenberg, MD, EdM
•  Contact: jagreenberg@augusta.edu

                                                                                                                                

UCSF                                                                                                                                                                                                                                                                                                 

•  Coach: Program Director: Kenzo Hirose, MD
  •  Contact: kenzo.hirose@ucsf.edu

•  Coach: Former Program Director: Linda Reilly, MD
  •  Contact: Linda.Reilly2@ucsf.edu

                                                                                                                                                                                                                                 Emory University                                                                                                                                                                                                                                                                              

•  Coach: Director of the Carlos and Davis Center for Surgical Anatomy and Technique & Former Program Director: Keith A. Delman, MD
  •  Contact: kdelman@emory.edu

                                                                                                                                                                                                                            Oregon Health & Sciences University                                                                                                                                                                                                                                             

•  Coach: Program Director: Karen Brasel, MD, MPH
  •  Contact: brasel@ohsu.edu
    

References                                                                                                                                                         

1. Daniel Orlovich P. Can Minor Changes in a Program Affect Resident Burnout? -Insights on Residency Training [Internet]. Insights on Residency Training. 2020. Available from: https://blogs.jwatch.org/general-medicine/index.php/2019/11/can-minor-changes-in-a-program-affect-resident-burnout/