5 Questions with Marisa Saint Martin, MD, ACC, FCAP, medical director, OneBlood Inc., Jacksonville, Florida, and associate certified coach with the International Coach Federation.

An AAPL member since 2018 and the winner of the 2019 prestigious Roger Schenke Award, Dr. Saint Martin discusses her team’s published work on a strategy for wellness in a pathology residency program.

Q You and your colleagues at Loyola University published an article in Academic Pathology, “A Strategy for Wellness in a Pathology Residency Program: Enhancing Chances of Success During an Epi- demic of Burnout.” How was the research conducted?

A The study and publication came about after identifying a need for a wellness curriculum. The methods were somewhat informal and unstructured, as the aim was to find out if our residents were feeling burned out and to identify wellness strategies to help improve our program.

An unannounced spot survey was administered to the residents and fellows present at a residents’ meeting in July 2017. The survey solicited their opinions about three positive aspects of the residency program, three frustrations, and three perceived things they would like to change. The opinions were handwritten and submitted anonymously. The responses were collected at the end of the meeting.

This spot survey was completed by trainees before any plans for educational intervention, and it was the catalyst for creating a Pathology Residency Wellness program. Subsequently, and after establishing a wellness curriculum and program, residents participated in two additional surveys to gauge the effectiveness of the wellness program. Both data surveys were voluntary and dependent on resident participation.

The two new surveys were conducted to gauge level of wellness education at day 0 (before the wellness curriculum was developed) and at one year after wellness education began. These surveys asked 17 trainees to anonymously answer a series of questions, scoring them on a scale from 1 to 10. While some components of statistical survey validation were utilized, such as the establishment of face validity and the clean collection of data, the surveys are intended to be a pilot for future data gathering and statistical analysis of the effectiveness of wellness education. Ongoing survey processes will include principal components analysis and measurement of scale reliability.

Q How does burnout manifest itself in medical residents?

A Studies nationwide suggest that more than 50 percent of U.S. physicians experience symptoms of burnout. A residency program director’s survey conducted in 2014 indicated that 92 percent of program directors estimated that more than 50 percent of residents show signs of burnout. In a recent study, nearly half of residents across all specialties, and 62 percent of residents in some specialties, reported symptoms of burnout.

As per Christina Maslach‘s definition, burnout is characterized by exhaustion (physical, mental, and/or emotional), cynicism, and sense of lack of personal accomplishment. The end-stage consequence of burnout is disengagement. Engagement, at the opposite extreme, is characterized by high energy, dedication, and finding a sense of purpose at work.

Trainees are particularly vulnerable to experiencing burnout as, in addition to the multiple causes for burnout most healthcare providers face, residents may not have the adaptability and experience to navigate daily stresses, increasing their feelings of inadequacy and isolation. They also are adjusting to new levels of complexities as they absorb knowledge and still comply with the innumerable duties the departments may demand of them.

Strategies that would help combat burnout such us sleep, exercise, connectivity with friends and family, practicing mindfulness, etc., take a second stage under the pressures of deadlines, exams, and work to be done.

To help our residents cultivate their resilience, our wellness program’s mission was “To creatively work on improving the health, joy, humanity, and satisfaction of our Department of Pathology and Laboratory Medicine trainees.” The vision was “Our group provides initiatives, tools, and action steps to continuously improve our work- place environment, resulting in enhanced provider and patient satisfaction.”

Q Does the medical community use “stress” and “burn-out” interchangeably — and do you believe there are defining characteristics of both of those classifications?

A Stress and burnout have many similarities, and the terms are often used interchangeably. However, there are clear differences between the two. Stress is not only part of our daily lives, but also can be a good mechanism for survival, such as in a fight-or-flight type situation. Or, it can give us a sense of urgency when we have a goal with a deadline coming up. Only when stress becomes chronic/toxic and we lose the ability to navigate through it, can it lead to burnout.

When someone is stressed, the emotions are usually over-reactive and over-engaged. There is a sense of urgency to fix the problem immediately, and the exhaustion usually manifests in a physical form.

With burnout we see quite the opposite. The emotions are blunted, and the person disengages from discussions and even daily tasks, becoming more and more isolated. The exhaustion is usually an emotional exhaustion, which comes with a sense of hopelessness and helplessness. The end stage of burnout is similar and somehow indistinguishable from major depression.

Q What results did you find when your team did the research project and what strategies did you outline?

A Interventions to prevent burnout should be a shared responsibility of individual healthcare providers and the organizations for which they work. In our department, after establishing the wellness curriculum, residents and fellows were introduced to information and strategies to build resilience during monthly wellness talks. Attendance was voluntary; however, residents on campus attended each meeting.

The curriculum was administered during noon meetings, with lunch provided. Different wellness topics were discussed by a single faculty member who was also the associate residency program director and an associate certified life, career, and executive coach. Confidentiality agreements were critical.

Topics for discussion included a tri-dimensional approach to burnout that included recognition, prevention, navigation, professionalism, physical health, mental health, spiritual health, suicide awareness and prevention, second victim phenomenon, the science of joy, gratitude as a tool for wellness, purpose, emotional intelligence, core values and core strengths, and mindfulness.A typical one-hour session was designed to include wellness education in addition to practical individual and program-driven measures. These measures included debriefings of stressful situations or encounters with patients and/or faculty members, mindfulness practices, and development of team-building activities at the department level.

Q One of the strategies in your paper points to teaming up first-year residents with senior residents. How was that accomplished and how was that strategy received by the residents?

A Our already functioning departmental faculty mentorship program consisted of pairing first-year residents with faculty members the residents selected to guide and counsel them in their career, and human aspects of our specialty and profession. Residents and mentors met in pairs a minimum of twice during the academic year. The mentorship program was assessed annually at our residency program evaluation meeting. In addition, the department used a “buddy” system, pairing first-year residents with senior residents to help them navigate the quirks of the onboarding period.