Enhancing Surgeon Wellness: Integrating a Multidimensional Behavioral Medicine Approach into a General Surgery Residency Program

Burnout, depression, and suicide have been increasing among physicians over the past decade at an alarming rate. A recent study found that 75 percent of general surgery residents demonstrated signs of burnout and 40 percent exhibited symptoms of depression.¹ The Accreditation Council of Graduate Medical Education (ACGME) has recently identified goals to broaden efforts in programs to promote resident wellness.² In response to these issues, in late 2015, we developed the Behavioral Medicine Program, which was specifically designed to address surgical resident wellness from a multidimensional perspective. Stanford University has also focused on different dimensions of surgeon well-being and found that such a program is feasible, highly valued, and is positively perceived by residents.³

Specific elements of our program are presented below:

The program presents frequent, highly interactive lectures that target surgeon wellness. Topics include the following:

Surgeon Wellness: Preventing Burnout

In this highly rated lecture, residents learn how to practice and implement four evidence-based stress management strategies, called the STM Model (Figure 1), which aims to reduce distress. Residents have been quite enthusiastic about learning these wellness exercises (Figure 2). We also strongly encourage residents to integrate at least 15 minutes of self-care time into their daily schedules. Preliminary findings from a pilot study at our institution indicated that after learning the STM Model, interns from multiple specialties ranked cognitive restructuring and daily self-care as the wellness strategies they used most often and found to be most valuable for decreasing stress.⁴

Figure 1. The Stress Management Model (STM)*

1. Cognitive-Restructuring (using thought records)
2. Mindfulness exercise
3. Diaphragmatic Breathing
4. A six-minute Relaxation/Imagery exercise

*See the University of Miami Health System's Family Medicine’s Stress Management Program Targets Healthy Mind and Body.

Figure 2. Sample of Surgical Resident’s Comments on The Stress Management Model (STM)

• (Learned) Relaxation techniques. Excellent talk.
• Very helpful to have an honest discussion about these topics.
• (Learned to) Use my “wise” side to help control my feelings and behaviors.
• (Learned) diaphragmatic breathing.
• (Learned) How to decrease anxiety.
• (Learned) breathing techniques and not to take things personally. Thank you.
• (Learned it is) Important to control our thoughts. Keep up the wonderful lectures.
• (Will use) Every aspect of the presentation. Great presentation, very informative.

Communication Skills for the Surgeon

Residents not only learn basic skills (for example, reflection, empathic responding, etc.), but also how to redirect patients during difficult consultations,⁵ how to remain calm during challenging interactions,⁶ and how to become more efficient when using electronic health records (EHRs) while also preserving a connection with their patients.⁷

Loss, Grief, Complications, and Breaking Bad News

We encourage residents to develop their own “loss lines” (in order to help them reflect back over their life experiences to identify any areas of unresolved grief). During the lectures, we discuss and normalize complications during operations and the concomitant distressful feelings surgeons often experience in the face of bad outcomes. Residents also learn how to utilize a structured protocol⁸ for breaking bad news.

Professionalism for the Surgeon

We encourage residents to reflect on the qualities of a surgeon which cause others to perceive him or her as a “professional,” and residents participate in a discussion on boundaries, boundary violations, and dual relationships.

Approaches to Help Interact with Difficult Patients: Substance Use and Other Psychiatric (Brain) Disorders and Motivating Patients to Change Unhealthy Behaviors: Motivational Interviewing and Stages of Change for the Surgeon

During the last two lecture topics (above), we aim to increase wellness by enhancing residents’ self-confidence when working with difficult patients. Additionally, our behavioral medicine faculty meets with residents and serve as confidential in-house resources to help with remediation and performance improvement. We also regularly shadow residents in trauma and burn clinics to provide immediate feedback and positive reinforcement about the learner’s interpersonal, communication, and professionalism skills.

In addition to formal performance improvement meetings, our behavioral medicine faculty is available to see residents and faculty for confidential, informal counseling. Beginning next academic year, we will initiate individual check-in meetings with the behavioral medicine faculty to assess wellness by identifying signs of distress early on. These confidential meetings are not considered therapy; however, we will make referrals for traditional therapy and psychiatry on a case-by-case basis.

University-wide “Wellness Weeks” with activities such as yoga, chair massages, and financial wellness seminars, as well as other activities (farmer’s market, jazz bands) give residents numerous opportunities to interact socially. In addition, all interns at our university participate in multispecialty learning communities where they bond and learn wellness techniques.⁹ In the upcoming academic year, we will initiate PGY-specific “complications groups” where residents can confidentially share their feelings and receive support from others about bad outcomes. A portion of orientation for incoming interns is focused on increasing bonding and overall fun vis-à-vis active team-building games—Beach Ball Alphabet, When the Big Wind Blows, and more—while teaching new learners stress and time management strategies. In 2000, our behavioral medicine faculty developed a mentorship program, The Buddy Project, for residents in family medicine. Incoming interns are paired with senior residents, who then contact the interns to welcome them to the program and provide support and encouragement. We are in the preliminary stages of integrating this project into our surgical residency program.

“Posture, strength training, and ergonomics need to be part of our training just as it would for (other athletes)… practicing surgery can exact a toll on surgeons’ physical well-being in ways that can shorten careers and contribute to professional dissatisfaction.”¹⁰ In addition to ongoing fatigue management seminars, we will begin training our residents in ergonomics and perioperative strategies for decreasing pain and enhancing performance without extending operative time.¹¹

During specific lectures, such as surgeon wellness and loss, and during intern orientation and meetings with the behavioral medicine faculty, we strongly encourage residents to “develop a framework from which to view death, pain, and suffering.” Whether they identify as atheist, agnostic, religious, or spiritual, we teach residents to utilize this framework in order to effectively restructure negative cognitions, which reduces their distress about the situation at hand.

In sum, our multidimensional behavioral medicine wellness curriculum includes frequent lectures, regular shadowing, performance improvement meetings, an “open door” policy with our behavioral medicine faculty, and promotion of team-building and stress/time management. We will be adding four more components this academic year:

1. “Complications groups”
2. Mandatory check-in meetings
3. Mentoring
4. Training in ergonomics and in perioperative avenues for attending to physical wellness.

1. Williford ML, Scarlet S, Meyers MO, et al. Multiple-institution comparison of resident and faculty perceptions of burnout and depression during surgical training. JAMA Surg. doi:10.1001/jamasurg.2018.0974.
2. Daskivich TJ, Jardine DA, Tseng J et al. Promotion of wellness and mental health awareness among physicians in training: perspective of a national, multispecialty panel of residents and fellows. J Grad Med Educ. 2015 Mar; 7(1):143-147.
3. Salles A, Liebert CA, Esquivel M, Greco RS, Henry R, Mueller C. Perceived value of a program to promote surgical resident well-being. Journal of Surgical Education. 2017 Nov-Dec (74): 921-927.
4. Allespach H, St. Onge JE, Diaz Y, Burg MA. Daily self-care and cognitive restructuring: The preferred wellness strategies of interns from multiple medical specialties. Research poster presented at the Learning Communities Institute Annual Meeting at the University of Washington, November 2016.
5. Allespach H, Marcus EN, Bosire KM. “Sailing on the 7 Cs:” Teaching junior doctors how to redirect patients during difficult consultations in primary care. Educ Prim Care. 2017; Apr 10: 1-3.
6. Pomm HA, Shahady E, Pomm RM. The CALMER approach: Teaching learners six steps to serenity when dealing with difficult patients. Family Medicine. 2004;6(7): 467-9.
7. Allespach H, Marcus EN. “The Rule of Six 2s”: Teaching learners simple strategies for structuring an outpatient adult primary care follow-up visit in the 21st century.Postgraduate Medical Journal. 2016; 92(1093): 629-630.
8. Buckman RA. Breaking bad news: the S-P-I-K-E-S strategy. Community Oncology. 2005; March-April: 138-142.
9. St. Onge JE, Allespach H, Diaz Y, Burg MA. “Promoting Wellness: Multispecialty Learning Communities for Interns.” Paper presented at the Learning Communities Institute Annual Meeting at the University of Washington, November 2016.
10. Oakes K. “This has to change:” Surgeon pain, disability on the rise. ACS Surgery News. https://www.mdedge.com/acssurgerynews/article/157238/pain/has-change-surgeon-pain-disability-rise. Accessed May 31, 2018.
11. Park AE, Zahiri HR, Hallbeck MS, et al. Intraoperative “micro breaks” with targeted stretching enhance surgeon physical function and mental focus: A multicenter cohort study. Annals of Surgery. 2017; 265(2): 340–346.

Heidi Allespach, PhD, is an associate professor of clinical surgery and director of behavioral medicine of the surgical residency program at the University of Miami Miller School of Medicine/Jackson Memorial Hospital. She is a clinical psychologist who has worked with graduate medical learners for more than 20 years and she devotes her time in the program exclusively to resident (and surgeon faculty as needed) well-being.

Danny Sleeman, MD, is a professor of clinical surgery, program director of the surgical residency program, chief of the division of surgical critical care, co-director of Ryder Trauma Center, and vice chair of residency education at the University of Miami Miller School of Medicine/Jackson Memorial Hospital.

Gerd D. Pust, MD, FACS, is an assistant professor of clinical surgery, associate director of the surgical residency program, and director of the surgical intensive care unit at the University of Miami Miller School of Medicine/Jackson Memorial Hospital.

Carl I. Schulman, MD, MSPH, PhD, is a professor of clinical surgery, associate director of the surgical residency program, and director of the William Lehman Research Center at the University of Miami Miller School of Medicine/Jackson Memorial Hospital.