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Wellness Guidelines for Postgraduate Trainees

University of Toronto Faculty of Medicine, Postgraduate Medical Education

Date of original approval: October, 2019
Date of last revision and approval: October, 2019
Date for next review: 2024

Table of Contents

INTRODUCTION AND OVERVIEW

Physician health and wellness is a priority in the Faculty of Medicine at the University of Toronto (UofT). The Faculty of Medicine, Postgraduate Medical Education (PGME) has developed several guidelines that support the health, wellbeing and diverse training needs of postgraduate trainees at UofT.

(i) Definition of Health and Wellness

According to the World Health Organization, health is "...a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.”
                                                                                                                                                                     (WHO Constitution, 2015)

At the University of Toronto, Faculty of Medicine, Postgraduate Medical Education (PGME), we acknowledge that achieving wellness for trainees involves an active process by individuals and the organization, of becoming aware of factors which affect health, and making decisions that promote health.

Further, we acknowledge that optimal health is not always achievable for individuals and, where it is not achievable, the university will seek to accommodate wellness needs in the work and learning environment, to support individuals to perform at their optimal potential.

(ii) Why Health and Wellness Matters

An essential aspect of becoming a physician is learning to take care of ourselves and our health, developing a work life that does not compromise our personal priorities and collaborating with colleagues to enable a positive work and learning environment that supports wellness. Wellness goes beyond the absence of distress and includes being “challenged, thriving, and achieving success in various aspects of personal and professional life”.
                                                                                                                                                                                   (Shanafelt, 2003)

Within the Canadian context the Canadian Medical Association describes the importance of considering the wellness of physicians stating:

“Being a physician can be deeply gratifying, but it also comes with stresses and challenges that can take a toll on…health and well-being. Heavy workloads, demanding standards of training and practice, and complex practice environments are just some of the factors that can put any physician at higher risk of personal and professional dissatisfaction, burnout and depression. The impacts of this — on (the individual) …on patient care and on the performance of the overall health system — make supporting physician health an imperative”.

“…Recognizing the range of challenges physicians face, we advocate for a shared responsibility approach — targeting both individual and systemic factors that negatively affect physician health — as the pathway to meaningful, sustained improvements.”
                                                                                                                                                                                          (CMA, 2018)

(iii) Responsibilities of Postgraduate Trainees and Programs

POSTGRADUATE TRAINEE RESPONSIBILITY

  1. Postgraduate trainees are responsible for reporting fit for duty and able to perform their clinical duties in a safe, appropriate and effective manner. Postgraduate trainees have a professional responsibility to appear for duty appropriately rested and must manage their time before, during and after clinical assignments to prevent excessive fatigue.
  2. Postgraduate trainees are responsible for assessing and recognizing the signs of impairment, including that which is due to illness and/or fatigue in themselves. Trainees experiencing such impairment are to seek appropriate help and/or access the Postgraduate Wellness Office for further support.
  3. If a postgraduate trainee is experiencing any disability-related barriers, including physical or mental conditions that could impair their ability to perform their duties, they are encouraged to seek assistance from the Postgraduate Wellness Office (PWO) before clinical, educational and/or professional performance, interpersonal relationships or health are adversely affected. Trainees are entitled to reasonable accommodation in accordance with and subject to applicable law and policy.
  4. If a postgraduate trainee recognizes physical, mental, or emotional problems affecting the performance of another trainee, including impairment due to excessive fatigue, that trainee should encourage their fellow trainee to notify a program director or designate and/or, if there is a risk to patient safety, consider notifying the program director, designate or applicable clinical-site lead.
  5. At no time will trainees be denied visits for acute care for illnesses (physical or mental) or dental emergencies during work hours.

RESIDENCY PROGRAM RESPONSIBILITY

  1. It is the responsibility of the Training Program Committee to be aware of themes and factors influencing postgraduate trainee health and wellness.
  2. If a program director or faculty member recognizes there may be physical, mental, or emotional problems affecting the performance of a trainee, including impairment due to excessive fatigue, the member must take steps to ensure the safety of postgraduate trainees and patients.
  3. It is the responsibility of the University, including the Program, to adhere to the Postgraduate Medical Education Accommodation Guidelines.

 

Policies and Guidelines addressing Health and Wellbeing at the University of Toronto; Faculty of Medicine; PGME

Multiple policies and guidelines have been developed to support postgraduate trainee and faculty navigation of various wellness needs at the UofT. These policies and guidelines govern student support for all UofT, and are not exclusive to postgraduate trainees. The Postgraduate Wellness Office (PWO) recognizes these policies and guidelines as the basis of student conduct, support and governance.

POSTGRADUATE WELLNESS OFFICE

The Postgraduate Wellness Office (PWO) is a champion for physician health and wellness at PGME and the Faculty of Medicine. The Postgraduate Wellness Office offers support to all currently registered trainees.

PGME at UofT seeks to enhance the wellness of postgraduate trainees and to contribute to a medical culture that values the well physician and the steps it takes to maintain that wellness.

We seek to:

  • Grow a culture of physician health and wellness that supports professionalism and patient care;
  • Support system-level approaches to address health and wellness in the work and learning environment;
  • Educate postgraduate trainees about health and wellness and how to maintain their own wellbeing;
  • Support postgraduate trainees in their efforts to maintain their wellbeing during training;
  • Support postgraduate training programs in their efforts to address health and wellness issues that arise and to implement preventative measures; and
  • Conduct scholarly work in the areas of physician health and wellbeing.

(i) Services of the Postgraduate Wellness Office

The Postgraduate Wellness Office provides all registered trainees (residents and clinical fellows) a safe and confidential venue to seek out resources that protect and enhance their health and wellbeing. Trainees have access to wellness support from Wellness Directors and can also access counselling with Wellness Consultants.

Over the last 15 years, the office has developed and become a champion for physician wellness and education on burnout and wellness strategies. Guidelines were developed for multiple areas that PG trainees often navigate when struggling with a health issue including leaves from training, accommodations, transfers and intimidation and harassment. Wellness program initiatives have included growing the office and developing resources and education regarding physician wellness and increased support for trainees experiencing health issues during training.

The office has advanced beyond supporting individual and program wellness initiatives to address and promote a culture of wellness at the University of Toronto and, more specifically, within Post MD Education. The office also works with programs through program directors, program assistants and the Wellness Subcommittee, with broad representation to support an organizational work environment, values and behaviors that promote self-care, growth, and compassion for ourselves, our colleagues and our patients.

(ii) Postgraduate Wellness Office: Who we are and what we offer

Wellness Directors

  • Provide support during remediation/academic difficulty
  • Provide career and postgraduate training guidance
  • Provide disability and accommodation support
  • Advise regarding leaves, transfers, intimidation/harassment
  • Administer the Board of Medical Assessor files
  • Support programs and program directors focused on enhancing health and wellbeing

Wellness Consultants

  • Assess and provide short term counselling to support trainee’s health, learning, and performance needs; certain time limited group interventions are also offered
  • Provide support to postgraduate trainees to navigate resources that exist in the University and beyond to support the health and wellbeing of trainees
  • Provide short term support to trainees in a group setting
  • Create and facilitate educational programming/workshops on themes related to wellness, learning, and performance

All members of the Postgraduate Wellness Office team aim to link trainees to services within PGME, the University of Toronto, and in the community appropriate to health, safety and learning needs.

The Postgraduate Wellness Office can be contacted by calling 416-946-3074 or by emailing pgwellness@utoronto.ca.

(iii) Boundaries between the PWO and other areas in Post MD Education

  • PWO operates at arms-length from the other areas in Post MD Education and the Faculty of Medicine
  • PWO will request a trainee’s consent before consulting with offices and individuals outside of the PWO, in order to assist trainees; except in the case of an emergency or where there may be a safety risk
  • When trainees engage with the Wellness Consultants for short term counselling, information is protected by PHIPPA, and disclosures are only made according to PHIPPA legislation.
  • Data regarding operations is reported in aggregate form to Post MD Education, in order to preserve the privacy of individuals who use services
  • In some circumstances (for example, where health/safety is at risk) the PWO will consult with other internal members of the University on a need-to-know basis and otherwise as required or permitted by applicable provincial privacy legislation or regulatory bodies
  • The PWO works with the Board of Medical Assessors (BMA) to assist trainees and reviews the needs for accommodations in the work and learning environment; medical information used in this process is disclosed to the BMA with permission of the trainee, and medical information is not shared with other arms of Post MD Education or the Faculty of Medicine

BOARD OF MEDICAL ASSESSORS

The BMA functions as a confidential process that provides recommendations to support and advocate for accommodations that enable a trainee’s success during training and remediation. The Board of Medical Assessors (BMA) considers and determines whether there is a disability that affects or may affect the ability of a student or trainee to participate, perform or continue in the Health Professional Educational Programs (Program) of the Faculty. The BMA makes recommendations regarding such matters to the Dean or delegate (ex. applicable Vice-Dean, Education). Program Directors are strongly advised to discuss referrals with the Directors of the PWO in advance of submitting the relevant documentation and/or referral in order to confirm the specific questions the referral is intended to answer prior to completing a referral.

Board of Medical Assessors - Terms of Reference

STATEMENT OF FATIGUE RISK MANAGEMENT

Fatigue is defined as:

A subjective feeling of tiredness that is experienced physically and mentally. It ranges from tiredness to exhaustion, creating an unrelenting overall condition that interferes with individuals’ physical and cognitive ability to function to their normal capacity. Its experience involves some combination of features: physical (e.g. sleepiness) and psychological (e.g. compassion fatigue, emotional exhaustion) (FRM Toolkit, 2018).

Fatigue in postgraduate training is an occupational risk that has been identified by the Royal College of Physicians and Surgeons of Canada (FRM toolkit, 2018). Fatigue increases the risk of medical error and increases the risk to personal safety and wellbeing. (FRM toolkit, 2019). While fatigue is an individual experience, the factors that impact on it are both individual and systemic, making the management of fatigue related risks a shared responsibility between training sites, programs, faculty and postgraduate trainees.

Fatigue Risk management is defined as a set of ongoing fatigue prevention and mitigation practices, principles, and procedures integrated throughout all levels of the clinical and academic work environment, and are designed to monitor, ameliorate and manage the effects of fatigue and associated risks for the health and safety of healthcare personnel and the patient population they serve (FRM Toolkit, 2018).

CAUSES OF FATIGUE (FRM Toolkit, 2018):

Physical:

  • Circadian rhythm
  • Amount and quality of sleep
  • Shift length/rotation
  • Overuse of countermeasures- caffeine/naps

Emotional:

  • Stress

Social and Cultural:

  • Some physicians object to sleeping during shifts
  • Pressure for physicians to work when fatigued

CONSEQUENCES OF FATIGUE (FRM Toolkit, 2018):

Physical: fatigue linked with occupational accidents, obesity and weight gain

Emotional: lack of sleep leads to increased stress and decreased tolerance for stress

Social/Cultural: fatigue leads to impatience, agitation, increased irritability and difficulty getting along with others leading to strained personal and professional relationships

Psychological: reduced ability to recognize specific emotions, lower levels of empathy, strains social connectedness and interactions with colleagues and patients and families

EXEMPLARY ACTION FOR FATIGUE RISK MANAGEMENT (FRM Toolkit, 2018)

UofT and PGME will follow these principles to develop initiatives and guidelines for a Fatigue Risk Management plan.

Guiding principles for Fatigue Risk Management:

  1. Leaders of both educational institutions and clinical learning environments are responsible for ensuring that FRM is a priority and that healthcare providers and trainees can effectively contribute to the creation of a management plan.
  2. Every trainee bears a responsibility to self, to their peers, and to those they provide care for, to manage their own fatigue during training and as they transition into practice.
  3. Clinical Training Facilities have a duty to uphold reporting practices and policies. All clinical institutions involved in clinical training must create a just learning environment that enables the reporting of fatigue related incidents.
  4. Shared Role to Support Deployment and Implementation. All clinical institutions involved in training must support faculty and trainee development in FRM policies, practices, and procedures

POSTGRADUATE WELLNESS OFFICE INITIATIVES (FRM Toolkit, 2018)

The Postgraduate Wellness Office Curriculum includes a Fatigue and Energy Management workshop that can be requested by all programs during their academic half days.

Wellness Consultants regularly work with trainees to address sleep, fatigue, and energy management issues related to health and wellbeing and assess need for referrals for further assessment and/or treatment

PGME at UofT will endeavor to contribute to the dissemination of good practices related to FRM. Clinical institutions participating in clinical training will actively identify, collect, and disseminate good practices and innovative research in FRM to the medical education community.

Fatigue Risk Management Toolkit

DEVELOPING PROGRAM SPECIFIC WELLNESS INITIATIVES

These PGME central Wellness Guidelines will be applicable to all PGME Specialty programs. In addition, many programs have their own thoughtful approaches, systems and processes in place to support trainee wellness concerns specific to their trainees. Each program will need to explicitly review their wellness structure and determine if their program supports the principles articulated in the Post MD Wellness guidelines.

To support programs to explore what they are doing locally, the PWO has developed guiding questions. These questions help program directors program committees to help organize and/or develop initiatives that support trainee wellness at a program level.

See Appendix 1 and Guiding Questions for Wellness Programming and Processes

ADDITIONAL SUPPORTS AND RESOURCES

Find provider and support in the community

References:

  1. World Health Organization, Constitution. Retrieved from: www.who.int/governance/eb/who_constitution_en.pdf
  2. CMA Statement on Physician Health and Wellness: Guiding Principles and Commitments of a Vibrant Profession. Retrieved from: www.cma.ca/sites/default/files/2018-11/physician-health-wellness-statement-e.pdf
  3. Joint Commission 2011, Health Care worker fatigue and patient safety. Sentinel Event Alert. (48) 1-4.DOI:10.1056/NEJMp1703690.
  4. Shanafelt, T, Sloan, J and T. Haberman, The well-being of physicians. The American Journal of Medicine, Volume 114, Issue 6, 513 – 519, 2003.
  5. Fatigue Risk Management Toolkit, Fatigue Risk Management Task Force, 2018.

Appendix 1: Guiding Questions for Wellness Programming and Processes

University of Toronto, Postgraduate Training Program Wellness Guideline Development

The questions and sample responses have been created based on feedback from program directors to highlight some of the activities your program may already be engaged in that would be considered part of your wellness program. The questions and responses below are quite detailed and by no means are programs expected to have all of these activities and initiatives in place. This document is meant to be a useful resource, available for programs that would like to use it as you determine your program’s wellness policy needs.

  1. What are the wellness needs of your trainees?
    1. Fatigue and call duties, sleep deprivation
    2. Exam preparation stress, MCCQE, Surgical Foundations, Royal College
    3. Competing demands of life outside medicine (children, elderly dependents, etc.)
    4. Financial pressures
    5. Finding time to for self-care – exercise, nutrition, attending healthcare appointments
    6. Excessive EMR demands, documentation demands
    7. Recognition of and mobilization around necessary culture change in medicine (impact of “the hidden curriculum”, experience of visible minorities in medicine)
    8. Career planning, job search, preparation for independent practice
  2. What wellness issues may be specific to your speciality or clinical setting?
    1. Long work hours
    2. Multiple training sites
    3. Exposure to physical, emotional, traumatic clinical content
    4. Team practice and learning
    5. Stigmatized clients
    6. EMR problems
    7. Physical demands of operating room
    8. Emotional demands of client care
  3. How do you teach trainees about these potential wellness issues and ways to mitigate their negative impact on wellness?
    1. Orientation sessions
    2. Safety and wellness reviews/audits of sites/programs
    3. Wellness days
    4. Wellness speaker/workshop series on physician health, managing stress and burnout, fatigue management, exam preparation, financial planning
    5. Debriefing opportunities after a traumatic clinical exposure, loss, adverse event
    6. Peer support, mentorship opportunities
    7. Involving trainees in residency planning committees that address residency policies affecting wellness (waivers of training, accommodations process)
    8. Role modelling of wellness attitudes and behaviours by faculty
    9. Implicitly via supportive culture of division
  4. How do you monitor the wellness of trainees in your program?
    1. Needs Assessment of trainees
    2. Burnout scale survey
    3. Annual/Biannual meetings with trainees/focus groups
    4. Site meetings with trainees to review work and learning environment
    5. Wellness team meets with each trainee – 1-2 x per year – separate from PD meetings
    6. Annual Trainee Retreat includes a program evaluation moderated/submitted by trainees which includes wellness issues on agenda
    7. Creating safe, available, responsive space – PD and faculty
  5. What aspects of your training program, clinical practice and work and learning environments support trainee wellness?
    1. Program and site directors
    2. Balint support groups for trainees
    3. Trainees advisors, Wellness leads in your program
    4. Leisure activities to acknowledge trainees, promote team development
    5. Mentoring program linking trainees with senior trainees or staff supports/mentors
    6. Attention to innovative on-call scheduling with input from our ‘On-Call’ committee
    7. Ensuring trainees are able to find time to attend healthcare appts (working with chief trainees and site supervisors to ensure such appts are prioritized in planning work flow)
    8. Culture of program and division
    9. Central PGME: PG Wellness office, Wellness workshops, Support sessions/groups,
    10. Coaching and learner support
  6. What aspects of your training programs, clinical practice and learning environments constrain trainee wellness?
    1. Large programs,
    2. On call experiences,
    3. Increasing autonomy/responsibility,
    4. Variation in support from staff,
    5. High clinical demands- on call shifts with high ED presentations,
    6. Long work hours,
    7. Research and scholarly projects,
    8. EMR/admin work
    9. #1 is long hours
    10. Increasingly complex patient populations
  7. How would your trainees access guidance if they need a work or training accommodation as the result of a health issue (for example, reduction of hours or duties to manage health issue), or time off for a health issue?
    1. Refer to PG Wellness
    2. Refer to Board of Medical Assessors
    3. Work with PG Wellness for Accommodations regarding specific needs for the learning environment to optimize success in the training and work environment
    4. Occupational health office in the hospital
    5. Work with PD and wellness leads in own department
    6. PD to “quarterback” and guide process
  8. Intimidation and harassment in the work and learning environment is linked to poorer health.
    1. The university has intimidation and harassment policies and procedures. How do you verify that your trainees are aware of these policies?
      1. i. Discussed at new trainee orientation
      2. ii. Discussed at biannual PD/wellness meetings if need arises
      3. iii. Posted on our own departmental Intranet pages
    2. Do you have any internal faculty/staff members who trainees can approach if they have a concern about intimidation/harassment?
      1. i. Trainees advisors
      2. ii. Wellness leads for the program/sites
      3. iii. Central PGME, PG Wellness Directors
    3. How do you track and monitor professionalism issues within your program?
      1. i. Site meetings and reviews,] POWER site evaluations, Program evaluations
    4. What does your program do to promote professional values?
      1. i. Education of trainees and faculty on incivility, intimidation and harassment
      2. ii. Education and awareness of UofT PGME Policy on Intimidation and Harassment and enforcement
      3. iii. Voice of the Trainees Survey and data on trainee experiences, TAHSN survey on the work and learning environment
      4. iv. Work with faculty to ensure professional behaviour is modeled (Fac Dev)
      5. v. Role modelling within the program and division
  9. Do you have a trainee or faculty lead for physician wellness?
    1. If so what is their role/job description?
      1. ▪ What are the deliverables of those roles?
      2. ▪ How do these individuals champion physician health in your program?
      3. ▪ How are these roles supported? (financial, admin, protected time)
  10. What physician wellness initiatives/programs are currently offered to your trainees and faculty in your program?
    1. Wellness Committee
    2. Wellness programming- social events, workshops, educational session, Visits from PARO
    3. Wellness lead/advisor for trainees to see/meet
    4. Peer support
    5. Mentorship
    6. Exercise programs
    7. Annual Trainee retreat (part social / part program evaluation)
    8. Book club
    9. Balint groups

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