Daily self-care and cognitive restructuring: A potentially potent prescription for physician wellness

Abstract Burnout among physicians has increased dramatically over the past decade. Recently, the United States Accreditation Council of Graduate Medical Education has prioritised the development of strategies aimed at promoting physician wellness and self-care. This pilot study sought to assess the feasibility of delivering a wellness curriculum in the context of multispecialty learning communities and to determine whether interns would benefit from being taught wellness strategies within these group settings. We examined outcomes of a wellness curriculum for interns from 14 different specialties at a large academic institution. 188 interns were assigned to one of 18 multispecialty learning communities (MSLC). Thirty-seven interns (20%) completed questionnaires at the end of the study. Interns reported an increased awareness of the need to take care of themselves and to practice wellness strategies, particularly cognitive restructuring and daily intentional self-care, as well as an improved ability to practice these wellness techniques. Almost all the interns reported they would be likely to continue to use these strategies throughout the remainder of their residency. Based on these preliminary findings, it appears that teaching wellness in multispecialty learning communities may be feasible and interns may benefit from being taught targeted, evidence-based wellness strategies in these focused group settings.


PUBLIC INTEREST STATEMENT
Rates of physician burnout and suicide have been increasing dramatically over the past decade. Helping young doctors combat burnout may be best accomplished by focusing on individual, as well as organizational, factors. In our work, we created Multispecialty Learning Communities for junior doctors who were in their first-year of training. Interns met with other residents from different specialties and learned powerful evidence-based wellness techniques, as well as ways they could become involved in institutional/organizational change. We discovered that interns found cognitive restructuring and setting time aside each day to practice self-care to be the most valuable wellness strategies, as well as the ones they used most often to reduce their stress. Interns additionally reported that they would likely continue to use these strategies throughout the remainder of their residency training. Future research will help to further clarify the exact interventions which may be helpful in the prevention of physician burnout.
in multispecialty learning communities may be feasible and interns may benefit from being taught targeted, evidence-based wellness strategies in these focused group settings.

Introduction
Depression has been likened to a phrase found in Dante's Divine Comedy which references finding oneself in a dark wood, because (he) had lost his path (Dante, Durling, & Martinez, 1996). Unfortunately, burnout, which may be strongly associated with the development of depression and suicidal ideation, has been increasing among junior physicians over the past decade, causing many of them to lose their paths due to these crippling conditions. Indeed, among physicians, there appears to be a storm gathering force, a crisis of profound proportions, which is evidenced by the startling fact that 300-400 doctors are killing themselves each year (about the size of three average medical school classes). It has been shown that male physicians are 1.4 times more likely, and female doctors 2.3 times more likely, to commit suicide than the general population (Schernhammer & Colditz, 2004). Studies suggest that stress and poor selfcare are related to the development of burnout in physicians (Sanchez-Reilly et al., 2013;Slaving & Chibnall, 2016). The Accreditation Council of Graduate Medical Education's (ACGME) Council of Review Committee Residents has identified actionable goals to broaden efforts in programmes and sponsoring institutions to promote resident wellness and mental health awareness (Daskivich et al., 2015).
In response to these issues, we developed a targeted wellness curriculum to be taught within Multispecialty Learning Communities (MSLCs) for all interns at our large academic medical institution. This pilot study was aimed assessing the feasibility of delivering a wellness curriculum in the context of MSLCs and to determine whether interns would benefit from being taught evidencebased wellness strategies in these focused small-group settings.

Methods
Five wellness strategies were selected based on their efficacy in decreasing stress and promoting self-care: 1) cognitive restructuring; 2) mindfulness; 3) diaphragmatic breathing; 4) "7-breath" breathing; and 5) a brief relaxation/imagery exercise. In addition, interns were directed to identify and practice "at least 15 minutes a day of self-care"; i.e., a healthy, "stress management" activity of their own choosing, throughout the entirety of the study. Homework, based on each wellness exercise, was assigned after each module. In the final session, participants were given a survey about different aspects of their experience with these selected wellness strategies as the result of attending the MSLC program.
IRB approval was obtained from the University of Miami's Human Subjects office and informed consent was obtained from all participants. Interns (N = 188) from 14 specialties were divided into 18 MSLCs which met every 6-8 weeks over the course of the first year of residency for a total of 5 modules plus a wrap up session. Of these 188 interns, a total of 98 were from specialties representative of primary care (family medicine, internal medicine, pediatrics, obstetrics/gynecology and medicine-pediatrics).
Fourteen faculty facilitators (13 MD's and 1 PhD), representing ten different specialties, were each assigned to a MSLC. All modules consisted of an open discussion, intensive focus on a specific topic, and instruction in utilising specific wellness exercises.

Results
Thirty-seven interns (20%) attended the final meeting. Frequency distributions were calculated for each question and survey results indicated that the majority of these interns agreed or strongly agreed that the MSLC was an overall valuable experience (76%), that they were "more aware of the need to take care of (themselves) and to practice wellness strategies since (they) started the MSLC modules" (76%), and that the entire MSLC wellness content was useful in improving their "ability to practice wellness/self-care" (73%) See Table 1. An overwhelming majority of the interns indicated they would be "likely to continue to use wellness strategies from here on out" (91%). When asked to rank the wellness exercises as "most valuable" to "least valuable" in terms of reducing their stress, the two strategies they ranked in first and second-place were cognitive restructuring (54.54%) and 15 minutes of self-care/day (50%). Additionally, these two strategies were the ones they used most often to reduce their stress (47% and 73% respectively). (See Figure 1) Of interest, some of the activities which interns identified for their "15 minutes of daily self-care" included: exercising, "playing with my dogs," "walking on the beach," "reading a non-medical book," and "binge-watching Netflix." These types of simple activities likely serve to focus the young doctor's attention momentarily on the present and, as a result, help to quiet the incessant storm of thoughts and worries arising from all the demands of internship.  Six of the 14 faculty facilitators (43%) also completed surveys (three facilitators who were researchers on this study did not complete evaluations). Faculty who responded to the survey were from the following six specialties: ophthalmology, gastroenterology, cardiology, otolaryngology, family medicine and obstetrics/gynecology. All respondents agreed that the MSLC was an overall valuable experience and 67% agreed that the entire MSLC wellness content was useful in improving their own ability to practice wellness/self-care. The wellness strategy faculty ranked as most valuable was mindfulness, followed by cognitive restructuring. Faculty reported the strategies they used most frequently were 15 minutes a day self-care (60%) and diaphragmatic breathing and relaxation/imagery (both 40%) See Figure 1. Moreover, when asked to choose several words to describe their experience as an MSLC facilitator, faculty used words such as, "innovative," "educational," "fun," "interesting," "insightful," "collaborative," "interactive," and "reflective," among other positive descriptors.

Conclusions
This pilot study provides preliminary support for training junior doctors in evidence-based wellness strategies aimed at decreasing stress and promoting self-care. These findings indicate that medical learners may be able to adopt and benefit from stress management techniques which can be taught by physician faculty; so much so, in fact, that the interns in this sample endorsed that they planned to continue to use these strategies throughout the remainder of their residency.
Interns ranked cognitive restructuring and daily self-care as the wellness strategies they used most often and found to be most valuable for decreasing stress. Cognitive restructuring, or changing one's thoughts to change one's feelings, may be a particularly powerful tool for junior doctors to regularly utilise to modify their perspective, and subsequent negative affective states and perceived stress, about the numerous difficult scenarios they encounter during their first year of residency training. Indeed, research in other populations has demonstrated that cognitive restructuring can enhance perceived control over challenging situations (Hogendoom et al., 2014;Lachman, Weaver, Bandura, Elliot, & Lewkowicz, 1992). This may help to attenuate the feelings of helplessness, uncertainty and anxiety which many learners experience during the challenging year of internship. Cognitive restructuring has also been shown to decrease depressive symptoms in many populations (Fiske, Loebach Wetherell, & Gatz, 2009;Hetrick, Cox, & Merry, 2015) and has been demonstrated to be an effective component of a suicide prevention program for at-risk adolescents (Stanley et al., 2009). Therefore, regular use of cognitive restructuring strategies during internship may serve to decrease the risk of burnout, depression and suicidality among junior doctors in their first year of training.
It appears that interns may place great importance on being given "permission" by faculty to engage in daily self-care activities outside of medicine. Hence, teachers may consider encouraging junior doctors to regularly practice activities which promote well-being; both inside and outside of the hospital or clinic setting.
Faculty facilitators endorsed mindfulness and cognitive restructuring as the most valuable techniques for reducing their stress levels. Furthermore, they reported using daily self-care, diaphragmatic breathing and relaxation/imagery most often to reduce distress. Based on the findings of this preliminary study, faculty seem to enjoy, and also practice, better self-care as the result of learning and then teaching these strategies to interns. Teachers who regularly engage in focused wellness techniques may create a positive learning environment which may promote learner well-being. In this regard, future research should continue to take a "top-down," as well as a "bottom-up," approach by placing increased emphasis on both faculty physician, as well as physician in training, well-being in order to best promote and ensure the wellness of all.
This study had limitations. Because attendance at the MSLC groups was not mandatory, full participation by interns in each module was not obtained. Therefore, these results represent a small proportion of all interns and may be prone to selection bias. The investigator's sent out an informal survey to all participants after they had started their second year of residency. Some of the reasons given for lack of attendance at the final MSLC meeting included "too many other demands on my time," "seniors wouldn't let me leave the service," and "the group was held at the wrong time of the day-I couldn't get away from my duties to attend." However, the majority of these learners indicated that they had found the groups to be helpful and would recommend MSLC to their interns. Based on this feedback, it would seem that if more interns had been able to attend the final session, we would have received an even stronger endorsement of these wellness strategies, as well as the MSLC initiative as a whole. Future research would be improved by larger numbers of intern and faculty respondents.
Whilst only 20% of interns completed the final survey, the findings from this pilot study are still quite important, as they may serve to assist residency programmes in the development of effective physician wellness curricula which may reduce stress and encourage self-care behaviors among junior doctors enrolled in primary care, as well as other, residency training programmes. These preliminary findings suggest that medical learners may be able to adopt and benefit from specific stress management techniques which can be taught by physician faculty. Importantly, at the end of both years, the majority of interns endorsed that they planned to continue to use these strategies throughout the remainder of their residency.
" While I cannot change how tough night float is, I am quite surprised to discover that by changing my thoughts, I can then change my feelings and overall stress-level and, therefore, no longer have to dread those difficult rotations."-Anonymous Intern Future research should explore the use of wellness strategies in a greater number of interns and faculty and systematically assess the potentially beneficial effects of the utilization of particular wellness strategies; specifically scheduling daily self-care time and practicing cognitive-restructuring, on outcomes such as burnout, depression and suicidality. By "prescribing" these wellness techniques, we may enable junior physicians to circumvent the dark woods of distress and keep their feet solidly on the path which will lead them to brilliant, bright and happy futures.