Category Archives: Education

Exploring Burnout and Resiliency Using the Photovoice Experience

Background:  

Understanding physician burnout is an area of intense research. Commonly cited studies by Mayo Clinic and Medscape indicate levels of physician-reported burnout continue to rise.  Traditional ways of measuring burnout include questionnaires and surveys.  While these are popular and validated ways to assess burnout, they do not allow providers to self-define burnout and use scripted words that limit individual expression.  The movement to discuss burnout and its causes is welcome. However, perhaps more important is the shift that has occurred in the conversation from problem to solution.  Increasingly, the focus has been on the study of resiliency and how systematic changes can impact burnout rates.  

This exercise uses photography as a way for individuals to connect with and express what burnout and resilience mean to them.  Individuals will have the opportunity to self-express and process the experience of burnout or distress with others. Participation in the group experience will allow for perspective-taking and recognizing commonalities with peers. The shared experience gives participants the opportunity to be exposed to new strategies for resilience building by learning from their peers. Additionally, the outcome from the collective experience can lay the groundwork for systematic change.   

Photovoice is a qualitative method generally used in community-based participatory research.  It is action-oriented and meant to give a voice to people that are considered disempowered.  The aim of this research method is to evoke dialogue and create movement on social issues.  In this curriculum, the residents are empowered to use photography to create a shared experience which can lead to bolstering personal resilience and promotion of systematic change.   

Objectives: 

After participating in the experience residents will … 

  1. Use photography to express their personal views on burnout and how to combat burnout 
  2. Enhance personal resiliency skills as a result of the shared experience  
  3. Create a collective dialogue that can be used to influence systemic change 

Photovoice Assignment Participants Guide

Take two photographs*, one to answer each of the following questions. 

  • What is burnout? 
  • How do I prevent or overcome burnout? 

With each image, write a brief statement describing why you chose the image. 

*photographs should be taken personally by the participant, not images found on the internet  

Instructions regarding photographs: 

Do not take photographs that: 

  • Include people who can be identified (you can see their faces clearly) 
  • Include people’s body parts in a dehumanizing way 
  • Are sexually explicit 
  • Include protected health information

You are allowed to edit photos, but don’t spend a lot of time on this. The purpose of the exercise is not the photographs themselves, but the experience of reflection. 

Take a photo that you are comfortable sharing with your group.  

The photos will be part of a group discussion. 

Photovoice Assignment Facilitator’s Guide 

(for virtual learning experience) 

Pre-Group Session:  

  1. Send out the assignment 1-2 weeks before the planned group session. 
  2. Give instructions for participants to email the photos and their descriptions to you several days before the group session. 
  3. Prior to the session, create a virtual visual display of the images and captions.
    1. Consider creating a PowerPoint or Google Slide presentation. 
    2. Place one picture on a slide and the caption on the following slide.
    3. The pictures and captions should be grouped with burnout images together and resiliency images together.
  4. Send out a link to an online meeting platform.
  5. Depending on the number of participants, 1-2 hours will be needed. 
  6. The recommended group size for online learning is no greater than 10 people

During the Session: 

  1. Create a safe space and discuss possible trigger warnings with the option for individuals to take a break if needed. 
  2. Share the presentation with participants
    1. The presentation, because it is full of images, will likely be too large to mail.  Consider posting it as an online secure link (Example – Google slide file that has access through invitation only)
      1. Give the participants dedicated time to review the images and captions:
      2. 20 minutes is a good estimate but more time may be needed depending on the number of participants. 
  3. Instruct participants to view each photo and answer the questions on a notes page:
    1. What do you see in the picture?  
    2. With which images do you connect and why? 
  4. Transition to a group discussion.
    1. Group discussions on online platforms can be challenging due to a loss of normal conversational cues and conversational flow
    2. Facilitators may need to be more direct to evoke conversation
    3. Consider having a way to go through each image so they can be discussed (for example, using screen sharing of the presentation).  
    4. Consider going through each slide and asking for comments- either ad hoc or round robin style
  5. Facilitator’s role in the discussion:  
  6. Ask open-ended and follow-up questions to allow the dialogue to flow from the participants. 
  7. Identify themes or highlight differing perspectives (for example, if there are similar images in both the burnout and resiliency categories). 
  8. Help participants understand how their own context influences their perception of the images. 
  1. Look for opportunities to highlight and normalize shared experiences (debunk the “I thought it was just me” myth). 
  2. End the session with a conversation about how this exercise might spark individual or system-level change and what that could look like. 

Photovoice Assignment Facilitator’s Guide 

(for in-person learning experience) 

Pre-Group Session:  

  1. Send out assignment 1-2 weeks prior to planned group session. 
  2. Give instructions for participants to email the photos and their descriptions to you several days before the group session. 
  3. Prior to the session, create a visual display of the images and captions.   
  4. Think of this as a gallery walk experience- all the images should be on display at the same time in the space. 
  5. This could be done by simply printing the pictures and captions and fixing them to large post notes on the walls of the room. 
  6. The pictures and captions should be grouped with burnout images in one area and resiliency images in another. 
  7. Depending on the number of participants, 1-2 hours will be needed. 

During the Session: 

  1. Create a safe space and discuss possible trigger warnings with the option for individuals to take a break if needed. 
  2. Give the participants dedicated time to walk through the images and captions:
    1. 20 minutes is a good estimate but more time may be needed depending on the number of participants. 
  3. Instruct participants to view each photo and answer the questions on a notes page:
    1. What do you see in the picture?  
    2. With which images do you connect and why? 

**Consider having a handout with the above questions and space for note-taking.  

  1. Transition to a group discussion- consider having a way to go through each image so they can be discussed- you may want to use a PowerPoint of the images to facilitate the discussion. 
  2. Go through each image asking participants to share their thoughts and reactions.
  3. Facilitator’s role in the discussion:
    1. Ask open-ended and follow-up questions to allow the dialogue to flow from the participants. 
    2. Identify themes or highlight differing perspectives (for example, if there are similar images in both the burnout and resiliency categories). 
    3. Help participants understand how their own context influences their perception of the images. 
    4. Look for opportunities to highlight and normalize shared experiences (debunk the “I thought it was just me” myth). 
    5. End the session with a conversation about how this exercise might spark individual or system-level change and what that could look like.  

Download the Resiliency Photos

Download the Burnout Images

Implementing A Continuity-Clinic-Centered (C-3) Scheduling Model in Family Medicine Residency Programs: The Efficiency of Templated Automation 

by Derek Baughman, MD; Salma Green, DO; and Abdul Waheed, MD, MS, FAAFP
WellSpan Good Samaritan Hospital Family Medicine Residency Program, Lebanon PA

Background

As a core Accreditation Council for Graduate Medical Education (ACGME) accreditation requirement for residency programs, continuity clinic forms the foundation for competence in outpatient family medicine and is a practice focus of most graduates. The Association of Family Medicine Residency Directors’ Clinic First Collaborative1 is a popular conceptual model of achieving this foundational goal. Although many residency programs have adopted a clinic-first model, there is limited literature detailing the implementation of such scheduling models. Thus, we outline a high-yield Continuity-Clinic-Centered (C-3) scheduling model that is simple to implement.

Problem

Resident scheduling is complex due to multiperiod assignments and multiple constraints, including ACGME work-hour regulations and demanding coverage of the residency program’s inpatient services.2,3 For example, an analysis of scheduling complexity for a 24-resident family medicine (FM) program with only nine annual rotations resulted in more than 3,000 variables and more than 850 constraints3 Programs embracing a C-3 model can produce higher quadruple-aim care and have been endorsed by national organizations.4 Studies on FM residencies embracing these models have shown the feasibility of tackling complex scheduling with a two-pronged approach: separate master block schedules for core rotations and continuity clinics.5 The literature has highlighted the superiority of automated approaches to residency scheduling6 due to its ability to decrease drafting time,7 increase schedule quality,7,8 and improve resident satisfaction.8 

Intervention

Our 7-7-7 FM residency program utilized schedule templates constructed in hierarchical stages by postgraduate year (PGY). Starting with designated resident clinic days for each PGY class, we established a clinic team template (Table 1).  A separate template (Table 2) designated alternate days to coordinate residents on hospital service rotations. Subsequently, a 13-block hospital service and longitudinal subspecialty rotation block schedule (Figure 1) was constructed (separate Microsoft Excel sheets built specific longitudinal subspecialty rotation blocks and continuity clinics). The Excel “countif” function confirmed accuracy and fairness of resident block schedules facilitating a threefold tabulation: (1) even numbers of resident core rotations, longitudinal blocks, vacation and electives; (2), even numbers of subspecialty rotations; (3) a balance of preceptors, clinical staff, and provider availability at clinics.

Impact

The automated Excel spreadsheets facilitated predictable clinic schedules, enhanced resident empanelment, and promoted continuity of team-based care to fulfill the 1,650 outpatient visit requirement.9 This improved schedule coverage of 273 unique 2-week blocks of core rotations and clinic coverage for our 21 residents across three PGYs (Figure 1). Automation provided more efficient and accurate tabulation than prior hand-counting methods resulting in fewer scheduling mistakes throughout the academic year. Spreadsheets served as templates for subsequent academic years and significantly reduced both quantity and duration of scheduling meetings for administrative staff, chief residents, and program director. 

Although automated cloud-based physician scheduling software was considered for our program, high implementation fees10 rendered this an unfeasible option given our residency budget. Alternatively, we found simple Excel formulas an affordable solution to ensure accuracy of the C-3 model. Additionally, Excel’s conditional formatting feature facilitated instant visualization of gaps, over- or undercoverage, and preceptor supersaturation. Making schedule changes with this method also avoided the need to manually recount blocks as “countif” works in real time. This was exceedingly helpful for quickly understanding the effects of multiple residents requesting vacation or CME conference attendance. Most importantly, this same method can be applied to the clinic block schedule ensuring prioritization of clinics and their C-3 coverage. 

Conclusion

Clinic-first models for residency scheduling can be streamlined with simple templates that ensure fairness, balance, and reproducibility of resident scheduling. Automated templating with spreadsheet software is an evidence-based approach to navigate accreditation constraints and solve complex multiperiod assignments for residency programs. 

Figures and Tables

Table 1: C-3 Model of Resident Team-Based Clinic

Table 2: C-3 Model for Hospital Service Rotations (Including Inpatient, OB, and Night Float)

Figure 1: C-3 Model Longitudinal Block Schedule by PGY

References

1. Topaloglu S, Ozkarahan I. A constraint programming-based solution approach for medical resident scheduling problems. Comput Oper Res. 2011;38(1):246-255. doi:10.1016/j.cor.2010.04.018

2. Franz LS, Miller JL. Scheduling Medical Residents to Rotations: Solving the Large-Scale Multiperiod Staff Assignment Problem. Oper Res. 1993;41(2):269-279. doi:10.1287/opre.41.2.269

3. AFMRD – Clinic First Collaborative. Association of Family Medicine Residency Directors. Accessed March 17, 2021. https://www.afmrd.org/page/clinicfirstcollaborative

4. Brown SR, Bodenheimer T, Kong M. High-performing primary care residency clinics: a collaboration. Ann Fam Med. 2019;17(5):470-471. doi:10.1370/afm.2452

5. Bard JF, Shu Z, Morrice DJ, Leykum LK, Poursani R. Annual block scheduling for family medicine residency programs with continuity clinic considerations. IIE Trans. 2016;48(9):797-811. doi:10.1080/0740817X.2015.1133942

6. Ito M, Onishi A, Suzuki A, Imamura A, Ito T. The resident scheduling problem: a case study at Aichi Medical University Hospital. Journal of Japan Industrial Management Association. 2018;68(4E):259-272. doi:10.11221/JIMA.68.259

7. Perelstein E, Rose A, Hong Y-C, Cohn A, Long MT. Automation improves schedule quality and increases scheduling efficiency for residents. J Grad Med Educ. 2016;8(1):45-49. doi:10.4300/JGME-D-15-00154.1

8. Howard FM, Gao CA, Sankey C. Implementation of an automated scheduling tool improves schedule quality and resident satisfaction. PLoS One. 2020;15(8):e0236952. doi:10.1371/journal.pone.0236952

The Importance of Refugee Care in Family Medicine

The Issue

Walden_pic

Jeffrey Walden, MD

Immigration as a whole, and refugees in particular, have been much in the news for the past several years. According to the United Nations High Commissioner for Refugees, as of 2018 about 68.5 million people worldwide have been forcibly displaced—more than at any other time in human history.1 Over a third of these people have crossed international borders while fleeing persecution and violence, and have therefore been labeled refugees.

While war and political upheaval have uprooted people for centuries, the plight of those fleeing persecution formally became codified into law with the 1951 Convention Relating to the Status of Refugees. Based on this definition, a refugee is someone who, “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country.”2

The United States has historically resettled between 70,000 and 80,000 refugees per year, with a steep drop-off in the past several years due to changes instituted by the current presidential administration.3 With almost 30 million refugees worldwide, these numbers mean less than 0.3% of the world’s refugees are resettled in the United States in any given year. We as a nation can thereby exercise much discretion when selecting which refugees enter the United States. Indeed, the process to vet potential refugees involves security clearances by numerous federal agencies, including the Department of Homeland Security, and can take upwards of 18 to 36 months.

Historically, the United States has not discriminated a refugee’s case based on his or her ability to integrate. While this ensures granting the most vulnerable equal access to protection and resettlement, refugees may therefore arrive with chronic or serious health problems.4

The Importance to Family Medicine

Although all applicants for refugee status undergo health screening overseas by a trained panel physician, refugees may have had little prior care for any of their longstanding medical issues. Family physicians, whether in academic centers or private practice, therefore often encounter refugee patients after arrival in the United States. Learning to care for these—and by extension other—underserved patients serves an important part of the undergraduate and graduate medical education curriculum.

Refugees form a heterogeneous group, arising from areas of the world as disparate as East and Central Africa, the Middle East, Southeast Asia, Eastern Europe, and Central and South America. Despite these differences, they have some unifying factors—all refugees have faced persecution, by definition of their status. Many have been subjected to various diseases of poverty and nutritional deficiencies. All will face challenges when resettling in the United States with cultural issues and social determinants of health.

Culturally appropriate care—the type of care typically provided by family physicians—can help these patients better integrate into US society. Assisting refugees along their path toward self-sufficiency and citizenship requires developing strategic partnerships and community engagement. Fostering such relationships can potentially strengthen a clinic’s outreach in the community to address other social determinants of health for all clinic patients.

Involving Learners

Since 2014, the Cone Health Family Medicine Residency Program has sponsored a dedicated refugee and immigrant clinic within our larger family medicine clinic. Structured toward both learners and patients, the clinic serves as an intake evaluation to review the patients’ overseas paperwork, obtain medical and social histories (often the main difference between these patients and “regular” patients), screen for infectious disease, and identify any current needs or issues. The first 30 minutes of each clinic are dedicated to didactic teaching about a specific refugee topic, after which residents interview and examine the patient. The resident who sees that patient then becomes his or her primary care physician. All residents rotate through the clinic during their community medicine rotation:  2 weeks during their second year and 4 weeks during their third year.

Our clinic also serves as a rotational site for visiting third- and fourth-year medical students. This has provided students the opportunity to experience underserved care within a primary care and family medicine context. By working specifically with refugees, learners gain opportunities for advocacy, improvements in cultural humility and competence, and the ability to pursue global health work without needing to find the time or funds to travel.

Due to ongoing worldwide conflicts, issues of migration won’t be going away anytime soon. Exposing learners to such issues can broaden medical education while serving a community need. Beyond that, caring for refugees and learning how they have responded to persecution can teach clinicians valuable lessons about resilience in this time of perceived physician burnout.

Ways to Get Involved

  • Commit to seeing refugee patients in your clinic
  • Develop a refugee, migrant, or other underserved clinic within your program
  • Volunteer at an underserved clinic or health department
  • Conduct medical forensic evaluations for those seeking asylum
  • Complete N-648 certifications—a topic for a future blog post

Further Reading

References

  1. The UN Refugee Agency, Office of the United Nations High Commissioner for Refugees. Figures at a Glance. https://www.unhcr.org/figures-at-a-glance.html. Accessed May 22, 2019.
  2. The UN Refugee Agency, Office of the United Nations High Commissioner for Refugees. The 1951 Refugee Convention. http://www.unhcr.org/pages/49da0e466.html.
  3. Migration Policy Institute. S. Annual Refugee Resettlement Ceilings and Numbers of Refugees Admitted, 1980-Present. https://www.migrationpolicy.org/programs/data-hub/charts/us-annual-refugee-resettlement-ceilings-and-number-refugees-admitted-united. Accessed May 22, 2019.
  4. Hebrank K. Introduction to Refugees. In: Annamalai A, ed. Refugee Health Care: An Essential Medical Guide. New York: Springer Science; 2014:3-11. https://doi.org/10.1007/978-1-4939-0271-2_1