By: Alison Banwell (https://ophthalmology.queensu.ca/faculty-staff/alison-banwell)
Competency Based Medical Education (CBME) seems like it should help with the so-called “wellness curriculum” as opposed to the previous teaching paradigm. With the adaptability of CBME to the individual, the tailoring the curriculum to a specific circumstance, it sounds like an ideal model in which to support residency education; and if you support education, you must be supporting the individual, correct? However, with the launch of Competence by Design, Canada’s approach to CBME, the Royal College’s Resident Pulse Check from 2022 elucidates the opposite, with most respondents feeling that CBME has actually negatively affected their personal wellness.1
How is wellness delivered and promoted within a CBME context? What does “wellness” mean to the resident, and what does it mean to the program? Can you assess someone on their resilience? Is it a checkbox at the end of a form, at the end of the mandatory check-ins that accompany the CBME journey? Is it a yoga session that residents are expected to attend before rounding at 6am? Is it a lunchtime rounds focused on time-management, typically aimed at business professionals? These types of interventions are more likely to evoke eye-rolls from residents rather than support, but what complicates the issue is that those may actually be the ideal interventions for some. For others, they may be irrelevant, or worse, give the impression that the program is tone-deaf to the resident’s struggle.
I have been privileged to discuss wellness issues at length with fellow residents as part of the Queen’s Residency Medical Education Committee (QRMEC). This committee has evolved since it was created during the launch of CBME at our institution, originally designed to amplify the resident voice across programs. QRMEC gives us a forum, with one resident representative from each program, to discuss educational issues that go beyond our chosen specializations. Personally, I think it is the unity in our goal of improving education, combined with the diversity of solutions to the challenges that face each program, that allows for richer discussion. It was in this forum that we put together an attempt to define what residents want from their programs in terms of wellness support and promotion.
It would be unfair to pretend that what we came up with will hold true for all residents and contexts. We are not wellness experts, but I would argue that we are experts at the lived experience of being residents. Our discussions revolved along some themes that can be considered in a broader CBME context when considering resident wellness initiatives:
Sharing of responsibility
Residents contribute an enormous effort to succeed within CBME. The administrative and cognitive load to log the required encounters, the effort that comes with chasing down assessments, and the seemingly endless self-reflections were not present in the old residency training paradigm, which often goes unrecognized by programs. Residents in our group described the stress associated with tracking, submission, and completion of required assessments as being the most likely to negatively affect their wellness, and yet, this is the basis of the CBME model. Almost like a holdover from the previous paradigm, the completion of these requirements is the resident’s responsibility. The QRMEC group felt that if our preceptors recognized, or even better, took on some of this responsibility, it would immediately improve resident wellness. This issue is most strongly felt when residents are struggling to complete requirements. How a program supports, or reprimands, a resident who is not meeting assessment targets is a major determinant of resident stress.
This seems like an odd theme at first, but in times of high stress residents’ wants are reduced to the basic needs. A successful intervention by two of the busier surgical programs at our institution was the provision of a “snack-fund” for overnight food when on call, although the snacks are available at all times. I would argue that this type of intervention would appeal to most – who doesn’t love free food? But it is more than that; when the hospital becomes a food desert after 10pm, raiding the snack cabinet at 2am between urgent ORs escalates from a nice perk, to an act of survival. The enactment of a snack fund also represented a time where residents had a discrete problem that was addressed by the program with a discrete solution; there is little else that makes a resident group feel more supported. Determining the particular issue facing your resident group is the foundation to creating a successful wellness intervention.
Time off acts as a release valve in periods of high resident stress. Residents agreed that what makes time off more valuable is that it be predictable and scheduled. It doesn’t even have to be frequent! Quarterly wellness half days have been instituted with success in some programs at our centre. Taking care of simple things, like appointments or banking, requires advanced planning, so having a clinic be cancelled and suddenly having the afternoon off is not a substitute. Secondly, the freedom to choose whether that time be used to complete appointments, exercise, research, studying, or simply to sleep, is actually part of what makes that time off valuable. At a seminar for graduating residents at our institution, when asked what we look forward to most after graduation, autonomy was second only to making enough money to put a dent our debt burden. The chance to choose, even if it’s just for one afternoon, gives residents a moment of control.
Finally, my last piece of advice is to remain adaptable with your wellness strategy. Figuring out what works within your group may be trial and error. Just like residents in CBME, programs are expected to have a growth mindset, and are allowed a few sub-par attempts at addressing resident wellness before they start achieving their goal. What’s important, is that you are trying in the first place.
Alison Banwell, is a PGY5 in Ophthalmology at Queen’s University. She is the previous Resident co-chair for the Queen’s Resident Medical Education Committee, and has a special interest in medical education and CBME, having been a part of the CBME program since starting residency.
- Resident Pulse Check 2022. Executive summary accessed Sept 4th 2023 from: https://www.royalcollege.ca/ca/en/cbd/understanding-cbd/cbd-program-evaluation.html
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