Championing well-being amid COVID-19

Sujata Prasad, MD, FACP, and the ACP Connecticut Chapter had it all planned out: a post-holiday retreat by the sea in late January.

“I thought after the holiday would be a great time to do it. … My idea of bringing this together was that, first of all, this should be fun. It's not another meeting,” said Dr. Prasad, a general internist in private practice who serves as chair of the chapter's Wellness Committee.

She said she organized the retreat because of the high burnout rates and decreased opportunities for socializing among physicians and trainees during the COVID-19 pandemic. During this time, Dr. Prasad experienced her own burnout, describing in a poem the spinning treadmill of another day in the office: “Patients, disease, COVID, emails, consults, Zoom, prescriptions, family, housework, dinner.”

In contrast, the retreat would invite physicians to connect, relax, and meditate at a spiritual retreat center, as well as showcase their talents through an art exhibition and a variety of musical performances by trainees. But as has happened so many times before, a COVID-19 surge changed well-laid plans.

“I didn't realize that this omicron virus was going to hit. … Half my staff is actually sick with the virus, they're all out. We have physicians, we have staff members, residents, and they are all getting infected,” Dr. Prasad said in a January interview. “We're all vaccinated but still getting sick.”

Although the retreat had to be rescheduled for May, well after the holidays, Dr. Prasad is looking on the bright side, especially since it's at capacity with more than 50 physicians attending. “At the end … we're going to have a gratitude session,” she said. “My thoughts are actually to have people explain their gratitude to life or whatever is important to them, so leaving the conference on a positive note despite the COVID.”

Throughout the pandemic's constant challenges, ACP members have emphasized the importance of physician well-being. They shared how they've taken care of each other by creating supportive spaces, working together, telling stories, and even climbing mountains.

Working together

In recent years, the College has sharpened its focus on improving well-being for its members.

Efforts started ramping up in 2014, when ACP began to establish its Well-being Champion program, a network of trained volunteers based in most of its 85 chapters. In 2018 and 2019, the program trained more than 150 champions in eight countries, according to a report published in December 2021 by the Journal of Wellness.

After training, more than 90% of champions felt able to articulate the evidence for burnout prevention and suggest interventions, access resources, and administer well-being surveys, according to the paper. In addition, 88% to 90% felt able to foster a well-being community, and 85% felt comfortable engaging leadership on this topic.

But during COVID-19, ACP's well-being community had to come together to support each other even more, said Susan Thompson Hingle, MD, MACP, a Well-being Champion for the Illinois Southern Chapter and Chair of ACP's Physician Well-being and Professional Fulfillment Committee.

“We're going through really difficult times with the pandemic, and when you're the people tasked with helping the people who are struggling, there's a big emotional tax that goes along with that, and it can be really draining,” she said.

The pandemic was an impetus for the College's well-being community to work together to support the champions and help them attend to their own well-being, said Dr. Hingle, who is a professor of medicine and associate dean for the Center for Human and Organizational Potential at Southern Illinois University School of Medicine in Springfield.

“One of the biggest additions to the goals was really, how do we support each other as we go through this?” she said. “So there have been opportunities for the champions from different chapters to work together, not only on sharing programming, but sharing that support.”

One way ACP has increased awareness of well-being programming is the I.M. Thriving newsletter for Well-being Champions, which started in 2019 and continues to bring chapters together, Dr. Hingle said. “People have reached out to other chapters doing things that sound interesting and worthwhile to them.”

Throughout 2021, Well-being Champions from across the country participated in an ACP Wellness series, which explored such topics as appreciative inquiry, organizational culture change, self-care, and organizational small wins. Chapters involved in planning and presenting the various webinars included Illinois, Arkansas, Michigan, New Mexico, Texas, and Puerto Rico.

Such collaborations help members learn together but also take care of each other on a more emotional level, said Dr. Hingle. “I think that health care and education have often recognized the importance of learning collaboratives and learning communities, but maybe not so much communities of caring,” she said. “That's what I think is really different about what's happening now.”

ACP members are reaching out to each other not only across the country but around the world. For Mukta Panda, MD, MACP, a Well-being Champion who was raised and educated in India, this has taken the form of being invited to virtually present on well-being to ACP members in India, Bangladesh, Saudi Arabia, and Japan.

In her presentation for a Doctor's Day event hosted by the ACP India Chapter last July, Dr. Panda spoke about why calling health care workers “heroes” is harmful. “It puts this undue pressure on us for no reason,” she said. “We feel we have to be at our best all the time, even be perfect. We fear failure and even being ridiculed and dismissed. Further, this label stifles any meaningful discussion about crucial issues that negatively impact our work, like the workload, dysfunctional processes or teams, and our own vulnerabilities. But we are human, and I think once we acknowledge ourselves as humans … it allows us to raise such fears and it also combats the moral distress that we feel, and we feel that we can ask for help.”

In her presentation, Dr. Panda also shared the Oath to Self-care and Well-being, which she cowrote with Kevin E. O’Brien, MD, FACP, and Margaret C. Lo, MD, FACP, and which was published in the February 2020 American Journal of Medicine. “The Hippocratic Oath is timeless, but our health care today is very different,” she said. “So I think this oath complements and adds to the Hippocratic Oath.”

Dr. Panda also touched on this theme in her presentation on why self-care is not selfish at ASIAN ACPCON, which was held in February 2021 and focused on resilient physicians. Neglecting one's own needs and exhausting the self in order to give to others can turn into destructive altruism, she said. (For more on this theme, see the sidebar by Maria Maldonado, MD, FACP, below.)

“How can you give to somebody if you've depleted yourself? … That's what the Oath to Self-care and Well-being is all about: It is this partnership with our colleagues, our organizations, our health care system, and ourselves to ensure that we are going to prioritize care of each other, care of our individual selves, so that we can offer the best care to our patients,” she said.

Sharing stories

Offering the best possible care to patients is always top of mind for ACP members, who also have a long tradition of sharing stories about doctoring. For example, Annals of Internal Medicine's “On Being a Doctor” section, which features reflections on the profession, started in 1990 and continues to inspire new ways of storytelling, such as Annals Story Slams.

The series also inspired the ACP New York Chapter's Well-Being Committee to try a different approach to alleviating physician burnout in 2021.

“We were doing a lot of talking and sharing ideas … and then we started to realize that it would be more useful to do things than talk about burnout or talk about being burned out,” said Lynn Cleary, MD, MACP, a Well-being Champion who chairs the committee and a general internist, professor of medicine, and vice president for academic affairs at Upstate Medical University in Syracuse, N.Y.

The committee had the initial idea of starting a book club, she said, but there was the reality that most members simply wouldn't have the time to read and discuss entire books together. Then there was an idea that stuck: providing a venue for ACP members to discuss short, provocative readings, such as “On Being a Doctor” essays, in a virtual format.

Louis Snitkoff, MD, MACP, who was then Immediate Past President of the New York Chapter, named the resulting series “Small Feedings of the Soul,” a twist on the College's longstanding “Multiple Small Feedings of the Mind” sessions held at the annual Internal Medicine Meeting. “This was a turn on that concept, emphasizing that you can do things in small amounts and get a lot out of them,” said Dr. Cleary.

The process from idea to implementation of the series took only two months, and the first event was held in April 2021, said Amanda Allen, the manager of communications and district relations for the chapter.

“It was really quick because we recognized that it was needed, and the other thing that allowed for it to be quick was the use of ‘On Being a Doctor.’ … It was a great resource that ACP already had for us to use, so that made implementation a bit easier,” she said.

Each monthly session has a theme, and previous themes have ranged from self-care to responding to substance use in patients, said Nandini Anandu, MD, FACP, a Well-being Champion and an internist in Westchester County, N.Y. “A lot of these pieces are about humanism, empathy. Some more serious subjects too are there: loss, grief.”

The event welcomes authors to read their full pieces, and sessions are not recorded, which allows for candid discussion, said Cori Salvit, MD, FACP, a Well-being Champion and program director of the Memorial Sloan Kettering Cancer Center Transitional Year Residency Program in New York City.

“It's surprising how moving listening to the piece is,” she said. “Sometimes you take even more out of the piece once you've heard it read for you, and I think that that often leaves the participants feeling like, ‘Wow, I got chills or goosebumps,’ because we've really had some moving authors join us.”

Dr. Anandu said one of her favorite moments of the series so far was when Steve P. Sanders, DO, FACP, read his “On Being a Doctor” piece “The Patient in Front of You,” which was published in Annals in April 2020. “It was sort of a reminder, in the day of [electronic medical records] especially, to really connect with the person sitting in front of you and take time to listen,” she said. (For more on this, read the Pearls from I.M. Peers column in this issue.)

After Dr. Sanders' reading, one attendee shared that she had saved the piece when it was first published and kept it on her desk as something to reference to keep her motivated and encouraged, Dr. Anandu noted. “It's been beautiful to see emotions felt, the sentiments expressed, and the community that's being built.”

The Tennessee Chapter also expanded its well-being offerings to include virtual discussions during COVID-19, said Dr. Panda, who is a professor of medicine and medical education and assistant dean for well-being and medical student education at the University of Tennessee College of Medicine Chattanooga.

Although the chapter had had a well-being task force for five years and regularly held one well-being session at regional meetings, engagement was mainly via email, she said. “Then COVID hit, and in 2020 … we learned the value of having Zoom meetings, so we started what was called Connections and Conversations,” said Dr. Panda.

As part of the weekly series, physicians speak about how they thrive and about what gives them meaning and purpose, and the Chapter's Well-being Champions share skills and tools through role modeling and conversation, she said.

“The purpose of Connections and Conversations is purely to say, ‘Hey, we are here. We care about you. We hear you. We want you to be present with us in whatever way you can,’” said Dr. Panda.

Walking the walk

Hiking is another way ACP members are connecting with each other, even during COVID-19.

Out in the mountain region, the University of Utah Internal Medicine Residency Program in Salt Lake City launched the Utah Internal Medicine Mountain Challenge in 2019, and members haven't stopped hiking since.

The challenge was one of four winning proposals in ACP's Well-being Champion poster competition, which were originally intended to be presented and displayed at Internal Medicine Meeting 2020. Eighty of 130 residents participated in the challenge, with 95% reporting that it contributed to their sense of community within the residency and 78% reporting that it contributed to their overall sense of well-being, according to the poster, which was submitted by Sonja Raaum, MD, FACP, a Well-being Champion for the ACP Utah Chapter.

The well-being initiative was the brainchild of program director Caroline K. Milne, MD, FACP, who is also active within the chapter, said ACP Member Josephine Wright, MD, who was then chief resident and part of the team that implemented it. “She reached out to past, present, and future chiefs, and we each contributed one of our favorite hikes.”

Challenge participants could choose from more than 15 hikes and received a point for each hike they completed. While the ultimate goal for challengers was open-ended, organizers encouraged them to go on at least five hikes, said Dr. Wright. Extra points were available for those who hiked with fellow residents, and there were even more points up for grabs for those who went out with a faculty member.

“It was just encouraging people to connect in this way, which ended up being really helpful in the pandemic when we couldn't really gather in indoor settings,” Dr. Wright said, adding that the participants who earn the most points are named the king and queen.

While COVID-19 hasn't deterred the hikers, it has affected how the group celebrates at the end of each year's challenge. “The first year, we had a taco truck and a huge celebration. We had pins for everyone and T-shirts for everyone who did five hikes,” Dr. Wright said. “The second year, because of COVID, we were unable to gather … and [in 2021] it did happen in an outdoor, socially distanced setting.”

There's no formal sign-up for the challenge (although many participants share their hikes on social media using #UtahIMMountainChallenge), and the difficulty of the hikes ranges from easier ones that take less than an hour to harder ones that can take all day, she said.

“There's really something for everyone, and I think it's easy to do after you get off work. Many of the residents would just go out for a hike after. … I think it's a really great escape from the hospital,” said Dr. Wright, who is now an associate program director for the residency program and works with the Medical Student and Resident Committee of the ACP Utah Chapter.

In addition to the benefits of unplugging from work (and often cell service), the hikes have fostered well-being by encouraging active, healthy lifestyles, she said. “Getting out there and being physically active was another main goal of ours, and really just to highlight the beauty of our region and the uniqueness of our landscape here.”

The natural world is also a major theme of the Connecticut Chapter's wellness programming. In 2021, Dr. Prasad organized several free events that invited chapter members to hike, practice yoga, meditate, and even attend a wine tasting together. She encourages physicians to make time for things they enjoy and to find others who have the same interests.

“Once we go through our medical education, we don't have enough time to follow our own hobbies. Medicine takes 100% of our time … so this kind of gets your mind off things,” said Dr. Prasad, who is also an assistant professor of clinical internal medicine at Yale University School of Medicine in New Haven, Conn.

In contrast to her poem about burnout, Dr. Prasad has also written “Meditation by the Sea,” a poem that describes the colors and rhythms of the seaside and culminates in her worries melting away in the natural landscape. Although Dr. Prasad practices daily meditations, she said meditation doesn't have to be a formal ritual; depending on the day, she fits in 20 minutes in the morning or at lunchtime.

“No matter what frustrations you have in your life, you can listen to your inner voice and you just calm down. … Even if you don't meditate, just to sit out and watch the birds and watch the nature and realize that there is more to life—that we actually live in a beautiful world—that's very helpful too,” she said.