Mayo Clinic
Rochester, MN

Program Director: Kianoush Kashani, MD
Program Type: Critical Care Medicine
Abstract Authors: Perliveh Carrera, MD, Alice Gallo De Moraes, MD, Amit Sood, MD, Kannan Ramar, MD, Kianoush Kashani, MD

BACKGROUND
Studies have shown that distress symptoms are commonplace among physicians. Burnout is a psychological syndrome arising in response to chronic emotional and interpersonal stressors on the job. In a study by Embriaco, 50% of intensivists exhibited burnout and those with high burnout levels reported conflicts with coworkers.1 Moreover, stress symptoms and depression have been associated with lowered standards of patient care and serious medical mistakes.2 Given the negative impacts of stress and burnout on a person’s well-being, initiatives have been described to help reduce its deleterious effects using resilience training with encouraging results.3 We started resilience training for critical care fellows using the Stress Management and Resiliency Training (SMART) program as an innovation to help decrease stress and improve burnout symptoms.

METHODS
A survey was conducted between March and September 2013 on 58 critical care fellows enrolled in the Pulmonary and Critical Care Medicine, Critical Care Medicine, Critical Care Anesthesia, and Neurology Critical Care fellowship programs at Mayo Clinic, Rochester.

The survey was a composite of the Gratitude Questionnaire-Six Item Form (GQ-6), Satisfaction with Life
Scale (SWLS), Subjective Happiness Scale (SHS), abbreviated Maslach Burnout Inventory (MBI) scale, and Perceived Stress Scale-14 item (PSS-14).

After one year, fellows who completed a brief course were resurveyed to assess the impact of the SMART program in their perceived stress, burnout, and overall quality of life.

Twenty-one first year Critical Care fellows went through the program. SMART program is a single, 90-minute session training adapted from the Attention and Interpretation Therapy (AIT), a structured form of therapy developed at the Mayo Clinic aimed to decrease stress and enhance resilience. The program consisted of handouts and presentation tackling causes of stress. It introduced ways of framing one’s mindset to reduce stress awareness by attention training, which consisted of focusing on the novel and shifting one’s attention from inward to outward. Higher principles of gratitude, compassion, acceptance, meaning, and forgiveness were instilled to guide interpretations. Finally, fellows were provided with structured relaxation training by utilizing paced breathing meditation and taught to practice deep diaphragmatic breathing.

RESULTS
There were differences in stress levels, gratitude, happiness, satisfaction with life, and burnout based on age, gender, type, and stage of fellowship on linear regression analyses. Graduating fellows had significantly higher aMBI scores compared to other groups.

Wilcoxon signed-rank testing for fellows who completed the SMART program training showed no significant change in both SWLS and aMBI scores. The PSS-14 score was significantly higher after the SMART program (p < 0.0001). Both GQ-6 (p < 0.0001) and SHS (p = 0.04) scores were significantly lower after the resilience training.

The SMART program evaluation was favorable with 67% expressing that their ability to deal with stressful situations have been strengthened and provided them with tools to avoid burnout. 61% have reported they still use the techniques they learned after one year.

CONCLUSIONS
One year after the SMART program, burnout and satisfaction scores remained the same while stress measures trended up. This may suggest that the initiative helped mitigate higher burnout levels as fellows advanced through training. Our innovative SMART program improved the fellows perceived abilities to deal with stressful situations, along with preventing burnout.

REFERENCES
1. Embriaco N,et al. High level of burnout in intensivists:prevalence and associated factors. Am J Respir Crit Care Med 2007
2. West CP,et al. Association of resident fatigue and distress with perceived medical errors. JAMA 2009
3. Schiraldi GR,et al. Resilience training for functioning adults: program description and preliminary findings from a pilot investigation. Int J Emerg Ment Health 2010