Brett Styskel, MD, a second-year resident in Baylor College of Medicine’s Internal Medicine Residency Program, recently recalled spending time at the bedside of an elderly patient who had received a serious diagnosis. Wanting to comfort the patient, who seemed especially down, Styskel and the rest of the small team of residents, interns, and students in the hospital room that day didn't limit the conversation to medical details.
They learned about the patient's supportive family and favorite activities and laughed at tales of the patient’s youthful antics.
“Spending time to understand the patient as a person really improved our rapport,” says Styskel, who with his wife Reina Styskel, MD, is coleading a novel program at Baylor meant to foster exactly this type of patient engagement. “It reminded us why we became physicians in the first place: to take care of people. Understanding our patient’s family situation and personal goals in more detail also helped us to tailor the treatment plan and follow up better.”
Dubbed “humanism rounds,” the Baylor program calls for internal medicine residents to intentionally set aside their cellphones, pagers, and medical records and truly connect with patients, taking time to ask about their families, jobs, and interests.
The goal? To better connect trainees with patients, which not only promises to improve patient care but could help combat the burnout that affects more than half of U.S. physicians and up to 76% of internal medicine residents. “The thing that fuels residents the most is engagement with patients,” says Tim Brigham, PhD, chief of staff of the Accreditation Council for Graduate Medical Education (ACGME) and cochair of the Task Force on Physician Well-Being.
In fact, the Baylor program is one of 30 trainee-led Back to Bedside projects launched this year at medical schools and teaching hospitals across the country. Spearheaded by the ACGME, the Back to Bedside initiative was originally designed to fund five projects. Instead, ACGME leaders funded six times that many after receiving more than 220 applications.
Combating trainee burnout
In recent years, physician and trainee burnout has emerged as a major concern for leaders in academic medicine. Burnout has been linked to increased odds for physician depression and suicidal thoughts as well as greater odds of medical errors and reduced quality of care, according to a 2017 Journal of Graduate Medical Education article.
To help fight physician burnout, the AAMC and ACGME, along with more than 50 other organizations, sponsor the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience, which is designed to identify the basic challenges to physician well-being, raise awareness of physician stress, and promote evidence-based, multidisciplinary solutions. This effort includes an online knowledge hub and has resulted in more than 150 organizations committing to fight clinician burnout.
Back to Bedside seeks to combat burnout in the first stages of a physician’s career. Conceived in May 2016 by the ACGME’s Council of Review Committee Residents, a national, multispecialty committee of 37 residents and fellows, the initiative identified several factors that might reduce trainee burnout. These include more time spent on patient care, a shared sense of teamwork, a reduction in the number of nonclinical tasks, and a supportive workforce, says Dink Jardine, MD, chair of the Back to Bedside advisory group.
The ACGME then called on trainees to submit proposals for transformative projects that they could implement in their learning environments. The projects, funded in January 2018 for one year with the potential for a one-year renewal, covered a wide range of specialties, locations, institution sizes, and approaches, Jardine says.
Increasing patient interaction
Baylor was not the only program to identify greater patient interaction during rounds as key to enhancing trainees’ sense of meaning in their work.
At the University of North Carolina (UNC) Department of Medicine, residents adopted a new rounding structure that brought in additional members of the care team and fostered a greater connection to the patient.
“There was universal discontent with the traditional rounding structure," says project coleader Katie Haroldson, MD, a second-year resident at UNC. “Patients felt that there was minimal face time with their care team and they had minimal involvement in their care. Nurses felt excluded from rounds. Physicians felt disconnected from their patients, spending most of their time speaking [to colleagues] or sitting in front of a computer screen.”
The project encourages all providers to complete a comprehensive review of a patient’s record before going on rounds. Each team member is engaged in identifying daily needs, says Anthony Mazzella, MD, a chief resident participating in the program, "and rounds is more of a time to reconcile these thoughts as a team, including the patients themselves.”
In the patient’s room, the team, which often includes a nurse and a pharmacist, discusses a proposed plan for the day. The conversation is led by a member of the team, usually an intern, who sits beside the patient. On their end, patients receive “FaceSheets” with names and photos of their providers to enhance the connection.
“Helping human beings when they are most vulnerable is what inspires hard work and dedication to our patients.”
Brett Styskel, MD
Baylor College of Medicine
Internal Medicine Residency Program
Mazzella says communication is already improving. “The main difference is that all of the discussion that traditionally occurred outside of a patient’s room behind a closed door is now being consistently moved inside, on eye level with the patient,” he says.
During the humanism rounds at Baylor, residents are encouraged to spend approximately 20 minutes at a bedside asking patients questions using the acronym PEOPLES— shorthand for Place, Environment, Occupation, People, Likes, Entertainment, and Service.
To prevent the rounds from lengthening already full schedules, resident teams choose days that typically offer more downtime, and most trainees participate once a week or every other week.
The time is well spent, says Styskel, adding that many involved in the program thus far have left the room visibly energized. “Helping human beings when they are most vulnerable is what inspires hard work and dedication to our patients,” he says.
At the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Back to Bedside focuses on boosting residents’ sense of autonomy.
“Historically, morning rounds are conducted by the attending, where most discussion and teaching is done by the faculty member,” explains Regina Makdissi, MD, associate director of the school’s residency program.
Under the new program, a resident or intern—the “Attending of the Day”—facilitates rounds, confirms the patients’ medical histories, elicits physical exam findings, communicates plans for the day, and, under the supervision of faculty, makes key care decisions, Makdissi explains.
Another new feature of the program is the daily “Close the Loop” rounds when residents and faculty meet bedside with patients who have complex conditions or other vulnerabilities. They educate these patients about their conditions, connect with family members, and answer questions. Families who aren’t able to attend can join in by Skype.
Restructuring the workday—including scheduling educational conferences weekly rather than daily—freed up two hours each week for these important patient encounters, Makdissi says. “The idea is that establishing a meaningful relationship with the patient is critical for medical residents to develop as physicians.
“The Attending of the Day and Close the Loop rounds also provide a critical opportunity for patients and families to discuss all aspects of their care in a more informal way,” Makdissi adds. “Teaching best practices in communications will have a positive impact on current and future patients.”
The ACGME is spending $130,000 on the inaugural Back to Bedside projects, and participating institutions provide matching grants. New applicants will be considered after two years.
“If this works, it will change everything.”
Tim Brigham, PhD
Some teams whose proposals didn’t receive grants are pursuing the projects anyway, which the ACGME encourages, notes Brigham.
Funded teams are required to provide outcomes data, and they have the opportunity to submit results for possible publication in the Journal of Graduate Medical Education. In addition, they are connecting through social media and periodic meetings to exchange ideas, identify barriers, and discuss strategies for national dissemination of successful projects.
“As far as I know there’s never been anything like this [for residents],” says Brigham, who notes that the program aims to put young physicians back in touch with the reasons they went into medicine in the first place. “If this works, it will change everything.”