“First Night-onCall” 2020: Preparing for Internship in the Face of a Pandemic

From the 8/7/2020 newsletter

Invited Commentary

 

 “First Night-onCall” 2020: Preparing for Internship in the Face of a Pandemic

 

Sondra Zabar, MD and Kinga Eliasz, PhD MS – New York University Grossman School of Medicine

 

Drs. Zabar and Eliasz are on the team that instituted the “First Night-OnCall” (FNOC) experience for trainees. In this essay, they describe the experience of modifying FNOC and running “FNOC 2020” in the pandemic era…

 

The transition from medical student to resident is difficult and dicey for patient safety in the best of times. In the US, virtually all recently-graduated medical students begin their residency training as interns on or about July 1. It has been reported that, in some academic settings, hospital-based risk-adjusted mortality rate goes up 4-8% in the first two months of a new residency year. While the cause of this bump in mortality is contested, we take seriously our responsibility to ensure all new house officers are as prepared as possible for unfamiliar clinical settings and dramatic increase in patient care responsibilities.

In COVID-19 times, everyone is looking at this transition through a new lens. Last spring, almost all near-graduate medical students across the country were pulled off their final clinical rotations. At the same time, these medical students needed to be ready to join the pandemic front lines on July 1 as interns. Special attention was needed for the safety of our patients, learners, staff, and faculty. We needed to design effective instruction to empower communities of learners with both the core values and outstanding diagnostic and communication skills that would be needed during a pandemic.

We knew that evidence-based orientation-to-residency strategies based on experiential learning and performance-based assessment are the most efficient and effective approaches to set expectations and build a resilient, unified workforce in this new era of practice.

How would we do this?

 

Adapting and Implementing First Night-onCall (FNOC) to the COVID-19 Era

We first created and implemented First Night-onCall (FNOC) at NYU Grossman School of Medicine (NYUGSOM) in 2017, a large-scale, authentic, immersive simulation developed to support incoming interns, address the hospital’s need to improve early escalation of seriously ill hospitalized patients, and cultivate our medical center’s culture of safety from Day One of residency. FNOC provided a collaborative, immersive “on call” simulation experience for all incoming interns across many of our largest residency programs. The program was so well-received by interns, faculty, and leadership, that it is now a core component of the residency orientation experience.

This year, FNOC – developed in collaboration with our simulation center (NYSIM) and core GME faculty – was adapted to the COVID-19 pandemic with the following goals:

1. Demonstrate the institution’s commitment to supporting both intern and patient safety.
2. Solidify each intern’s core knowledge base using WISE-onCall (WOC) Modules, a transition-to-residency curriculum on common safety issues which is part of the Aquifer collection of online clinical learning tools.
3. Reinforce the importance to patient safety of checking two patient identifiers and the appropriate escalation of urgent care.
4. Ensure each intern could properly “don and doff” Personal Protective Equipment (PPE).
5. Address interns’ concerns and comfort with caring for COVID-19 patients.
6. Provide a forum for interns to meet their peers and leaders, voice their concerns, and understand resources available to them.

To accomplish these goals, “FNOC 2020 COVID Edition” orientation included the following features:

1. Priming pre-work:  Incoming interns were asked to complete at least five out of the available twelve WISE-onCall online modules.
2. Shortened, in-person three-hour immersive simulations: New interns, in small groups, were challenged to:

o   Don/doff PPE and engage in a mannequin-based team simulation.

o   Evaluate a decompensating, hypotensive patient and activate a rapid response team (escalation) using remote standardized patient and nurse interactions, where learners were assessed using behaviorally-anchored checklists.

o   Recognize a mislabeled blood culture bottle.

o   Conduct an effective patient handoff.

o   Engage in a faculty facilitated debriefing of the entire experience emphasizing COVID-19 specific concerns.

 

Assessing Interns’ Concerns Prior to FNOC 2020

At the start of FNOC, interns reported being concerned about having adequate access to appropriate PPE. They worried about virus exposure despite the use of PPE. They felt unprepared, uncomfortable, intimidated, and anxious. They recognized they needed additional PPE don/doffing training and ventilator management. Despite their concerns and skills deficits, they were committed to caring for COVID-19 patients and were eager to learn current care protocols, and care for patients. 

Prior to FNOC 2020 COVID Edition, only 13% of the 215 participating interns from twenty-two residency programs reported having had seen, and only 19% felt comfortable with, providing care for a COVID-19 patient. Although 42% of the brand-new interns reported having ever witnessed a medical error, only 26% reported any formal patient safety training, and only 2% had any experience reporting a medical error.

 

FNOC 2020 was successful

Assessing and addressing our new interns’ knowledge and attitude regarding caring for COVID-19 patients was critical.

The impact of the session was reassuring for our institution.  80% of the interns reported greater comfort caring for a COVID-19 patient. This year, for the first time, 94% of entering interns completed more than the required number of WISE-onCall modules and over 90% agreed that the modules increased readiness-for-internship by providing a framework to organize clinical information. Almost all interns endorsed that FNOC 2020 was an effective, fun, and engaging way to learn patient safety, and 100% felt that it was an overall good approach to improve readiness-for-internship.

Patient safety awareness was also improved. They were reminded of the importance of checking two patient identifiers, and properly donning/doffing PPE. After FNOC 2020, 91% of interns reported that they were more comfortable speaking to a supervisor, to escalate an urgent situation and report a medical error.

 

As medical educators we must challenge ourselves to create engaging, immersive, innovative, and flexible simulation group experiences such as FNOC that can be rapidly adapted to the educational needs of any level of learners. In our experience, a deliberately-designed experiential orientation reduces the variability seen in entering interns, builds community and instills aspirational institutional norms – generating a culture of safety for patients.

 

 

Sondra Zabar, MD is a Professor of Medicine and Director of the Division of General Internal Medicine at the NYU Grossman School of Medicine, and Affiliate Professor of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. She is a national award-winning medical education researcher with expertise in performance-based assessment of clinical competence.

Kinga Eliasz, PhD MS is a Postdoctoral Research Scientist and Assessment and Evaluation Analyst in the Research on Medical Education and Outcomes (ROMEO) Unit of the Program for Medical Education Innovation and Research (PrMEIR), Division of General Internal Medicine and Clinical Innovation, NYU Grossman School of Medicine. She is also a Deputy Editor of Teaching and Learning in Medicine: An International Journal.

How to Be an Antiracist by Ibram X. Kendi Chosen as the MCW Common Read

 From the 8/7/2020 newsletter 

 

 

How to Be an Antiracist by Ibram X. Kendi Chosen as the MCW Common Read

 

Anna Janke, MCW Class of 2023

Associate Editor

 

Ms. Janke discusses the process and outcome of this year’s search for the book that will be the MCW Common Read…

 

It took us the entire school year to choose this upcoming year’s Common Read selection. Led by then-M4 Sophia Lindekugel, the Book Selection Committee read dozens of books suggested by MCW community members to pick a book that would be timely, readable for a wide audience, and actionable to spark meaningful change. As a lifelong reader and now a member of the Book Selection Committee, I really enjoyed reading books that opened my eyes to topics I had not explored in depth before, ranging from the opioid epidemic, to the Flint water crisis, to the individual and societal impacts of sexual assault.

However, after selecting a book with which we were all thrilled to announce, these plans were pivoted once we noticed, and joined in on, the outcry surrounding the deaths of George Floyd, Breonna Taylor, and far too many others. The MCW Common Read Leadership felt that it was necessary to shift this year’s Common Read to one that would center around race and race relations in America, shelving our previous selection for another year.

While the time allotted to select a book was now much shorter after the decision to pivot, many inspiring voices came forward to recommend titles that would spark discussions throughout the MCW community about race. It was humbling to realize that we have been late to join this movement; The MCW Office of Diversity and Inclusion (ODI), Student National Medical Association (SNMA), and the Center for the Advancement of Women in Science and Medicine (AWSM), among others, have been leading MCW for decades towards progress in health equity, workplace climate, and the dignity of every person.

In the end, we wanted as many community voices to be heard as possible for this year’s Common Read. We met with key stakeholders, including representatives from the aforementioned groups, to select three books from which MCW would vote. After 548 people weighed in, we are thrilled to have How to Be an Antiracist by Ibram X. Kendi as the 2020-2021 MCW Common Read.

While I am both elated and terrified to be a Co-Chair for this year’s programming, I am confident that the Common Read Leadership and the rest of the MCW community will come together to get our hands dirty and make mistakes so we can learn from those mistakes and take important steps forward in the lifelong journey that is Antiracism.

 

  

Anna Janke is an MD Candidate in the MCW Class of 2023. She serves as an Associate Editor of the Tranformational Times.

Milwaukee is Special; Let’s Make Some “Good Trouble, Necessary Trouble”

From the 8/7/2020 newsletter

 

Milwaukee is Special; Let’s Make Some “Good Trouble, Necessary Trouble”

 

Adina Kalet, MD MPH

 

 

Dr. Kalet shares how the message of Representative John Lewis’s farewell letter to the American people resonates with how the Kern Institute must take up the challenge to create inclusive, equitable medical education systems …

 

 

On the day of his funeral, John Lewis, the civil rights warrior and seventeen-term Congressman from Georgia’s 5^thCongressional District, published a love letter to the American people in the New York Times. He wrote his inspired and inspiring essay while dying of cancer, knowing that the country he loved was in crisis. “You filled me with hope about the next chapter of the great American story when you used your power to make a difference in our society.” 

 

Lewis reminds us that “Redeeming the Soul of Our Nation” will require a “long view” which, I believe, is also our approach as we redesign medical education to create a new physician work force. Doing meaningful and important work is a process, not an outcome.  As an ancient Jewish ethicist reminds us, we are not responsible for finishing the work of "perfecting the world,” but neither are we free to stop trying. 

 

 

Our home: Milwaukee is a very segregated city

 

We have some complex work to do in our own hometown.

 

Milwaukee has the long-standing, dubious distinction of being among the worst places in America to be Black. A black child born into poverty in Milwaukee is more likely to continue to be poor than in any other large city in the country. Deeply entrenched, persistent and concentrated poverty, extreme racial segregation, and exclusionary zoning or “redlining” have been blamed for the poor social mobility for our children. There are endless, complex explanations for this “special” status. 

 

Research studies confirm that health disparities are both directly and indirectly linked to these social determinants of poor health. Scientists from multiple institutions have identified that the incremental, accumulated physical effects of racism over a lifetime contribute to health inequities. Recently, this disparity has included the disproportionate illness and death of Black Milwaukeeans from COVID-19. No matter how you assess the current situation, things appears bleak. 

 

Yet, John Lewis – a Black man who lost as many battles for racial justice as he won and who was beaten and arrested over fifty times for engaging in militantly non-violent protest against racial injustice – was optimistic when he died. 

 

Lewis believed in us. He exhorted us to be aspirational. He wrote “Ordinary people with extraordinary vision can redeem the soul of America by getting in what I call good trouble, necessary trouble.” It is time for those of us in medical education to do some significant envisioning. But where do you look for the leadership? Inward? 

 

 

Time to make some good and necessary trouble

 

As the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education, I am always on the lookout for opportunities to think boldly and make a bit of good and necessary trouble! 

 

I am proud of MCW and its 125-year history of being an anchor institution in Milwaukee and the region. In John Raymond’s most recent Letter from the President, he reviews a list of the substantive ways in which MCW has been an exemplary institutional citizen of the city, the region, and the state over the past decade. He also invites all of us to join in the conversation and contribute to the MCW 2025 Strategic Framework as we set a new vision and as we rise to current challenges; we must “… think boldly and to share how you would reimagine MCW.” How do we prepare to make changes? 

 

 

Be bold. Set audacious goals. 

 

Many years ago, my mentor diverted me from an unproductive tirade by saying, playfully, “Don’t get mad. Get data.” This admonition literally was the birth of my academic career. Below, I offer an example of people who will change Milwaukee by first gathering data. 

 

The African American Leadership Alliance MKE (AALAM) was founded in 2017 to link influential individuals dedicated to making Milwaukee a place where African Americans thrive. AALAM has set the audacious goal of putting Milwaukee into the top ten US cities for African Americans by 2025! That is when our current first-year students will be interns. 

 

Recognizing the need for benchmarks for their work and seeking to identify the levers to drive positive change, AALAM commissioned the UW-Milwaukee Center for Economic Development (UWMCED) to produce  the study, “The State of Black Milwaukee in National Perspective: Racial Inequality in the Nation’s 50 Largest Metropolitan Areas.” The study was funded by the Greater Milwaukee Foundation. Here is an interview with the study lead, Professor Marc Levine.

 

As part of their work, the UWMCED team created a “Composite Index of African American Well-Being.” The index synthesized thirty indicators of community well-being, typically studied individually – for example, employment, income, poverty, social and community health, and conditions specific to youth and children – into a single number allowing big picture comparisons and holistic analyses across large metropolitan areas of the country. Milwaukee ranked 50^th out of 50. 

 

The study pinpoints three inter-related drivers for change: 

·      Reducing racial segregation

·      Enhancing Black educational attainment

·      Increasing the numbers of Black executives and managers at Milwaukee companies, including MCW

 

These actions will help make strides toward racial equity. For AALAM and the rest of us, it is a call to action, a time to make some good and necessary trouble. 

 

 

Building trust and taking action

 

On July 22, 2020, Drs. Lenard E. Egede and Rebecca J. Walker from the MCW Division of General Internal Medicine Center for Population Health published a perspective in the New England Journal of Medicine identifying six recommended action items for mitigating structural racism. Directly in our Kern Institute lane is the recommendation to “be consistent in efforts by health systems to build trust in vulnerable communities.”

 

How do we build trust? We must commit to long-term, trustworthy partnerships in “pipeline to the health professions” programs that will measurably accelerate the diversification of the health workforce in Milwaukee. We must intentionally and assertively recruit and support students, residents, faculty, and staff from underrepresented minority (URM) communities making special effort to identify those from economically deprived backgrounds. And as our leaders are seeking to do, we must support, listen to, and engage with all of MCW’s URM community-including all levels of staff- to be the kind of employer where everyone feels they belong, have an influence and can create a meaningful work life. This will require carefully examining how we traditionally have approached fairness, as compared with equity, in admissions and hiring processes. 

 

How do we prepare our trainees to practice medicine so that it is experienced by communities as trustworthy? Beyond a curriculum which provides the critical historical context for the distrust of the health care system by vulnerable communities, we must provide meaningful ways for our students and residents to work with and in communities. I have been involved with many “patient-as-teacher” programs. These programs train and employ community members- to be medical school teachers. With their active participation, for instance as standardized patients student can learn clinical material practice skills and receive critical feedback. With community guides and coaches students and residents can contribute to research and engage in  community social action. These experiences need to be substantive, rigorous and longitudinal allowing for the development of strong trustworthy relationships.  This is making some good trouble! 

 

In his essay, John Lewis wrote that he once heard the voice of Martin Luther King on the radio. “He said we are all complicit when we tolerate injustice. He said it is not enough to say it will get better by and by. He said each of us has a moral obligation to stand up, speak up and speak out. When you see something that is not right, you must say something. You must do something. … I urge you to answer the highest calling of your heart and stand up for what you truly believe.”

 

If we are truly committed to transforming medical education – as well as society writ large – we must reshape our own community, focus on character and caring, and offer to partner with organizations, like AALAM, that carry visions of a better, diverse, equitable world. Our entire community will benefit. 

 

 

 

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.

 

 

Learning Communities at the Medical College of Wisconsin: Past, Present & Future

From the 7/24/2020 newsletter

Learning Communities at the Medical College of Wisconsin: Past, Present & Future 

Cassie Ferguson, MD, Kurt Pfeifer, MD, Marty Muntz, MD, Cassidy Berns, Kaicey von Stockhausen, and Adina Kalet, MD, MPH 

This Kern Institute team describes their work on the rapid evolution of Learning Communities at MCW and the proposal for expanding the effort putting the learner at the center of education ...

The new academic year is upon us. New medical students arriving in Milwaukee will be find a campus than that looks very different from the one they saw on interview day. Orientation will be mostly virtual. Those unscripted moments and chance encounters that allow students to make connections with new people in the first few weeks of school will be few and far between. Everyone will be wearing masks and sitting at least 6 feet apart in classrooms. There won’t be the option to wander the hallways or find that perfect place to study. It all must be scheduled in advance.

These changes to medical education necessitated by COVID-19 pandemic are layered upon the preexisting challenges of rapidly expanding biomedical knowledge and increasing time and fiscally constrained clinical environment. These challenges may have compounding consequences, including burnout and increasing rates of depression, anxiety, and suicidality. To better support our students and to help promote a sense of connection and community amidst social isolation, the MCW School of Medicine (SOM) is implementing learning communities (LCs). 

LCs were first developed on undergraduate campuses to foster professional growth of students with similar academic interests. LCs partner faculty members with groups of students longitudinally to promote communitybuilding, academic and personal support, professional development, and curricular activities. LCs transform the medical school curriculum from coursestructured to learner-centered; putting the student- embedded in cohesive communities, at the center of the curriculum. 

Since the early 2000s, many medical schools have implemented LCs, and a 2012 survey showed that 52.4% had LCs and 48.3% of those without them indicated that they were considering creating them.1 Studies of LCs have demonstrated substantial improvements in faculty engagement, student wellbeing, and professional development.2 2018 surveys of MCW students and faculty conducted by the Kern Institute confirmed strong support for the implementation of LCs. 

With implementation of a pass/fail course grading system for the first two years at MCW, a strong system of mentorship for students is imperative not only to identify students who would benefit from additional support and intervention, but also to encourage students who are already successful to develop goals in the pursuit of excellence. LCs can promote inclusive behaviors and ensure effective transitions for all students. Finally, as the COVID crisis persists and social distancing limits interactions between students and faculty, LCs are an excellent means of assuring support for students and development of student faculty relationships. 

Current State of Learning Communities at MCW 

REACH Well-Being Curriculum 

As referenced above, LCs can positively impact student well-being. Growing evidence detailed in the National Academy of Medicine’s 2019 report on professional well-being indicates that learner burnout may negatively impact the quality and safety of patient care, the adequacy of the workforce, and the professionalism and personal health of learners. While system factors are the major contributors to burnout, attention to well-being in the learning environment may mitigate their effects. 

In Fall 2019 at the MCW SOM with much support from Academic Affairs and the Office of the Dean, the Kern Institute Student Pillar implemented a well-being curriculum aimed at teaching well-being skills and providing opportunities to talk with and learn from peers and faculty members. The REACH (Recognize, Empathize, Allow, Care, Hold each other up) curriculum, which is intentionally structured as longitudinal groups of faculty, staff, and students, uses an LC model. 

Designed and directed, by Dr. Cassie Ferguson, Director of the Kern Institute Student Pillar, The objectives of the REACH curriculum are to describe how the well-being of medical students, trainees, and physicians is integral to becoming caring and competent physicians; and, to identify characteristics and practice the skills that will help students thrive in medicine. The curriculum is designed around research-based best practices across several disciplines, including psychiatry, positive psychology, and mindfulness; pilot program data; and, interviews with students. The content emphasizes the importance of several fundamental concepts: storytelling, embracing vulnerability, nurturing selfcompassion, creating space and opportunity to examine one’s thinking patterns, developing emotional health, and fostering community. These concepts are woven into discussion of core topics including seeking behavioral health help, community building, creating boundaries, mindfulness, meditation, suicide prevention, imposter syndrome, productive generosity, beginner’s mind, digital minimalism, and looking for joy in the learning and practice of medicine. 

REACH consists of four didactic sessions and three facilitated small-group sessions in the first year, and three didactic sessions and three facilitated small-group sessions in the second year. Each small group comprises 10 medical students and two volunteer facilitators- a clinical faculty member and either a behavioral health expert (some of whom are also clinical faculty members) or a student support staff member. Facilitators receive detailed session guidelines with learning objectives, suggested discussion questions, activities, and links to related resources (e.g., didactic session videos, podcasts, articles, books). 

Evaluation of the curriculum was accomplished through a 17-question survey made up of Likert scale and open-ended questions completed by 62 students at MCW-Milwaukee (30%). 85% of respondents believed that what they were asked to learn in REACH was important; 70% would recommend that other medical schools adopt REACH. The REACH small group sessions played a significant role (>70%) in building relationships with peers and faculty. Students commented on the benefits of getting to know their peers, realizing they were “not alone” in how they felt, and feeling faculty were genuine and cared about them. 

4C Coaching Program 

The Kern Institute at MCW identified LCs as also having great potential for pursuing innovations supporting character and caring in medical education. After exploration of LC-related components and features with Kern National Network partners and MCW students and faculty, the Coaching for Character, Caring, and Competence (4C) program was launched in August 2019. 4C is structured around the core concept of LCs – groups of students and faculty in a longitudinal relationship to cultivate professional growth. Within this framework, multiple different components can be implemented to meet specific objectives (See diagram). Roughly 50 students volunteered for the program during AY2019. 13 volunteer faculty were grouped with 3-4 students each, and these groups meet monthly covering character and professional development topics. In addition, faculty meet individually with each of their students every other month. The program is directed by Kurt Pfeifer, a faculty member in the Student and Curriculum Pillars of the Kern Institute. 

With its initial launch, 4C centered on longitudinal coaching at the Milwaukee campus, but in AY2020, near-peer mentorship will also be piloted, and activities will be extended to the Central Wisconsin campus. 

Initial data show great support for the program as a whole and strong impact on development of mentorship and support for students and sense of faculty engagement. Students in the program were less likely to have feelings of isolation and reported strengthening of several character traits, including perspective, self-regulation, perseverance, and social intelligence. 

Incorporating Learning Communities into Curriculum for Fall 2021 

The Office of the Dean identified a pressing need to intentionally and thoughtfully expand on the existing LC structures at the MCW Milwaukee campus this fall. As detailed above, LCs can mitigate the potential consequences of social distancing rules by providing a “home” for every student and built-in opportunities for connection with peers, faculty, and support staff. 

Based on discussions between Academic Affairs, Kern Institute faculty, Dr. Lisa Cirillo, Jennifer Hinrichs, Mary Heim, and Dean Kerschner, a proposal was created for a longitudinal, tiered structure of LCs, where smaller groups of students roll up into larger groups of students allowing for intimate discussions without missing out on interacting with a variety of people. The objectives, activities, and facilitation of each group will be appropriate for their size and will enhance students’ experience and learning at MCW. 

Class of 2024 will be broken into 5 “On-Campus Learning Groups” each of which will be broken into three Orientation Groups of approximately 16 students each (again, depending on the size of the class). These groups will be established during the Orientation week. The Orientation Groups will be broken into two REACH Groups. The REACH curriculum is currently a mandatory part of the Clinical Apprenticeship course (conducted in the spring of M1 and fall of M2 years). Dr. Ferguson, Director of REACH, is engaging in discussions with Academic Affairs and Dr. Cirillo about incorporation of REACH into the Foundations of Clinical Medicine and Foundational Capstone courses as well. 

Students will additionally have the option to sign up for the 4C coaching program, which has groups of 4 students led by a volunteer faculty coach and a near-peer coach (M3 student). Current plans are for two 4C coaching groups to combine to form a REACH group, with the 4C faculty coaches also serving as those students’ REACH facilitators. Because the 4C Coaching Program is optional, not all students will receive this content. 

Vision for the Future of LCs at MCW 

We envision LCs evolving to provide a longitudinal structure that both supports and challenges each student as they achieve required competencies and develop and pursue individual goals at MCW. Students will be welcomed into an intentionally created group of peers, faculty and staff that will provide a sense of belonging from Day 1 at MCW – with LC faculty leading small group activities during Orientation and presenting the coats to their group at the White Coat Ceremony. With consistent expert faculty and staff guidance, LCs will provide meaningful opportunities for shared learning, peer teaching, and social connectedness through the challenges and joys of medical school that we are currently unable to guarantee given our large class size and reliance on a traditional curricular and advising model. LCs will also enable MCW to more fully transform to a competency-based education model of learning and assessment, as each student and their LC faculty share responsibility in ensuring that progress toward competence and excellence is consistently pursued. The bond among LC members will grow with time and shared experiences, culminating with the opportunity for LC facilitators to meaningfully participate in the Hooding Ceremony and Commencement. Both faculty and students desire and would greatly benefit from the realization of the community described in this vision statement. 

Cassie Ferguson, MD, Kurt Pfeifer, MD, Marty Muntz, MD, Cassidy Berns, Kaicey von Stockhausen, and Adina Kalet, MD, MPH are working on the rapid evolution of Learning Communities through their work at the Kern Institute, Medical College of Wisconsin.

1 Smith S. Acad Med. 2014 Jun;89(6):928-33. 

2 Eagleton S. Adv Physiol Educ. 2015;39(3):158-66. Smith SD et al. Acad Med. 2016;91(9):1263-9. Rosenbaum ME et al. Acad Med. 2007;82(5):508-15. Wagner JM et al. Med Teach. 2015;37(5):476-81. 

3 https://nam.edu/systems-approaches-to-improve-patient-care-by-supporting-clinician-well-being/