BACKGROUND
The specialty of emergency medicine (EM) requires physicians to deal with acutely ill patients in a fast-paced, dynamic environment. Throughout training, EM residents are frequently exposed to challenging cases while on shift. However, the inconsistencies of shift work, combined with patient flow pressures in the emergency department (ED), provide limited opportunities for debriefing after difficult encounters. In addition to work environment stress, residents face pressures inherent to specialty training. All these factors can create stress and burnout.Reference Cohen, Leung and Fahey 1 - Reference Fahrenkopf, Sectish and Barger 4 Physicians who experience burnout are more likely to make medical -errors, overuse resources, and have less satisfied patients.Reference Prins, van der Heijden and Hoekstra-Weebers 3 , Reference Hall, Johnson, Watt, Tsipa and O’Connor 6 Feeling unwell can lead to difficulties with academics and relationships and is linked to depression and substance abuse.Reference Cohen, Leung and Fahey 1 , Reference Eckleberry-Hunt, Van Dyke, Lick and Tucciarone 7
PURPOSE/RATIONALE
We sought to adapt and implement a peer-support and debriefing program within a Canadian EM residency training program modelled after an “ice cream rounds” format that has previously been used in Canadian pediatric residency training programs. 5 Regular peer-support wellness rounds may help to improve resident well-being, by creating an environment in which residents can debrief critical events and address stressors in a healthy way, creating resilience and protection from emotional burnout.Reference Goldhagen, Kingsolver, Stinnett and Rosdahl 8 - Reference Wallace, Lemaire and Ghali 10
A needs assessment survey was conducted to gauge interest and obtain input from residents on the format and frequency of the rounds. Fellow of the Royal College of Physicians of Canada and Canadian College of Family Physicians-EM residents were surveyed using an anonymous online survey. Moreover, 87% (26/31) of the responders identified their co-residents as their main source of support after difficult patient encounters, and 70% (22/31) of the responders identified that current opportunities to debrief after difficult experiences were only “sometimes” or “rarely” adequate. Overall, 84% (25/31) of the responders were interested in a peer-support debriefing program in the form of “ice cream rounds.” These survey results suggested that EM residents at the University of Ottawa needed a more organized and consistent space to debrief and share their experiences. Survey respondents also expressed that they wanted sessions to be voluntary, confidential, and peer-facilitated (no staff present at sessions).
DESCRIPTION OF INNOVATION
The first ice cream rounds in our program were conducted in 2014. Each one-hour session was semi-structured and peer-led in a private hospital location. Participation and attendance were optional. Sessions were co-led by two residents who had been trained in a one-hour tutorial of peer-support facilitation through the wellness program of the Faculty of Medicine. Ice cream was provided by the residency program. Between 40% and 60% of the residents attended each session.
The ice cream rounds followed a structured format that consisted of four phases: introduction, check-in, discussion, and checkout (Figure 1). Facilitators began sessions by reviewing ground rules and asking a general question to check-in. An example of a check-in statement would be: “Starting a new [postgraduate year] PGY year can bring up many emotions and challenges, how has everyone been feeling during this transitional time?” Following check-in, a free-form discussion began. Residents shared stories, emotions, and coping strategies surrounding challenging clinical or personal experiences that they chose to bring up. Common themes of discussion included imposter syndrome, patient complaints, medical errors, and challenges of transitioning between residency milestones. During discussions, facilitators ensured that dialogue was shared among all residents and encouraged transitions between conversation topics. Facilitators also had potential discussion topics prepared in advance in case conversations faltered; however, these were rarely needed once residents became familiar with the ice cream rounds format. Finally, after approximately 50 minutes, facilitators guided unfinished conversations to a close, summarized key take aways from the discussions, and reminded the group of wellness resources available at our institution.
Figure 1 Ingredients and steps to conduct a successful ice cream rounds.
Between 2014 and 2017, ice cream rounds were conducted during protected academic time, three to four times a year. In 2017, a postimplementation feedback survey showed that 95.0% (19/20) of survey respondents felt that the sessions fostered collegiality and support among residents, and 58.8% (12/20) of respondents felt that they gained an increased awareness of coping strategies for challenges in residency. Further, 50.0% (10/20) of respondents felt that the ice cream rounds impacted them mostly by helping them reflect on their clinical practice. Some residents also felt that the rounds decreased their sensation of burnout (4/20), decreased their stress and anxiety (2/20), and changed their clinical management of patients (1/20); others did not feel the rounds changed their practice but were glad that they existed (5/20). Overall, 89% (18/20) of respondents would recommend ice cream rounds to other residents.
Discussion
The adaptation and implementation of ice cream rounds have been successful in addressing a wellness gap in our EM program. We believe that ice cream rounds have created a healthy outlet to address stressors, potentially protecting residents from burnout.Reference Eckleberry-Hunt, Van Dyke, Lick and Tucciarone 7 Furthermore, residency program director support for the program has subsequently helped improve the wellness culture in the residency program, by promoting reflection around the challenges of working and training in the ED.Reference Eckleberry-Hunt, Van Dyke, Lick and Tucciarone 7 - Reference Sood, Prasad, Schroeder and Varkey 9 Evaluation of these rounds is limited by being mainly opinion-based self-reported survey data that may result in the overreporting of bias.
Adaptation and implementation of similar rounds can be achieved by any EM training program. To reproduce the innovation, we recommend conducting a needs assessment and involving residents in the design to help generate resident interest and meet their specific needs. Important elements to the success of ice cream rounds involve having department and program support, creating a safe space during the protected academic time, having a trained facilitator, and serving treats.
SUMMARY
We adapted, implemented, and evaluated a peer-support wellness and debriefing program to address the unique challenges faced by residents in an EM training program. This was the first Canadian initiative to implement such rounds in an EM setting. We believe this template can be easily adopted by other EM training programs and could be part of a national strategy to address resident wellness.
Competing interests: None declared.
