Maintaining Social Support in the Era of Social Distancing: Transitioning an in-person family-oriented wellness event to a virtual venue

Physician burnout can contribute to poor patient care, broken relationships, decreased professionalism, and physician suicide [1, 2]. Various factors can contribute to the reduction of physician burnout, including social support, relationship building, and physician engagement [2]. Interventions for burnout can be classified into two main categories: physician-directed interventions targeting individuals and organization-directed interventions targeting the working environment [3]. Studies have shown both types of interventions can decrease burnout, and the benefits may be potentiated by combining the two approaches [1, 3]. Studies also demonstrate an association between the psychological well-being of residents and social relatedness [4]. Thus, an organization-initiated, physician-directed intervention integrating support persons of physicians may be a promising approach to the improvement of physician well-being.

In 2017, our institution developed and implemented a Family Anesthesia Experience (FAX) innovative wellness event for first-year clinical anesthesiology residents' (CA-1) and their support persons (family members and close friends) [5].The event was well-received by both residents and their support persons, with evidence showing support persons gained an improved understanding of the role of an anesthesiology resident from the event. Thereafter, we made FAX an annual event for all incoming CA-1s in our residency program. In response to the COVID-19 pandemic, we converted this traditionally in-person event to a virtual experience in 2020. This reactive adaptation of the event format allowed us to evaluate the program through a new lens. In this article, we describe the design and implementation of our first virtual FAX event and report preliminary evaluation findings. Using the 2019 in-person event data as a historical control, we hypothesized that the virtual FAX would be as well-received by participants as the in-person version. Additionally, feedback from the attendees was reviewed and synthesized to assess the highlights, advantages, and challenges the participants perceived in the educational process of both formats.

Intervention

The details of the four-hour in-person FAX event have been previously described [5]. Due to the concern of losing participants' attention with a virtual event, the decision was made to shorten the virtual event to two hours, split between two 1-hour sections, and eliminate the lunch break [6]. It was held via Zoom on a Saturday morning in late summer 2020.

Similar to the in-person event, the virtual event started with didactics delivered to all of the participants. These didactics included a brief “Day in the Life” video to show participants the CA-1 resident workspaces, as well as their day-to-day responsibilities. There were also informational lectures delivered by faculty members on wellness and burnout, substance abuse, and local wellness resources, which were adjusted to fit the shortened virtual event schedule. A panel of senior anesthesiology residents and their support persons answered questions about their own experiences during anesthesiology residency and provided information on the board certification process, duty hours, and scheduling expectations.

During the second section of the event, the group was divided into three stations. Participants virtually rotated through each station to observe the demonstration of critical elements of anesthesiology practice with the aid of simulation task trainers (Laerdal Medical, Wappingers Falls, NY) These demonstrations included anesthesiology-related invasive procedures, airway management, and observation of a high-fidelity simulation of an intraoperative cardiac arrest. To simulate this experience during the virtual event, participants were split into three groups using breakout rooms. The faculty and resident facilitators changed breakout rooms, while all participants stayed in their original breakout room. The time in each small group station was adjusted from 30 to 20 minutes, again to maintain participant attention. Each session began with a brief video demonstrating anesthesiology procedure simulation components. One session demonstrated airway management techniques (bag-mask ventilating, laryngeal mask airway and endotracheal tube placement, video laryngoscopy, and fiberoptic bronchoscopy). Another session demonstrated common anesthesiology procedures on task trainers (central line, neuraxial blocks, and peripheral nerve blocks). The final station was a high-fidelity simulation including an anesthesiologist, senior resident, and standardized actors to demonstrate a preoperative assessment, induction of anesthesia, an intraoperative cardiac arrest with a resolution, and a phone handoff to the intensive care unit. Following the video, each session had time for a debriefing discussion with questions from participants.

Context

We collected data from the participants within a week of the virtual event via an anonymous electronic Qualtrics survey on their perceptions of the benefits and drawbacks of the virtual FAX event and ideas for program improvement. Participants were asked to rate their perceived enjoyment, learning, and value of the experience in improving the communication and support between the resident and family/friends using a four-point Likert scale (not at all, a minimal amount, a moderate amount, and a significant amount). They were also asked to comment on their favorite component of the event, the specific things they found most helpful, what can be improved regarding the event, and the perceived benefits and downsides of doing the event virtually. The descriptive statistics of the sample were summarized. Two members of the research team independently reviewed the responses to the open-ended questions, made notes, and identified themes. The two reviewers discussed and agreed upon the themes. The themes were reviewed and confirmed by a third researcher.

Impact

A total of 28 of the 62 participants (45.2%) responded to the 2020 virtual event survey, including 9 of the 13 residents (69.2%) and 19 of the 49 support persons (38.8%). For the 2019 in-person event, 30 out of the 35 participants (85.7%) responded to the survey. There was no question asking whether the participant was a resident or support person in the 2019 questionnaire, so we are not able to calculate the response rate by subgroup. All 2020 responders (100%) and 96.7% of 2019 responders enjoyed the event a moderate or significant amount. When asked how much they learned from the event, 89.3% of 2020 responders and 93.3% of 2019 responders felt they learned a moderate or significant amount. All (100%) of the 2020 responders and 83.3% of 2019 responders felt the event would improve communication between residents and support persons a moderate or significant amount. All (100%) responders in both years would recommend the event to a family member or friend.

Most 2020 responders were satisfied with the accessibility of the virtual event platform (92.3%), their experience navigating the virtual event platform (96.2%), and the social networking opportunities during the virtual event (84.6%). When asked if they would have attended the event if it would have been in person at UNC Chapel Hill when COVID was not an issue, 26 (92.9%) responded yes and only 2 (7.1%) responded no.

When asked about what they liked about the event, both groups appreciated having a better understanding of the role of an anesthesia resident. The simulation sessions and the panel discussions with senior residents and their family members were the most favorite components regardless of the format. When asked which component was most helpful, the most common responses were related to an increased understanding of the trainees’ role and stressors. Several participants also appreciated learning more about support and wellness resources for residents and specific strategies that could be implemented at home. The suggestions for improvement were mostly related to technical issues, the flow of the agenda and additional activities to be included in the event. Most feedback regarding improvements to the in-person event were minor technical issues and increasing the content shared about support and wellness resources. The minor technical issues referred to increasing the audience’s ability to hear the speakers and panel. Feedback around the virtual event included improving the use of Zoom’s function to mute participants, sending out an agenda in advance, restructuring the agenda to discuss “heavy” topics such as addiction and burnout later in the day, and increasing time for support persons to introduce themselves and interact. See Tables 1, 2, and 3 for a summary of the themes and illustrative quotes.

Some benefits to a virtual event were identified. The 2020 responders found the format eliminated travel as an accessibility barrier, reduced the financial burden of travel, and increased attendance. The virtual format also provided flexibility, made it easy to attend for families with young children, and minimized exposure risk to COVID-19. Having the event virtually helped make it more accessible to a larger population of support persons that would have otherwise not have been able to participate, namely support persons that are geographically distant or may have limited ability to take time in their schedule to come to the hospital. It is important to note that this same population of support persons may also experience the most “disconnect” or “difficulty supporting” their residents, as they have their barriers that prevent them from attaining a deeper understanding of the profession.

The limitations of holding the event virtually, as reported by the 2020 responders, include loss of “hands-on” and interactive activities, challenges with networking, inability to see the actual environment of the campus and hospitals, and technical difficulties. Furthermore, participants cited factors such as “technical difficulties” and “at-home distractions” as decreasing their engagement and participation during the event.

Table 1. Summary of the Most Liked Components of the Event

Table 2. Summary of the Aspect of the Event that the Participants Found Most Helpful

Table 3. Suggestions for Improvement

Lessons Learned

We have described the experience of moving an in-person wellness event to a virtual event due to contextual necessity. Although certain things were lost in the virtual venue compared within the in-person format, there were also some benefits by hosting the event virtually. While the sample size for both years is small and from a single institution, attendees appeared to find the event to be informative and enjoyable, with 100% recommending that it continue for future cohorts.

Our experience with these two consecutive years served as evidence that the FAX program is amenable to different modes of implementation, including in-person and virtual delivery. The difference in format, though, may equate to variation in the population of participants, especially support persons. Some support persons who were able to attend the virtual event may not have been able to make the in-person event due to financial or schedule considerations. On the contrary, those who prefer in-person interaction and hands-on experience over virtual workshops might not have been motivated to attend the virtual event. In the future, hybrid options [7, 8] or blended design [9] could be explored to better accommodate and engage participants with diverse needs and preferences while maximizing the benefits of both the in-person and virtual platforms.

To optimally design and implement a successful FAX event, it is important to obtain buy-in from the incoming residents and facilitators (i.e., faculty and senior residents). We relied on the CA-1 residents to invite their loved ones to the event. The ultimate goal is to provide an experience that improves daily interactions between CA-1 residents and their support persons, as well as improve the overall well-being of these residents. It is necessary to reach out to facilitators early to establish an interested core team consisting of both faculty members and senior residents. We also sent a “save the date” announcement to incoming CA-1 residents 6 months in advance to increase the participation of the CA-1s and their support persons. Some programs may deem this a mandatory event as part of the required wellness curriculum.

As with any virtual event, attempts should be made to minimize technological issues. Some suggestions for a smooth event include:

1. Ensuring all facilitators have a stable internet connection.
2. Setting up the virtual platform to mute participants at the entrance to avoid interruptions.
3. Asking participants to rename themselves so it is clear who is participating from each device.
4. Ensuring time is allotted for transition between breakout rooms.
5. Encouraging participants to turn on video cameras, especially in breakout rooms.

There are other learning process considerations we would recommend as well. For example, one may consider preparing talking points for residents and faculty members in breakout rooms in case there are no questions from participants. Another thing to consider is telling residents that they can be on the phone with their support persons during the event to help address questions and to make the virtual event more personal and relevant.

We also described our curriculum design and reported results focused on the learning experience of the participants. Effective anesthesiology wellness programs often involve the use of incentives and a comprehensive curriculum [10, 11], which may not be viable for some resource-restricted programs. Our experience showed the Family Anesthesia Experience event may be a reproducible, cost-effective wellness intervention approach, particularly with the support of technology for community outreach. Like many medical residency wellness programs, we did not collect longitudinal data regarding the impact of the event on physician wellness and burnout. Moving forward, utilizing more objective measures in addition to survey questionnaires would help to assess the long-term influence of the experience on physician mental health. Furthermore, the event primarily focused on educating support persons about anesthesiology residency. In the future, it may be beneficial to incorporate training on communication skills and self-care techniques with anesthesiology residents as the target population, thus allowing us to address burnout using a multi-faceted approach. This program may be modified to serve as a useful medical education wellness offering for other specialties as well.

Conclusion

The FAX event was created out of a need to help combat the issue of physician burnout. By providing a platform for support persons to both understand the duties of anesthesiology residents and voice their concerns and questions, we believe this event could be a major step in promoting the well-being of trainees. Survey data show participants gained valuable insight from this event. Although the lasting impact of this project is yet to be determined, the potential of this initiative should not be ignored.

Acknowledgements

The project was funded by the Department of Anesthesiology at the University of North Carolina at Chapel Hill. Drs. Susan Martinelli, Fei Chen and Robert Isaak received a three-year Joy in Medicine Practice Transformation Initiative support from American Medical Association for the Family Anesthesia Experience project.

References

About the Authors

Dr. Fei Chen is an assistant professor in the Department of Anesthesiology at The University of North Carolina at Chapel Hill. She also serves as the founding co-director of The Excellence in Anesthesiology at Chapel Hill Education Research (TEACHER) Lab and the Academic Medicine Rotation of the department. Dr. Chen is chair of the scholarship committee and a member of the leadership council of the Academy of Educators of UNC School of Medicine. Dr. Chen received her doctorate in educational psychology and methodology from the State University of New York, Albany. Her recent research work focuses on assessment and instructional design for enhanced learning in medical education. Dr. Chen has designed and implemented multiple research projects on competency-based assessment, simulation-based education, and formative assessment.

Sania Rahim is a fourth-year medical student at the UNC School of Medicine. She received her Bachelor of Science with honors in evolutionary anthropology at Duke University and Master of Science in medical sciences at Boston University. She taught biology at Garinger High School in Charlotte, NC through Teach for America. Her research interests include physician wellness, reproductive justice, and quality improvement.

Rob Isaak, DO, FASA is a professor of anesthesiology at the University of North Carolina at Chapel Hill. He completed his medical school training at Nova Southeastern University College of Osteopathic Medicine and his anesthesiology residency training at Vanderbilt University. Currently, he serves as the vice chair of education and the division chief of liver transplant and vascular anesthesia. He has previously served in a variety of leadership roles at UNC including being anesthesiology medical director for the Enhanced Recovery After Surgery Program at UNC, medical director of the cardiovascular and thoracic ICU, associate residency program director, and the director of the Anesthesiology Simulation Program and Residency Curriculum. Additionally, he served as the chair of the American Board of Anesthesiology (ABA) OSCE Exam Committee and is an ABA oral board examiner.

Dr. Brooke Chidgey is an associate professor of anesthesiology with subspecialty certification in pain management at UNC School of Medicine where she is the director of pain management clinics and division chief of pain medicine. She is a physician lead of the UNC Opioid Stewardship Initiative for UNC Hospitals and president-elect of the Carolinas Pain Society. She has worked and lectured extensively on perioperative opioid prescribing practices and patient usage, storage, and disposal of these drugs.She is currently a Co-PI for UNC’s site of The BEST Trial (Biomarkers for Evaluating Spine Treatments), a NIAMS-sponsored clinical trial being conducted through the NIH HEAL Initiative's Back Pain Consortium (BACPAC) Research Program.

Dr. Emily Teeter is an associate professor of anesthesiology at UNC Chapel Hill. At UNC, she serves as assistant residency program director, and chairs both the Clinical Competence Committee and Residency Recruitment Committee. As a cardiothoracic anesthesiologist, her areas of interest include enhanced recovery after thoracic surgery, intraoperative transesophageal echocardiography, and residency education. An Atlanta native, Dr. Teeter is a graduate of Dartmouth College and the University of Virginia School of Medicine. She completed residency training at UNC and cardiothoracic fellowship at Duke University.

Dr. Harendra Arora is a professor in anesthesiology at The University of North Carolina School of Medicine. He has previously served as the vice chair of education and the residency program director at UNC Chapel Hill. Dr. Arora currently practices cardiothoracic, vascular, transplant, and regional anesthesia. He has years of experience in education, clinical practice, quality improvement and research. Dr. Arora has served as an oral board examiner for the American Board of Anesthesiology (ABA) since 2014. He has also served on ABA’s Objective Structured Clinical Examination (OSCE) committee from its inception. Aside from the ABA, Dr. Arora is involved with several other prominent anesthesiology national societies and organizations. Dr. Arora has published quite extensively in the areas of cardiovascular and transplant anesthesiology. Most recently he was involved with the POISE-3 trial, which is a large multinational, multi-center trial looking at improving cardiac morbidity and mortality after major non-cardiac surgery.

Susan M. Martinelli, MD, FASA is a professor of anesthesiology and the anesthesiology residency program director at The University of North Carolina School of Medicine in Chapel Hill. She attended medical school at the University of Wisconsin, did her residency training at the University of North Carolina, and completed a cardiothoracic anesthesiology fellowship at Duke University Medical Center. Dr Martinelli is a member of the Accreditation Council for Graduate Medical Education Review Committee for Anesthesiology. Her career has centered on being a clinician-educator with a focus on research in education. One of her research interests is in innovative approaches to graduate medical education, such as the flipped classroom. Additionally, she has developed programs that utilize family and friends to improve the well-being of healthcare providers, including medical students, residents, and attending physicians. She has received grant support from the AAMC, AMA, and the Foundation for Anesthesia Education and Research for these efforts. She enjoys collaborating with other institutions in this work