Well-Being Within a Radiation Oncology Department: A Single Institution’s Experience in Creating a Culture of Well-Being

Radiation oncology residency is a stressful experience in which residents are entering a new environment, often away from support networks, coupled with the complex task of caring largely for oncology patients, which comes with a steep learning curve. Imposter syndrome and psychological distress are common.¹² Understanding that well-being is a critical issue for residents, as part of our annual didactics, a clinical psychologist working with the Department of Student Services in a learner support role met with the residents and discussed the topic of isolation in medicine. This prompted an informal needs assessment of the residents, which identified both an interest and a need for a dedicated well-being curriculum. A resident champion with a passion for well-being partnered with a psychologist, a medical humanities professional, and the associate program director to formalize monthly well-being sessions. Residents underwent a formal needs assessment to identify topics associated with burnout, imposter syndrome, depersonalization, work-life balance, financial strain, second victim phenomenon, and coping with anxiety and depression being identified as areas of interest. During the 2019-2020 academic year, the inaugural well-being curriculum consisted of monthly 1-hour small group sessions focused on one of the identified topics of interest. Sessions were held during protected education time and were optional for residents to attend. Optional sessions during protected education time was an intentional part of the design and implementation of the curriculum to avoid further contributing to burnout and feeling overburdened.¹¹ To provide a balance of topics, sessions alternated between a psychological tool-focused approach and humanities exercises. Incorporation of humanities into medical training has been shown to improve the ability to empathize with patients and promote a more patient-centered approach to care13,14 Efficacy was evaluated using the Stanford Professional Fulfillment index, which assesses aspects of a culture of wellness, personal resiliency, and efficiency of practice.¹⁵ Survey results were used to modify the well-being curriculum for the next academic year with the goal of continuously refining the sessions and ensuring that residents found them meaningful and useful.

The resident champion and associate program director received grant funding via a competitive educational grant. Following the grant period, the initial results of the first 23 months of the curriculum were presented to the department leadership in the summer of 2021 to obtain an annual budget to sustain the efforts. Costs during the grant period and benchmarking examples from other departments with resident well-being budgets were also utilized to determine an appropriate amount of funding, resulting in a departmental fund allocation of $70/resident per year to be used for quarterly resident wellness events outside of work hours. Events are determined by resident suggestions, with the activity itself or food for the activity being funded by the department allotment. Events have included an annual welcome pool party to start the academic year, sporting event watch parties, indoor climbing, and paint nights, all of which have been well attended by residents.

To sustain the program, a resident well-being committee was created, led by a senior resident, consisting of residents in different years of training with an interest in well-being to be mentored to continue the program after the original resident well-being champion graduated. The committee selects topics for well-being sessions and coordinates well-being activities to build camaraderie. An award with funding was created for the resident champion to attend an educational conference in recognition of time and efforts. We have also continued to have quarterly humanities-focused activities with the help of the institutional Humanities in Medicine group, such as a focus on narrative writing or a hands-on artistic endeavor. An example of such an exercise includes reviewing a short narrative piece, such as an excerpt from Art of Oncology, and then following up with residents writing their own reflections on experiences that relate to the topic being discussed.

Our program also implemented an annual 1-day-long retreat. Residents, the department chair, and program leadership participate in well-being-focused activities, designed by the resident and faculty wellness champions. The structured component of the day consists of a candid group discussion of well-being topics or a pertinent journal article. This is followed by a creative activity, such as painting or photography, and free play with sports and aquatic activities. The retreat occurs early in the academic year to promote team building and engagement.

In addition to tools to build community and camaraderie, our program added structure opportunities for bidirectional feedback about the health of the program and any concerns that may be present. For example, in addition to existing group residency and program leadership meetings, PGY-level-specific meetings with program leadership occur regularly. Research time was enhanced for added flexibility to be used over the PGY3-5, depending on goals. In addition to preferences for research timing, residents were also given the opportunity to submit preferences for rotation timing and mentors. All proposed schedules require final approval by educational leadership; however, added flexibility and input into determining rotation schedules has afforded a welcomed autonomy within the program.

The grassroots efforts that began with the residency program sparked a department-wide strategy that has resulted in improved community and intention for well-being. A departmental well-being and social committee was established consisting of members with different departmental roles to ensure the interests of all groups are represented, including attending and resident physicians, nurses, APPs, administrative and desk staff members, and radiation therapists. Members from our satellite locations were included to represent the unique needs of our other locations as well. The committee holds a monthly meeting to discuss ideas, brainstorm activities, plan for future events, review the outcomes of previous events, and implement interventions that may contribute positively to departmental morale. The committee is led by a physician, who has granted protected time for the role. The department provides $12,000 per year to the committee to support initiatives, in addition to $3000 provided from a separate fund that staff physicians contribute to.

Events are chosen with the goals of promoting social connectedness and teamwork, especially across departmental roles. With representatives from diverse departmental roles, locations, and life stages, events are appealing to a broad audience.

Social distancing required early in the COVID-19 pandemic at the inception of many of these initiatives created additional unique challenges, especially in creating a sense of camaraderie within the department. Despite this challenge, we held events that allowed safe social distancing, such as a team trivia night conducted over Zoom, teaming with a private company that specializes in virtual trivia events, Trivia Hub. Our institution developed specific “Joy at Mayo” grants to empower recipients to improve the culture in their local working environments. Department Social and Well-being Committee members were awarded one such grant for Minnesota and Wisconsin state park passes. Group outings with trail hikes, snacks, and activities were planned for those interested as a method to build community outside of work, while including family.

As social distancing restrictions were eased, additional events were organized, including a departmental outing to a local baseball game, community volunteer opportunities, and creating teams to participate in local 5Ks to further promote a sense of community within the department.

A month-long departmental fitness challenge was started in winter 2021, and it has been popular and sustained, with challenges occurring 1 to 2 times annually. Participants choose a team member and are strongly encouraged to choose a partner in a different departmental role to build connections across job titles. The goals of the challenge are focused on promoting activities that are evidence-based and associated with improved overall well-being, as noted in Table 1. To encourage engagement among participants, weekly challenges for additional points were added, such as posting photos of trying a new fitness activity, recipe, or outdoor activity. For administrative ease, points are tracked using a commercial challenge application, Challenge Runner, where participants are also able to post their weekly challenge photos. At the end of the challenge, participants with the most points are awarded gift cards to local businesses. Prizes are also given in other categories, such as best photo or most creative team name.

To promote social engagement, a department Facebook group was created where people can post about upcoming activities and share exciting personal endeavors. In a recent example, employees have been sharing their senior photos as part of a department-wide scavenger hunt.

A weekly department newsletter was also created. The department was engaged for naming, and ultimately voted on the “HotDish,” a reference to the popular Minnesota dish and the process of sharing information. The HotDish consists of a message from the department chair or other appropriate department leader, professional and personal celebratory announcements, a “getting to know you” section featuring 1 to 2 randomly selected department members, and news about upcoming events.

In addition to community building and teamwork, efforts to improve workplace processes have been instrumental in promoting professional fulfillment. Using information from annual well-being surveys, including the Sirota survey, specific departmental surveys, and employee feedback, our department implemented strategies to identify departmental workflow pain points. Groups consisting of representatives of different job roles within the department met to discuss methods of addressing the identified areas, with consideration of how each group would be affected before developing a plan that could be presented to leadership for consideration. Investment from leadership within the department was a high priority. The department leadership encouraged innovative solutions and presented a general openness to optimize workflows. Examples of successful interventions include the creation of new workstreams and roles, several of which we will note below.

One such intervention was the creation of the “dosimetry bridge,” which consists of radiation therapists who prepare CT images for contouring and initial imaging fusion that is then approved by the treating physicians. This new therapy role enhanced opportunity and professional satisfaction for radiation therapists, as well as improved efficiency for medical dosimetrists and physicians. The role of the medical dosimetry assistant was also created to assist with normal structure contouring, plan verifications, research protocol submissions, and various other planning-related tasks. This increases the efficiency of physicians and medical dosimetrists, while also providing a strong foundation for radiation therapists with aspirations to train as medical dosimetrists. Together, these roles streamlined the process of completing contours and treatment planning, while providing an avenue for professional development and job satisfaction.

Another minor change with improved satisfaction was adopting a new call schedule. Call physician responsibilities include covering late treatments for the proton facility, which is scheduled to complete treatment at approximately 11 pm, in addition to inpatient call responsibilities and serving as backup physician for covering image checks and new starts at the machine. Recognized challenges with the on-call schedule included handoff of weekend consults and fatigue from the long hours. The attending physicians were surveyed and afforded the opportunity to provide input regarding optimization of the schedule. Proposed options included decoupling late-evening coverage from call, implementing call as a single day, rather than a 1 week, and simply adjusting the timing of call from Monday through Friday to Wednesday through Tuesday. After a review of preferences with stakeholder feedback, the call structure was adjusted to Wednesday to Tuesday to facilitate improved longitudinal care of weekend on-call patients and for the weekend to break up the week of consecutive late-evening coverage. Call dates for radiation therapists and residents were adjusted in kind to ensure a consistent call team. In addition, a system was implemented for on-call attendings to opt out of late-night coverage if desired.

The inpatient component of call consists of the primary physician covering inpatient consults, while still seeing on-treatment visits and scheduled follow-ups. Inpatient call coverage includes two hospitals, approximately 1 mile apart. Balancing the triage and management of inpatient consults with the needs within the department and seeing scheduled clinic patients was also identified as an area with potential improvement through an institutional Practice Optimization and Acceleration (POA) program designed to increase practice efficiency.¹⁶ Using a POA project structure, the department piloted the creation of an inpatient APP and nurse service to assist with initial inpatient consults during the day. We leveraged the improvement in call physician schedule to enable additional access for follow-up and urgent outpatient consults. The inpatient APP and nurses provide reliable coverage to evaluate urgent consults and facilitate treatments under the supervision of the call physician. The pilot was well received by staff, and the inpatient APP and nurse have now been established as full-time positions within the department. These inpatient APP and nurse roles provided increased autonomy and professional fulfillment, while providing efficient inpatient care with enhanced continuity. The inpatient APP and nurse also rotate in 3-month blocks with an outpatient service, which aids in preventing burnout with the less predictable inpatient call schedule.

The clinical practice committee continually reviews the processes and satisfaction to identify other opportunities for improvement. Two pilots are ongoing within the department to address coverage of high-dose treatment image review and improve communication across the department through standardized processes and platforms.

A department survey was created in 2021 based on the questions previously used in the Sirota survey to assess improvements or declines in department culture. The survey evaluates the workplace culture in the domains of safety culture, innovation, decision-making, and inclusivity, as noted in Table 2. A composite score was created based on whether each survey statement was viewed favorably or unfavorably. Compared with 2021 and trending back to 2020, the 2022 results for attending physicians showed an increase in the composite score from 55% to 70%, following the implementation of many of the interventions described above.

Additional efforts have also been made specific to radiation therapists and medical dosimetrists. Radiation therapists were engaged when deciding how to schedule patients with the upgrading of linear accelerators and CT sims as they are most directly affected by the treatment schedule. With this consideration, the ultimate decision was to have an earlier daily treatment start time to prevent therapists from working late each day, as later days had greater potential to overlap with home and childcare responsibilities. This decision impacted other workers, including desk staff, physicians, and physicists. Each group communicated closely, which ultimately allowed for the accommodation of these preferences. With respect to medical dosimetry, a work-from-home option was created as data support that working from home can have a positive effect on reducing burnout.4,17 An internal survey of medical dosimetrists was conducted, and 100% of the respondents reported maintaining or increasing quality of work, productivity, and well-being while teleworking. Initiatives were explored to maintain quality and continuity of care within department teams, including virtual collaboration avenues, alternative clinic coverage models, and virtual plan review options. With this, team members in many roles collaborated to pilot then standardize the communication platform for remote treatment plan review and processes to ensure consistent, high-quality communication. As on-site dosimetry support continues to be a need in the department, an on-site rotation schedule was developed with dosimetry staff input.