The concept of the Center for psychological support of resident doctors during the training period.

Tuillet Polina Sergeevna ORCID: 0000-0002-7146-1109 Assistant professor at Institute of Leadership and Health Management of the I.M. Sechenov First Moscow State Medical University (Sechenov University) 109004, Russia, Moscow, Alexander Solzhenitsyn str., 28/1, office 203 tuillet_p_s@staff.sechenov.ru

Introduction

Strengthening human resources is one of the key management tasks of health systems, recognized at the global level. At the present stage of health care development, the emphasis of personnel policy will be mixed with attracting new personnel to retain already trained qualified specialists who leave the system due to dissatisfaction with working conditions and excessive psychological burden. The World Health Organization (WHO), in the document "Health and care workforce in Europe: time to act", proposes the following policy measures to protect the health of medical workers: 1. To adapt educational programs in accordance with the urgent tasks of public health and healthcare (Action 1); 2. To create working conditions conducive to maintaining an adequate work and rest regime (Action 5); 3. To protect the physical and mental health of medical workers (Action 6) ^[1].

Taking into account the importance of the profession of medical workers and the need of citizens for affordable, timely and high-quality medical care, it is necessary to develop a set of organizational and psychological measures aimed at preserving the mental health and well-being of medical workers. At the same time, the primary importance is the protection of the psychological health of resident doctors who are at the initial stages of their careers, since not only correction, but also prevention of emotional disorders is possible during this period.

Features of psychological problems of resident doctors

Contrary to the prevailing perceptions, it has been established that burnout syndrome (CMEA), anxiety disorder and depression are widespread among residents just starting clinical practice, both in Russia and abroad ^[2,3].  The COVID-19 pandemic has also had negative consequences for young doctors. In the 2021 study, the authors studied the condition of residents during the COVID-19 pandemic and came to the following conclusions: 43% of 130 respondents noted symptoms of moderate and high depression, 11% — the presence of suicidal thoughts, 30% — symptoms of high—intensity anxiety, 55% — symptoms of post-traumatic stress, 24% - high indicators of professional burnout in all its aspects ^[4]. In another work, the authors focused on studying the prevalence of "burnout" among 143 residents of a short—term hospital who provide care to patients with coronavirus infection: 69% showed a high result on the scale of emotional exhaustion, 85% showed a high result on the scale of depersonalization ^[5].

The specific factors associated with the "burnout" of resident doctors, according to the literature, are primarily the relationship between the resident and the mentor doctor (supervisor), working conditions, the performance of less significant tasks and lack of autonomy due to a low position in the medical hierarchy, as well as general social well-being, for example, the lack of decent housing and a sufficient amount of financial resources ^[6-8]. According to other researchers, concomitant depression and health problems may be important factors associated with the presence of burnout syndrome of resident doctors ^[2].

Perhaps the most severe risk factor for the development of burnout syndrome in residency may be dysfunctional relationships within the team. A systematic review, which included the results of surveys of 29980 resident doctors, showed that 63% of them were subjected to harassment, 43% - discrimination, 29% — unwanted harassment (harassment) and 27% — sexual harassment during residency training ^[9].  At the same time, girls experienced such an unacceptable attitude more often than their male colleagues, and most residents did not seek help for fear of retaliation from the administration of a medical organization ^[10].

Thus, the period of training in residency is difficult for young professionals for a number of reasons, which makes them the most vulnerable in terms of the development of emotional disorders, namely burnout syndrome, anxiety disorder and depression. All this determines the importance of developing measures to protect the psychological health and well-being of this category of medical workers. At the same time, it is important to note that there are projects in Russia and abroad that provide psychological support to medical workers. The analysis of these practices is presented further in the text.

Analysis of existing practices of psychological support of medical workers

Some medical organizations are implementing full-fledged projects to ensure the psychological well-being of their employees. Such an example is one of the largest and most reputable clinics in the world – the Mayo Clinic. The clinic's program to ensure the psychological and professional well-being of employees, residents and medical students includes a Well-being INDEX monitoring program, the development of leadership qualities and employee engagement, the creation and maintenance of a favorable working environment and a high level of corporate culture, career consultations and large-scale research within the organization for a scientifically sound personnel policy. Within the framework of these studies, all the variety of personal, professional and organizational factors affecting the well-being, satisfaction and productivity of medical workers are studied, and optimal organizational approaches to the prevention of occupational stress and the creation of a favorable workspace are developed.

Major medical associations, the American Medical Association (Joy in Medicine), have also taken initiatives and strategic documents to prevent the burnout syndrome of medical workers and ensure their professional well–being. Health system Recognition Program, American Medical Association), American College of Physicians (Physician Burnout. Improve Physician Satisfaction and Patient Outcomes, American College of Physicians), American College of Surgeons (Professional growth and wellness. Surgeon well-being, American College of Surgeons).

There are also projects in the Russian Federation to ensure the psychological well-being of medical workers. The following are the practices of psychological assistance and support for medical workers that have already been implemented in the Russian Federation and in the CIS countries. Practices are divided depending on which organizations they were implemented by. In total, two types of proposed programs will be considered, namely: programs implemented in state-owned organizations and independent social projects.

Programs implemented in state-owned organizations

The Center for Monitoring Occupational Risks and Psychological Support of Medical Workers of Grodno State Medical University (GrSMU) implements various areas of psychological support for the professional activities of medical workers, which includes not only psychological counseling, but also educational events, group trainings on the prevention of burnout syndrome, as well as psychodiagnostics of medical workers and senior personnel of medical organizations. The Center is the only example of the implementation of the policy of psychological support for medical workers at the state level, the creation of the Center was initiated by the Order of the Ministry of Health of the Republic of Belarus No. 119 dated 16.11.2018, the strategic objectives of the project include the creation of a network of similar centers throughout the country.

In the Russian Federation, the practice of organizing psychological assistance to medical workers exists mainly at the level of hotel organizations, but there are also examples of such activities at the level of the executive authority of the region. The Moscow Center for Accreditation and Professional Development in the Field of Healthcare, which is part of the Moscow Department of Healthcare, not only provides training, advanced training, skills assessment and accreditation of medical workers, but also provides an opportunity to participate in psychological trainings on the prevention of burnout syndrome and the development of stress tolerance, as well as conducts skills training conflict-free communication with patients. For medical workers of organizations that are part of the Moscow Department of Health, training and trainings are provided at the expense of the employer.

The regional program of psychological support for district pediatricians is being implemented for medical organizations of the Moscow region on the basis of the training center for the development of competencies in pediatrics of the State Medical Institution of the Ministry of Health of the Moscow Region "Scientific Research Clinical Institute of Childhood of the Ministry of Health of the Moscow Region". The unique practice of the program consists in the formation of visiting teams of psychologists who carry out visits to medical organizations in the region to provide psychological assistance. The program also offers online activities that include not only group work, but also individual anonymous online consultations with a psychologist. As of July 2023, three visiting teams of medical psychologists have carried out 211 visits to medical organizations, more than 60 doctors have undergone individual therapy with a psychologist. According to the preliminary results of the program, in six months it was possible to reduce the prevalence of emotional burnout syndrome by 11%.

Perhaps the only program that includes both methods of psychological support and recreational activities was developed by the staff of the State Medical Institution "Scientific and Practical Psychoneurological Center named after Z.P. Solovyov". The program of psychological and psychotherapeutic assistance to employees of the State Medical Institution "Infectious Clinical Hospital No. 1" consists of their psychological support practices, including stress management trainings, and a complex of wellness techniques, namely wellness massage, physical therapy and physiotherapy.

The City Center for the Prevention of Emotional Burnout "Burn and don't Burn" also operates under a state–owned medical organization - the State-owned Public Health Institution "City Psychiatric Hospital No. 6" in St. Petersburg. The center's work is not focused only on the prevention of this syndrome in medical workers, the center's staff conducts educational events, face-to-face and group classes and programs for the systemic prevention of burnout syndrome for organizations of various profiles. However, the center provides services specific to medical professionals, for example, organizes the work of Balint groups, is engaged in mass prevention of "burnout" among medical university students, including with a series of lectures and seminars on communication skills in medicine. Also, during the COVID-19 pandemic, the center's staff recorded and released a free online course "Psychological and psychotherapeutic course for medical workers". It is important to note that among the staff of the center there are psychiatrists who, if necessary, can provide not only psychotherapeutic assistance, but also prescribe pharmacological treatment.

As it was shown earlier, the burnout syndrome can develop at the earliest stages of a medical career, including during training, therefore psychological support of medical university students is a reasonable practice. The Psychological Center of the Siberian State Medical University (SibSMU), established in 2020, provides psychological assistance to students, employees and patients of the University and its clinical bases. Employees of the center provide services for psychological diagnostics and psychocorrection, preventive measures to reduce the impact of occupational psychological risks during training and medical practice, as well as conduct educational events. For individuals belonging to the structures of SibSMU, services are provided without payment, financing of the center's activities is carried out within the framework of the financial activities of the university. 

Organizational factors of the work of a medical organization, such as the level of corporate culture, fair workload and work organization, relationship with management, etc., are important factors associated with the burnout syndrome of medical workers ^[11,12]. At the same time, programs aimed at positive changes in the organization of work of medical teams show a positive effect on reducing the level of emotional burnout syndrome ^{[13, 14, 15]}. 

The personnel policy of the Regional Clinical Hospital largely contributes to the precise search for employees who share the values and level of professional competencies of the medical organization's staff, their proactive adaptation and evaluation already at the workplace. HR specialists use the following technologies: welcome-chain (interview in coaching format, welcome-training, including presentation of the mission, values of a medical organization, attitude to quality control of medical care and principles of patient orientation, "Beginner's Book" with basic information for a new employee), methods for assessing staff satisfaction, Gallup Q12 questionnaire in its Russian adaptation, gamification of work tasks – the "Game" platform on the corporate portal of the hospital. I would like to dwell on the last tool in a little more detail. On this platform, in a playful way, employees should give feedback on their performance of various work tasks, including training, passing internal inspections, timely delivery of medical documentation, and also using the platform, you can quickly register an incident that occurred at the workplace, or thank colleagues by sending them a virtual "Thank You". The most involved and active employees get into the League of the best, and they can also count on bonuses from the employer – free rental of a parking space on the territory of the organization or receiving branded clinic products. Additionally, the platform implements pulse surveys, short surveys that allow you to quickly track the working atmosphere in the team and the level of employee satisfaction. The Regional Clinical Hospital is one of the leaders in creating a corporate culture of a medical organization that promotes the psychological well–being of employees.

Independent social projects

In addition to the practices implemented by state-owned medical organizations, there are also public initiatives and social projects aimed at combating the burnout syndrome of medical workers. Such an example is the online school "Burnout.no" and the social project "STOP.Burnout" on a gratuitous basis, carrying out educational, educational activities on the issues of psychological well-being of medical workers in the workplace, as well as free psychological consultations of healthcare professionals who are faced with emotional burnout syndrome.

The variety of factors determining the burnout syndrome of medical workers largely determines the variety of measures for its prevention and correction. In this regard, the assistance of charitable organizations that provide not only psychological support, but also financial assistance becomes relevant. The Charity Fund for Assistance to Medical Workers "Thankfulness" implements programs of targeted assistance to medical workers who are faced with difficult life situations. At the moment, the Foundation is working on a large-scale project for the prevention of burnout syndrome "Caring for doctors" in cooperation with the Ministry of Health of the Nizhny Novgorod region.

Thus, when analyzing the existing practices of psychological support for the professional activities of medical workers, it was found that the programs work in the following major areas: educational and educational activities for healthcare professionals and a wide audience, psychological counseling in individual and group format, psychological trainings, events aimed at the development of corporate culture and personnel policy of medical organizations, in particular including corporate health promotion programs, as well as social and material support for medical workers. All measures, except the last one, can be carried out during the training of young specialists in residency programs within the framework of the activities of the Center for Psychological Support of Resident Doctors, the concept of which is set out further in the text of the article. 

The concept of the Center for Psychological support of resident doctors during the training period

The Center is considered as a structural subdivision of an educational organization of higher education that trains specialists in residency programs, with the name "Center for Psychological Support of Resident Doctors" (hereinafter referred to as the Center). The Center carries out its work in accordance with the Charter of the organization and local regulations, the Ethical Code of the Psychologist (adopted on 02/14/2012 by the V Congress of the Russian Psychological Society), as well as other current regulatory documents of the Russian Federation. The target audience of the Center are those who study under the programs of training highly qualified personnel in residency, as well as managers and managers of medical organizations on the basis of which resident doctors work and receive education. The inclusion of heads of medical organizations in the target audience is due to the fact that organizational factors and factors due to the conditions of training are associated with the presence of emotional burnout syndrome in residents, while the results of research by other authors demonstrate the effectiveness of organizational measures at the level of the organization's management to improve the psychological well-being of medical personnel.

Thus, the purpose of creating the Center is, on the one hand, to provide psychological support to students enrolled in residency programs, and on the other hand, to improve the skills of heads of medical organizations in the field of personnel management and to create favorable conditions at the workplace.  In accordance with the proposed goal, the main objectives of the Center are:

1. Monitoring and identification of emotional and other psychological disorders in resident doctors, as well as factors determining them.
2. Providing assistance to resident doctors suffering from burnout syndrome and/or other emotional disorders.
3. Organization of measures for the prevention of occupational disorders among resident doctors related to residency training and clinical practice.
4. Conducting educational events, including lectures and seminars, as well as master classes, on the problem of burnout syndrome and other emotional disorders of medical workers in order to improve their psychological literacy.
5. Assessment and study of the internal environment of medical organizations and their corporate culture.
6. Conducting training programs and trainings for management personnel on leadership, personnel management and improving the personnel policy of a medical organization.
7. Organization of open scientific and educational conferences for the professional community in order to exchange experience.

 Based on the goals and objectives, the mission of the Center was formulated, which reads as follows:

"To support those who have chosen to take care of others with their work, in gratitude for their work today and with hope for their long and successful professional path tomorrow."

The objectives of the Center's activities are determined by the following activities implemented on the basis of the Center:

Event 1. Conducting educational events on the problem of emotional burnout syndrome and other emotional disorders of medical workers within the educational program of resident doctors in the areas 31.00.00 "Clinical medicine", 32.00.00 "Health sciences and preventive medicine" and 33.00.00 "Pharmacy". The programs are implemented for all residents studying in the organization in full-time format on the basis of the Center and using distance learning technologies.

Event 2. Conducting unscheduled educational events on the subject of the Center's work with the invitation of freelance lecturers in the format of master classes.

Event 3. Conducting group psychological trainings in order to prevent emotional disorders of resident doctors. Trainings are conducted in person on the basis of the Center on topics approved by the director of the Center, for example, the development of stress tolerance, prevention of emotional burnout.

Event 4. Conducting trainings on the development of "flexible" skills of medical specialists, namely communication skills, conflict-free communication skills, etc.

Event 5. Organization of coaching sessions, career counseling and professional orientation for resident doctors. Career self-determination and conscious choice of specialty can increase commitment to the profession, which, as shown in the study, reduces the chances of residents having emotional burnout syndrome. This event can be implemented in a group or individual format.

Event 6. Step-by-step monitoring of the prevalence of burnout syndrome of resident doctors and other emotional disorders during the training period.

Event 7. Analysis of the problems identified by the results of monitoring, determination of the causes of their occurrence and their solutions. The monitoring results should be used not only as an individual psychological diagnosis of residents, but also analyzed on the scale of the organization.  

Event 8. Organization of psychological assistance to resident doctors who have been diagnosed with emotional disorders. Psychological correction of disorders related to the professional activities of resident doctors is carried out with the help of trainings, group and individual psychotherapy, as well as through Balint groups. 

Event 9. Organization of psychiatric care for resident doctors. Psychiatric care for resident doctors is relevant due to the high prevalence of depression and anxiety, which require consultation and dynamic observation by a psychiatrist with a possible prescription of drug therapy.

Event 10. Assessment of the corporate culture and internal environment of a medical organization. Organizational factors and culture play an important role in shaping the psychological climate within the team of a medical organization, so it is important to evaluate them with subsequent correction of identified problems, for example, using tools such as "The Organizational Biopsy" of the American Medical Association, "Well-being index" of the Mayo clinic, methods for assessing the culture of the organization OCAI, OCP, OCI ^{[16, 17, 18, 19, 20]}.

Event 11. Formation of a culture of safety and tolerance to mistakes for resident doctors within a medical organization. Building a mechanism for safe feedback and establishing a dialogue between students and the management of a medical organization, developing a system for registering incidents in the workplace, encouraging a culture of discussing mistakes will also contribute to improving the psychological climate in the workplace.

Event 12. Conducting psychological assessment and testing of heads of medical organizations to assess their leadership potential, "flexible" skills and personal qualities.  Conducting psychological diagnostics of personal characteristics will allow current managers to more precisely choose educational programs suitable for them in more relevant psychological and managerial competencies for them, as well as identify managers with strong leadership potential to conduct effective personnel policy. 

Event 13. Training of managers and managers of medical organizations in the programs of leadership in healthcare, personnel management, team building and effective leadership.

Event 14. Implementation of organizational and methodological work, including preparation of information and methodological materials on psychological support of medical activities, technologies of career self-determination and planning, building a favorable corporate culture within a medical organization that is friendly to students.

Event 15. Conducting scientific research in the field of prevention and correction of burnout syndrome of medical workers. Scientific research makes it possible to justify the decisions made within the framework of the functioning of the Center, as well as to plan its strategic development, evaluating previous experience.

Event 16. Organization of professional forums, congresses and scientific and practical conferences on the psychological well-being of medical workers and psychological support of medical activities.  This event is aimed at exchanging experience in the field of mental health and well-being of medical workers, popularization of psychological knowledge in the medical environment, as well as strengthening the brand of the university and its medical organizations. 

Structure and employees

     To achieve the goals and objectives, the Center carries out activities in four main areas: psychological and psychiatric care, methodological work, educational and scientific activities. The psychological service of the Center works in all four directions with the possibility of routing residents to provide psychiatric care. Also, psychologists conducting trainings (trainers) and coaches engaged in career counseling and career guidance work within the framework of the psychological service.

            The second area of activity of the Center is methodological work. The duties of the methodologist include methodological development and support of the educational programs of the Center, as well as the preparation of information and methodological materials in collaboration with other employees of the Center.

            The third area of work is the creation and implementation of educational programs, including programs for resident doctors and managers of medical organizations, on the basis of which residency programs are implemented. On the basis of the Center, training programs on leadership, personnel management, effective management and creation of a favorable working environment for managers of medical organizations can be implemented.

           Finally, the fourth area of the Center's work, scientific activity, involves the collection and analysis of data at the population level collected as a result of a monitoring program to assess the dynamics of the prevalence of burnout syndrome and other emotional disorders, changes in the prevalence of risk factors that determine these conditions, as well as the analysis of changes in the "internal" environment of medical organizations, on the basis of which residents are being trained. The scientific approach will allow the analysis of the experience gained to make informed decisions when planning the activities of the Center.

          The planned staff of the Center includes administrative staff and performers, namely:

• Administrative staff – the head of the center;
• Psychological service – medical psychologists, psychologists of training programs, coach;
• Psychiatrists of the clinical center (internal part-time);
• Scientific staff;
• Methodology;
• Volunteers.

         Thus, the Center is a structural subdivision of an educational organization of higher medical education, providing psychological assistance, as well as carrying out educational and scientific activities in cooperation with other departments using the available material and technical base.

Conclusion

          Psychological support programs for medical activities are implemented on the bases of educational and medical organizations, as well as in the form of social projects, abroad and on the territory of the Russian Federation, covering various specialists, including doctors, nursing staff, resident doctors and teaching staff. At the same time, the main areas of work of these programs are psychological consultations and trainings, career guidance and counseling, educational events, as well as the development and implementation of an effective personnel policy for medical organizations. The concept of the "Center for Psychological Support of resident doctors during training" is aimed at the implementation of psychological support for students under residency programs and advanced training of heads of medical organizations in the field of personnel management and creating favorable conditions at the workplace.  To achieve this goal, the Center carries out activities in four main areas: psychological and psychiatric care, methodological work, educational and scientific activities, with the involvement of the following specialists: medical psychologists, psychologists of training programs, coach, psychiatrists, researchers and methodologist.