NAMAH—An Innovative Tele-ECHO Mentoring Program to Foster Well-being Among Physicians

Abstract

Background:

The current study aimed to develop and implement the National Assistance in Mental Health for Health Care Providers (NAMAH) module, which focused on wellness and building resilience for a cohort of physicians.

Methods:

The NAMAH module is a 12-week tele-mentoring program leveraging videoconference technology that uses the ECHO (Extension of Community Healthcare Outcome) HUB and SPOKE and consists of real-life case discussions and a brief didactic. The module’s content was developed after iterative feedback from experts and incorporated suggestions from healthcare providers (HCPs) following a needs assessment. A pre and post-design was used to assess the impact of the module on psychological distress using the self-reported Kessler Psychological Distress Scale (K10) and burnout using the Maslach Burnout—Inventory-Human Services Survey (MBI-HSS) among the 32 physicians who participated.

Results:

There was a significant decrease in the mean scores before (19.5 ± 6.27) and after (17.38 ± 6.23) the NAMAH module (p < .05) in the psychological distress as measured by K 10 with a Cohen’s d of 0.41 (95% CI: 0.05–0.77). There was also a significant decrease in the mean scores after the intervention in the emotional exhaustion and depersonalization domain of the MBI-HSS with a medium effect size (Cohen’s d of 0.65) and large effect size (Cohen’s d of 0.94), respectively.

Conclusion:

The findings from this pilot study lay a foundational framework, encouraging further exploration, research, and scaling-up of such interventions to enhance mental health among physicians and HCPs.

Keywords

Well-being Doctor mental health digital health NAMAH ECHO

Key Messages:

The NAMAH ECHO intervention significantly reduced psychological distress, emotional exhaustion, and depersonalization domain of burnout among physicians.

Implementing the NAMAH module using a tele-mentoring approach demonstrates the effectiveness of digital platforms in providing mental health support to healthcare professionals in remote places.

The positive outcomes of the NAMAH ECHO program lay a foundational framework for scaling up such interventions to improve mental health among physicians and healthcare providers on a larger scale.

Physicians are susceptible to a broad spectrum of mental health issues.¹ These range from milder conditions, such as burnout, to severe conditions, such as depressive and anxiety disorders. Burnout symptoms are prevalent among physicians. A systematic review involving 109,628 physicians from 45 countries reported that the prevalence of burnout varied widely, from 25% to 50%, depending on the definitions used.² Burnout symptoms are associated with substantial personal and professional consequences, including quitting the service, reducing working time, and experiencing emotional distress. They are also associated with health consequences such as a higher risk of road traffic accidents,³ sickness absence for both mental and cardiovascular disorders,⁴ and all-cause mortality.⁵ At an organizational level, they are associated with reduced productivity and early retirement.

Furthermore, they are also associated with poor clinical outcomes, unprofessional behavior, and reduced quality of care.⁶ Studies from around the world also reveal that physicians experience higher levels of mental disorders, including substance misuse and suicide, compared to the general population. For instance, a survey of over 12,000 Australian physicians found that 27.2% reported symptoms of depression and anxiety above the cutoff score on the General Health Questionnaire 28.⁷ A systematic review of studies conducted among doctors during the COVID-19 pandemic reported the prevalence of depression as 20.5%, while the prevalence of anxiety was reported to be 25.8%.⁸

In low- and middle-income countries (LMICs), the shortage of doctors is more acute, and by 2030, it is expected to have a deficit of 2.8 million doctors. As a result, doctors in these countries deal with very demanding working conditions, financial and infrastructural constraints, limited career opportunities, and income differences, all of which have a negative impact on mental health.⁹

A survey conducted in India at a tertiary care teaching hospital among 376 resident physicians and 69 faculty found that 30.1% had depression, and 16.7% had suicidal thoughts.¹⁰ Approximately two-thirds of the group (67.2%) experienced moderate stress, and another 13% reported high stress levels. Over 90% of the participants reported some level of burnout. Residents were more likely than faculty to experience stress, depression, and burnout.¹⁰ A recent meta-analysis has shown that the prevalence of depression among Indian medical students is 50.0% (95% CI: 31%–70%). The prevalence is higher among females than males (38% vs. 34%).¹¹

Potential solutions to improving mental health among physicians are complex. Harvey et al. (2021)⁹ suggested three levels for effective interventions: individual, health system, including professional colleges, and external regulators. Improving the organization and ensuring a better workplace has a significant impact; however, addressing individual physician-level issues is equally important.

As a part of the MBBS curriculum in India, psychiatry training typically constitutes a mere 20 hours of lectures (1.4% of the total) and two weeks of elective clinical postings.¹² There has been a recent welcome move to increase the duration of psychiatry training for undergraduates with a greater focus on mental health promotion, etiology, diagnosis, and management of severe and common mental disorders, suicide risk assessment, and disability assessment.^13,14 However, training in skills such as self-awareness, effective coping, improving resilience, and normalizing help-seeking for one’s mental health distress, which are critical components for the wellness of a future physician, remain absent from the curriculum.⁹ Studies have shown that teaching physicians mindfulness-based interventions (MBI) was significantly helpful in handling stress and improving emotional well-being.¹⁵ However, the primary challenge lies in implementing these interventions on a large scale and at the required speed.^16-18 One viable solution is to leverage digital technology to facilitate this process.⁹ The ECHO (Extension of Community Healthcare Outcome)^19,20 tele-mentoring model was planned to deliver a 12-week wellness and resilience-focused module for physicians. The first objective was to create a comprehensive 12-week module that focuses on health and resilience to cater to the specific needs of physicians. The second objective consists of implementing the module. The third objective involved evaluating the pre- and post-implementation outcomes, such as changes in psychological distress and burnout, as well as engagement.

Material and Methods

The study was conceptualized and implemented between June 2022 and July 2023.

Development of the NAMAH Module

The ADDIE, an instructional design model, was used to design and develop the National Assistance in Mental Health for Health Care Providers (NAMAH) digital module. ADDIE stands for Analysis, Design, Development, Implementation, and Evaluation.²¹ The primary objectives of the NAMAH module are to (a) recognize the factors that help build resilience among healthcare professionals; (b) integrate happiness-enhancing strategies into daily life; (c) construct a personalized plan to incorporate the same into one’s personal life. The NAMAH ECHO curriculum blueprint was created in August 2022 by gathering evidence-based practices from the literature review and iterative discussions with the hub team of three psychiatrists and two psychologists.

In November 2022, a survey questionnaire was designed to determine if the curriculum aligned with its objectives, gather overall ratings, and collect any open-ended suggestions to assess the felt need for the program among healthcare providers (HCPs).

Implementation of the Module

NIMHANS ECHO tele-mentoring model was used for implementation. This capacity-building program leverages videoconference technology and uses a HUB and SPOKE knowledge-sharing network to provide training and tele-mentoring to healthcare professionals in remote and rural areas. Each tele-ECHO session consists of spoke-led presentations of de-identified cases and discussion of the cases, whereby peers and hub experts (NIMHANS and AIIMS Deoghar) advise on the diagnosis and management. The session ends with a brief didactic from a subject expert.^19,20,22,23 Those physicians who expressed interest in being part of the program were invited to join NAMAH ECHO.

The program was conducted for 12 weeks, from March to June 2023. During the 90-minute weekly tele-ECHO sessions, the physicians (participants spoke) presented at least one real-life case study pertaining to mental health issues faced by them or someone known to them in a structured format. They discussed how they found solutions for the same. Following this, the hub facilitator generated the peer-led discussion and summarized the learning points. At the end of each session, an expert delivered a short lecture on various topics. These included “Physician Wellness,” “Work-Related Issues,” “Mental Health and Substance Use Disorders Among Physicians,” “Perseverance,” “Flexibility,” “Perfectionism: Boon or Bane,” “Preventing and Managing Patient-Related Violence,” “Self-Regulation,” and “Spirituality.”

Evaluation

The evaluation process for the tele-ECHO program included both quantitative and qualitative measures. The pre-assessment data was collected on February 23, and the Post-assessment data was collected on July 23, at the end of the NAMAH. The transcripts during each tele-ECHO session were recorded for qualitative evaluation.

Questionnaire

A 25-item questionnaire was developed to gather information on demographics, professional and practice attributes, mental well-being, and burnout.

The initial section of the questionnaire included 12 items, such as age, gender, city, highest medical qualification, and time spent in hospital duty, that is, outpatient, inpatient, and emergency.

The second section assessed emotional health using the self-reported Kessler Psychological Distress Scale (K10).²⁴ K10 is a 10-item scale that measures anxiety and depression experienced by an individual over the past four weeks. Each question is scored as (1) none of the time, (2) a little of the time, (3) some of the time, (4) most of the time, and (5) all of the time, and scores are added to provide a total K10 score. The lowest possible score is 10, and the highest possible score is 50. The total score falls into four categories as follows: well (10–19), mild distress (20–24), moderate distress (25–29), and severe distress (30–50).

The baseline burnout was assessed using the validated 22-item Maslach Burnout—Inventory-Human Services Survey (MBI-HSS) for Medical Personnel (M.P.).^25,26 It has already been used in many research on burnout in various medical and health specialties²⁷ worldwide, including in developing countries.²⁸

The MBI-HSS measures three domains, that is, emotional exhaustion, depersonalization, and personal accomplishment. The emotional exhaustion domain primarily assesses the emotional reaction resulting from excessive work pressure, a sense of being emotionally and physically overextended, and a decrease in enthusiasm for work. The depersonalization domain primarily evaluates the pressure caused by an individual’s attitude and feelings toward work, including impersonal and callous responses to patient care, diminished empathy, and increased cynicism. The personal accomplishment domain mainly evaluates the pressure caused by the person’s view of their work and feelings of competence, achievement, and meaningfulness.²⁹

Nine items are under the emotional exhaustion domain, with a score range of 0–54. Five items measure the depersonalization domain with a score range of 0–30. The personal accomplishment domain includes eight items with a score range of 0–48. All the items are measured on a seven-point scale, that is, from 0 (never) to 6 (every day). The total score of each domain is classified as low, moderate, or high. The emotional exhaustion domain score is considered high if it is above 27, moderate between 17 and 26, and low if it falls below 17. The depersonalization domain is classified as high if the score is more than 13, moderate between 7 and 12, and low if less than 7. The personal accomplishment domain score is considered high if the score is more than 39, moderate when between 32 and 38, and low if less than 32.²⁸ Higher scores in emotional exhaustion and depersonalization domains contribute to increased burnout. In contrast, higher scores in personal accomplishment indicate reduced burnout.^26,28 The MBI-HSS survey tool is validated as the most reliable method in reporting burnout among medical personnel, with a Cronbach’s alpha of 0.86.^30,31

The license for this tool has been bought from Mind Garden.³²

Transcript of the Case Discussions

The weekly tele-ECHO recorded presentations and real-life case scenarios were transcribed into written scripts. Subsequently, these textual transcripts underwent a thematic and sub-thematic analysis as a part of a qualitative study. This method was used to identify prominent themes and the corresponding subthemes connected to them.

Institutional ethics committee approval has been obtained for the ECHO-related evaluation and assessment. The participating physicians also consented to anonymized data analysis and publication.

Statistical Analysis

Baseline characteristics of the study participants were reported using descriptive statistics, including means and standard deviations for continuous variables and frequencies and percentages for categorical variables. If a participant cannot complete the entire cycle, the last entry has been considered for analysis. The paired t-tests were used to compare pre-and post-intervention scores on the K10 and the MBI-HSS for emotional exhaustion, depersonalization, and personal achievement domains. We calculated effect sizes using Cohen’s d to measure the significance of the differences observed, that is, small (d = 0.2), medium (d = 0.5), and large (d = 0.8). The analyses were conducted using IBM SPSS Statistics for Mac OS, version 29.³³

Result

Development of the NAMAH Module

The questionnaire survey form was shared with 9268 HCPs in a secured HIPAA-compliant survey (in our mailer list). Of the 2302 HCPs who opened the survey link, 319 (14%) completed it. Among those who completed the survey were 122 Physicians (MBBS or above), 72 psychologists, 26 educators, and 99 other health providers (including nurses, pharmacists, etc.). For the question “meaningfulness,” the mean score was 8.84 (SD 1.54) out of 10; for the “curriculum meeting required objectives,” the score was 4.41 (SD 0.71) out of 5; and for the “overall design,” the score was 4.39 (SD 0.72) out of 5.

The prominent themes for the qualitative responses were related to “Patient Care and Professional Boundaries,” “Practical Techniques for Daily Professional Routine,” “Stress Relief and Mental Health Awareness,” “Coping Strategies for Challenging Work Environments,” “Holistic Approach and Art-Based Activities,” and “Happiness Enhancement and Personalized Plans.” The themes were included in the final NAMAH curriculum. More than 90% (N = 290) desired to join the upcoming NAMAH ECHO sessions.

Implementation of the Module

Of 32 enrolled Physicians, 18 (56.3%) participants were male, and 14(43.8%) were female. The majority were more than 30 years old. The mean years completed after medical degree (MBBS) was 9.62 (SD: 6.02). The mean hours spent in an outpatient setting per week was 28.94 (SD: 17.68). The mean hours spent in an inpatient setting per week was 24.69 (SD:22.95). The mean hours spent in an emergency setting per week was 15.31 (SD 20.24). Twenty-one of them continued to participate in the program until the end. We used the last observation carried forward method for those who dropped out from the cohort (Table 1).

Table 1.

Baseline Profile of NAMAH Participant Physicians (n = 32).¹

Domain	Frequency	Percentage
Gender	Male: 18 Female: 14	56.3% 43.8%
Age group (yrs) 21–30 31–40 41–50	15 11 6	46.9% 34.4% 18.8%
Qualification Pursuing MD/MS Practicing clinician or Academic faculty	8 24	25% 75%

Evaluation

Quantitative Analysis

K10 was used to measure psychological distress. The questions asked about the physician’s emotional state during the past 30 days. At the baseline, 53% were well adjusted, 25% mild distress, 12.5% moderate distress, and 9.4% were severe distress. There was a significant decrease in the mean scores before (19.5 ± 6.27) and after (17.38 ± 6.23) the NAMAH module (p < .05) with a small to medium effect size (Cohen’s d = 0.41) (Table 2).

Table 2.

Comparison of Psychological Well-being and Burn Out Inventory Pre & Post NAMAH (Paired t-test).¹

Domain	Pre-NAMAH (Baseline)	Post NAMAH	Significance
K10	19.5 ± 6.27	17.38 ± 6.23	0.01 Effect Size (Cohen’s d) 0.41 (95% CI: 0.05–0.77)
MBI-HSS emotional exhaustion	15.38 ± 11.16	10.22 ± 8.19	<0.001 Effect Size (Cohen’s d) 0.66 (95% CI: 0.27–1.03)
MBI-HSS depersonalization	7.81 ± 7.45	3.84 ± 4.65	<0.001 Effect Size (Cohen’s d) 0.93 (95% CI: 0.51–1.35)
MBI-HSS personal achievement	36.25 ± 11.93	38.41 ± 8.86	0.16 (Not significant)

The baseline score in the emotional exhaustion domain of the MBI-HSS was 15.38 (± 11.16), that is, low. For the depersonalization domain, it was 7.81 (± 7.45), that is, moderate, and for the “Personal Achievement” domain, it was 36.25 (± 11.93), that is, moderate. Greater emotional exhaustion and depersonalization contributed to burnout, whereas greater personal accomplishment diminished burnout.²⁸

As Table 2 suggests, there was a significant decrease in the mean scores from the baseline to the end of NAMAH ECHO in the domains of depersonalization and emotional exhaustion. Specifically, the mean score for emotional exhaustion decreased by 5.16 points (t = 3.71, p < .001), with a medium effect size (Cohen’s d = 0.66). Similarly, the mean score for depersonalization decreased by 3.969 points (t = 5.29, p < .001), with a large effect size (Cohen’s d = 0.94). However, there was no statistically significant change in personal achievement, with a mean difference of –2.16 points (t = –1.45, p = .16).

Qualitative Analysis

The heart of the ECHO model is the real-life case discussion. During this weekly tele-ECHO session, each physician presented one anonymized case scenario related to their life challenge or another physician colleague or physician who had consulted for emotional problems. There were 25 case scenario presentations, of which nine related to themselves, and the rest were about their physician friends (Table 3).

Table 3.

Common Themes that Came up During Case Scenario Presentations by Physicians.¹

Sl no	Themes	Subthemes
1	Emotional and mental well-being	• The feeling of loneliness and lack of support • Experiencing feelings of anxiety, depression, guilt, or inadequacy • Impact of professional challenges on mental health • Dealing with emotional turmoil and stress due to professional demands
2	Work-life balance	• Juggling between family responsibilities, personal life, and professional commitments • Challenges of living away from family, the impact of work commitments on family time and relationships
3	Career progression, aspirations, and decision-making	• Struggles in achieving desired career goals and specialization • Pressure and challenges faced during academic and professional growth
4	Interpersonal and relationship challenges	• Managing conflicts and disagreements in personal and professional relationships • Navigating through misunderstandings, lack of support, or empathy
5	Societal and peer pressures	• Facing judgment, criticism, and lack of empathy from peers and society • Navigating societal expectations, e.g., marriage and settling down • Managing perception and attitudes from colleagues and society
6	Impact of professional circumstances	• Coping with the challenges posed by the COVID-19 pandemic • Dealing with emergencies and critical duties during a crisis
7	Organizational and systemic issues	• Handling bureaucratic challenges and organizational inadequacies • Navigating the difficulties posed by organizational structures and systems

Discussion

The current study aimed to develop and implement the NAMAH Providers 12-weekly module, focusing on wellness and resilience for healthcare professionals. The content was developed using the ADDIE instructional design model.²¹ The NAMAH module was implemented through the NIMHANS ECHO model, which leverages a HUB and SPOKE knowledge-sharing network to deliver tele-mentoring and training to healthcare professionals.

Development of the NAMAH Module

We compiled evidence-based practices from the literature review and engaged in iterative discussions with experts to develop the NAMAH ECHO curriculum. The feedback from the survey of more than 300 healthcare professionals (HCPs) was included before the module was finalized. The survey feedback revealed that HCPs were highly satisfied with the module’s “meaningfulness,” “relevance,” and its ability to “meet objectives.” Through qualitative analysis, we identified key themes that resonated with HCPs, including “Patient Care and Professional Boundaries,” “Stress Relief and Mental Health Awareness,” and “Happiness Enhancement and Personalized Plans.” These themes were subsequently incorporated into the final NAMAH curriculum.

A similar wellness and resilience ECHO program was developed and implemented for first responders (FR) in New Mexico, USA, during the COVID-19 pandemic.³⁴ The FR were doctors, nurses, emergency health workers, etc. The stages of development were similar in the current study. Psychological first aid, self-care, resilience, peak performance skills, communication methods, and the development of adequate peer support were included in the program.

Implementation of the Module

The NAMAH module was delivered through the ECHO tele-mentoring model for a cohort of 32 physicians. The majority belong to the age range of 21–40 years. The mean years completed after obtaining the medical degree (MBBS) was 9.62, indicating a combination of early-career and mid-career professionals. Over 65% of physicians completed the full 12 weeks of this blended module, that is, a combination of weekly synchronous tele-ECHO and asynchronous e-learning. This completion rate is much higher than reported in pure e-learning. Studies have supported that the retention rate is higher in blended learning compared to pure e-learning.^35,36

Short-term Impact on the Wellness of Participating Physicians

The results from the NAMAH ECHO telementoring program underscored the impact of structured mental health programs to enhance physicians’ resilience and psychological wellness, similar to prior studies.^3,6,9,37 K10 and the MBI-HSS scores (emotional exhaustion and depersonalization) after the intervention showed that both psychological distress and burnout got a lot better.

The strength of the NAMAH ECHO lies in real-life case discussions, fostering a collaborative learning environment, and encouraging physicians to share their experiences. The use of the NAMAH ECHO model corresponds with current trends toward digital mental health interventions, which are effective techniques in enhancing healthcare professional education and well-being.^19,38

The current study has limitations. Despite the observed improvements in psychological wellness, the domain of personal accomplishment of MBI-HSS did not reflect significant enhancement. The possible reason may be selection bias, that is, the physicians who joined this program were more resilient. Additional research with larger sample sizes, diverse medical specialties, patient care outcomes, and longer longitudinal assessments would be helpful to the NAMAH model’s generalizability and sustained impact.

Conclusion

The NAMAH ECHO model emerges as a promising, innovative approach, facilitating a synergistic confluence of knowledge sharing, mutual learning, and supportive mentorship for mental health resilience and well-being among physicians. The findings from this pilot study lay a foundational framework, encouraging further exploration, research, and scaling-up of such interventions to enhance the mental health of healthcare professionals, including medical students.

Footnotes

Acknowledgements

We want to thank Project ECHO, USA, ECHO India, AIIMS Deoghar for supporting this study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Declaration Regarding the use of Generative AI

While preparing this work, the corresponding author used Grammarly and Writefull to improve grammar and academic writeup. After using this tool/service, the corresponding author reviewed and edited the content as needed and took full responsibility for the publication’s content.

Ethical Approval

Ethical approval was taken from Institute Ethics Committee, NIMHANS, Bangalore, Dated 22th April 2015, number XVIII, Sl no 18.1.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Informed Consent

An informed consent was taken from the participating doctors for scientific publication.

Prior Presentations

This paper as such was not presented anywhere nor published. However, a part of the findings was presented at the Royal College of Psychiatrists Dean’s Grand Round webinar in January 2024. Details of the webinar can be found here. Additionally, information about the content and curriculum is available here.

Note

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