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Abstract

Objectives

High rates of distress and burnout continue to plague physicians. The Sustaining and Training for Resilience, Engagement and Meaning (STREAM) curriculum is a Health Resources and Services Administration (HRSA) funded program, developed by experts in faculty and trainee wellbeing from 7 academic institutions, to help address this ongoing and pervasive issue.

Methods

We used Kern's 6-step model to develop the STREAM program. STREAM content was developed and iteratively revised to highlight evidence-informed methods to improve wellbeing. STREAM content is grounded in the PERMA-H framework and highlights 4 pillars: Optimizing your Well-Being, Building Resilience, Collaborative Engagement to Improve your Work, and Connecting with Joy and Meaning in Medicine. Within sessions, implementation of skills was discussed at the individual level and within the work environment. This manuscript describes the process of development, implementation, and pilot program evaluation for the STREAM curriculum for the first 2 years.

Results

Based on review and assessment of year 1, we made multiple revisions of the curriculum. We revised the original four pillars and strengthened connection with the PERMA-H model. We transitioned from synchronous virtual model to in-person sessions to enhance engagement, buy-in, and meaning. We further increased time with interactive elements and limited didactic content. We deepened content related to equity and inclusion. We separated faculty and resident sessions to improve community-building and group dynamics. Additionally, we provided the option for sessions to be delivered “a la carte,” depending on the needs of the institution and participants.

Conclusions

The STREAM wellbeing curriculum is a promising model to promote positive behavior change in pediatric academic medicine. Curricular activities related to wellness may require adjustment and modifications while in process to improve delivery and participation—and enhance chances of successful education/training. We must continue to build evidence for the effectiveness of STREAM and other wellness interventions.

Keywords

wellbeing curriculum development pediatrics

Introduction

High rates of distress and burnout continue to plague physicians. The World Health Organization's 11th revision of International Classification of Diseases (ICD-11) released in 2019 defines burnout as an occupational phenomenon and “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.”¹ Physician burnout includes symptoms of emotional exhaustion, depersonalization, and lack of sense of personal accomplishment.^2,3 Burnout overall is higher in physicians than in the general population and peaks during graduate medical training and mid-career.^4–6 Multiple studies have demonstrated that pediatricians and pediatric trainees have persistently high rates of burnout.^7–10

The cause of burnout is complex and multifactorial and includes both individual and organizational factors. The longitudinal PLACES (Pediatrician Life and Career Experience Survey) study identified burnout risk factors such as less personal support from physician colleagues, chaotic work environments, lack of adequate resources, and personal factors including depression, negative life events, and work–home conflicts.¹¹ In addition, less autonomy, greater workload and longer work hours, less control of one's schedule, and electronic heath record (EHR) burden are factors contributing to burnout.¹¹ Moral distress, such as working with abusive patients/family members and providing aggressive, but futile, medical treatment, was also associated with burnout.¹²

Both organizational and individual strategies combined are needed to ensure physician wellbeing. Underscoring this need, the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements now include addressing trainee wellbeing, both in clinical settings and in the provision of education regarding identification of symptoms of mental health disorders in themselves and colleagues. Many interventions targeting physician wellness have been investigated, including shortening clinical work hours, modifying clinical work processes, stress management, resilience training, debriefing, communication skills training, meditation, reflective writing, peer mentoring, and others; some of these have shown to be helpful in improving wellbeing.^13,14 Factors that contributed to a successful wellness intervention included developing curricula informed by educational learning theories, seeking out participant feedback, and integrating the intervention into existing curricula.¹⁴

Reducing burnout is essential to ensuring high-quality care, patient safety, professionalism and physician health, and the healthcare system overall. There remains a need for comprehensive medical education curricula for Pediatric faculty and trainee wellbeing that teaches lifelong skills to promote wellbeing and prevent burnout. The Pediatric Resident Burnout-Resilience Consortium Study (PRB-RSC) is a national consortium of pediatric residency training programs focused on exploring issues related to burnout and resilience. Its primary goal is to offer a collaborative platform for conducting multicenter research on resident burnout and developing interventions aimed at improving resilience.¹⁵ Inspired by the PRB-RSC, the Sustaining and Training for Resilience, Engagement and Meaning (STREAM) curriculum is a Health Resources and Services Administration funded program, developed by pediatric faculty and experts in trainee wellness from 7 academic institutions across the country. STREAM's purpose is to provide resilience and mental health training to help address the ongoing and pervasive issue of burnout among practicing physicians and physician trainees. Utilizing the PERMA-H model,¹⁶ a psychological wellbeing model developed by psychologist Martin Seligman, as a foundational conceptual framework and the Kern approach to medical education curriculum development, here we describe the development and evolution of the STREAM curriculum.

Methods

Target Learners and Curricular Setting

The target learners for the initial curriculum were pediatric faculty and trainees from 3 large academic pediatric institutions. These institutions were selected for the year 1 pilot because they were existing PRB-RSC institutions, and their leaders were on the STREAM faculty leadership team. This allowed the opportunity to generate in-person recruitment for the program and to facilitate local buy-in. IRB approval was obtained from Nationwide Children's Hospital (STUDY00002656) and included PRB-RSC institutions.

We obtained written informed consent from participants. For those who did not complete the registration prior to the session, they were registered after the session and thus provided consent that way. Consent and registration were recorded on the STREAM Learning Management System platform. The reporting of this study conforms to the Defined Criteria To Report INnovations in Education (DoCTRINE) statement¹⁷ (Supplemental file).

Conceptual Framework

We utilized the PERMA-H model of wellbeing as a conceptual framework for the curriculum development.¹⁶ This model is rooted in positive psychology, which is the study of human strengths, virtues and flourishing. It was developed by Martin Seligman, a positive psychologist, and describes six core components that contribute to overall wellbeing: P—Positive Emotions, E—Engagement, R—Relationships, M—Meaning, A—Accomplishment, and H—Health. Positive Emotions, which are feelings like joy and gratitude, help us feel good and improve overall wellbeing. Engagement is the sense of being fully involved in activities we enjoy and that fulfill our needs, which allows us to feel a sense of accomplishment. Relationships are connections we have with family, friends, and others, which create support and belonging. Meaning is having a sense of purpose and feeling that our lives matter. Finding meaning provides a sense of fulfillment. Accomplishment denotes setting goals and actually achieving some of them. Health refers to taking care of us, both physically and mentally to create physical and mental wellbeing. We chose this conceptual framework as a guide for the curriculum development because it incorporates a multifaceted approach to wellbeing, and several of its components, such as Meaning and Accomplishment, may be particularly relevant to physicians. Several studies have utilized PERMA-H as a framework for wellbeing in school and in the workplace.^18–20

Educational Framework

Kern's 6-step approach is a widely accepted and utilized method for curriculum development in medical education.²¹ Step 1 is the overarching problem identification and general needs assessment. Step 2 is a targeted needs assessment for a specific group of learners. Step 3 is the generation of goals and objectives. Step 4 is the development of educational strategies which best meet the goals and objectives. Step 5 is the implementation of the curriculum. Step 6 is evaluation and feedback for subsequent revision and refinement of the curriculum.

Steps 1 and 2: Problem Identification and Needs Assessment

As described above, the wellbeing of physicians, trainees, and experienced physicians continues to be a pervasive problem in medicine. The body of literature demonstrating and describing this problem is substantial, with no meaningful improvement over time. While this problem is well-known and has been well-described in every medical specialty, effective, and lasting interventions which improve wellbeing are limited and the need remains clear and significant.

Step 3: Goals and Objectives

Utilizing the PERMA-H model and the clear need for effective wellbeing interventions as foundational drivers, investigators determined the overall objective of the STREAM curriculum would focus on pediatric faculty and residents development and implementation of skills in the following 4 areas: (1) Attending to Your Mental Health, (2) Professional Resilience, (3) Engagement in Health Systems, and (4) Joy and Meaning in Work. These 4 pillars of the STREAM program were determined utilizing our needs assessment and the PERMA-H framework. Objectives for the individual sessions for these pillars were developed by session presenters and ultimately approved by STREAM leadership (Table 1).

Table 1.

STREAM Curriculum, Year 1 Overview.

Pillar	Session Title	Learning Objectives
Attending to your Mental Health	Mental Health as a Vital Sign: Addressing Health Professionals’ Suicide Risk & Enhancing Mental Health (Part 1)	Reflect on the foundational concepts that put physicians at risk for mental health conditions Identify evidence-based methods that promote positive mental health by mitigating the negative aspects of the “medical culture” Develop and implement a mental health wellbeing plan and identify an accountability buddy or team Discuss personalized, proactive strategies for optimizing mental health and protecting against suicide risk
Attending to your Mental Health	Mental Health as a Vital Sign: Addressing Health Professionals’ Suicide Risk & Enhancing Mental Health (Part 2)	Deepen understanding of physician mental health including the concept of “mental health as a vital sign” Discuss personalized, proactive strategies for optimizing mental health and protecting against suicide risk Know when and how to approach a colleague you may be concerned about Identify organizational strategies that can reduce the suicide risk among health workers, trainees, and employees
Professional Resilience	Resilience	Identify the 6 facets of the PERMAH Model of Well-being Apply the concept of wellbeing to your own life Examine how the components of wellbeing appear at different times in your life
Professional Resilience	Flourishing	Understand role of Positive and Negative affect/emotion as normal processes within PERMAH Model of Well-Being Understand Flourishing Ratio as it applies to everyday living Practice exercises designed to cultivate positive emotion
Engagement in Health Systems	Engagement in Health Systems (Part 1)	Appreciate the relationship between physician engagement and overall wellness Reflect on areas of personal importance related to systems issues that contribute to their own/their colleagues’ burnout
Engagement in Health Systems	Engagement in Health Systems (Part 2)	Identify explicit ways to become involved in systems-improvement efforts in their organizations
Joy and Meaning in Work	Joy and Meaning in Medicine (Part 1)	Understand the importance of promoting positive psychology, connecting to colleagues and purpose, and improving the clinical-learning environment Utilize reflection with colleagues and re-discover joy and purpose in medicine, sense of calling, and purpose Describe the power of sharing stories
Joy and Meaning in Work	Joy and Meaning in Medicine (Part 2)	Strengthen learnings from prior STREAM Sessions Connect with what is most meaningful to you in medicine Emphasize relationships with patients and colleagues to amplify joy as a pediatrician

Step 4: Educational Strategies

Our learners were busy pediatric trainees and faculty, with many competing professional and personal responsibilities. Our priority in the educational strategy was to utilize active and interactive learning, with attention to practical and implementable content and skill development. We chose to include both faculty and residents together in each session to facilitate perspective-taking and shared experiences.

In each session, emphasis was placed on interactive skill-building, reflective practice, and connection to current working environment to support meaningful behavior change. Specific content areas and interactive activities were developed by session facilitators and a medical education consultant. Our curriculum development team included physician content experts in medical education and in all areas of the 4 key pillars. The medical education consultant, a part of our investigator team, had advanced doctoral training and expertise in curriculum and instruction

In effort to promote ease of connection with STREAM content experts and learners from the three pilot institutions, the virtual learning environment was utilized. The initial year 1 STREAM curriculum was a sequential series of live, synchronous, virtual sessions. The complete curriculum was comprised of 8 one-hour sessions, with 2 sessions dedicated to each pillar. The series was presented separately to each of the 3 institutions, with the intention of building camaraderie among participants at each site. The curriculum was delivered over a course of 4 months, with 2 sessions (1 complete pillar) each month. Sessions were designed to build on one another, for cohesiveness of curriculum and integration of content domains and skills practice. Each pillar was led by trained facilitators, who were also content experts. Online learning resources relevant to each pillar topic were offered to participants as optional complementary learning activities.

Another key educational strategy for the curriculum was the explicit incorporation of equity, inclusion, and belonging principles into all sessions. For each pillar, sessions were reviewed by a faculty consultant, experienced in health equity and diversity, for content addressing cultural competence and inclusiveness. We prioritized this strategy in the curriculum because resilience and wellbeing in the workforce is different for faculty and trainees underrepresented in medicine (UiM).

To help inform educational strategies and address any unique needs of pediatric trainees, a Resident Advisory Committee (RAC) was formed. The RAC was comprised of 8 residents from the three different initial pilot institutions. All session content was presented in “dress rehearsal” style to RAC and STREAM leadership prior to the year 1 pilot. Feedback was obtained, and revisions to curriculum content were made based on this feedback.

Results

Implementation

The year 1 curriculum was delivered in Summer and Fall 2022. In year 1, a total of 162 pediatric care providers participated in at least one STREAM session, including 116 faculty and 32 residents. Of note, there were over 300 total pediatric residents in training at the pilot institutions at the time of introduction of the STREAM curriculum. The STREAM curriculum was advertised to physicians (pediatric faculty and residents), but upon evaluation of registration data, other participants (advanced practice providers, fellows, and others) were noted to have attended (Table 2). Attendance at each session was variable.

Table 2.

STREAM Participant Demographics.

Category	N = 162	Percentage
Professional role
Faculty	116	71.6
Resident	32	19.8
Advanced practice provider	5	2.5
Fellow	4	3.1
Other	4	2.5
Prefer not to answer	1	<1
Gender
Male	39	74.1
Female	120	24.1
Gender nonconforming	1	1.2
Prefer not to answer	2	<1
Race/ethnicity
Caucasian	115	71.0
Asian/Pacific Islander	24	14.8
African/Afro-Caribbean/Black	6	3.7
Multiethnic	6	3.7
Hispanic	4	2.5
Arab/Middle Eastern	3	1.2
Prefer not to answer	2	1.9
I do not identify as any of these	2	1.2
Age (years)
30 and under	21	13.0
31–35	31	19.3
36–40	29	18.0
41–45	35	21.7
46–50	11	6.8
51–55	13	8.1
56 and older	21	13.0

Program Evaluation

Year 1 Evaluation

After the completion of the full curriculum (8 sessions), a review of the experience was conducted using structured interviews with STREAM faculty and participants, narrative participant feedback, RAC feedback, and attendance data. Based on this feedback, STREAM sessions were felt to be relevant, engaging, and worthy of recommendation to colleagues. Narrative feedback of the content was largely positive, with comments like

“They’ve been fun and engaging and a “bucket filler” … it's been fun to meet people from different disciplines and to hear shared struggles as well as common solutions.” [faculty participant]

and

“They are very well-designed and probably some of the best residency wellness talks I’ve ever heard.” [resident participant]

However, despite positive feedback on the content and the experience of the sessions themselves, time was a significant barrier for most attendees to completion of the entire curriculum (or even 1 full 60min session), particularly for residents. This was reflected by the low resident participant numbers and by RAC feedback. Clinical responsibilities were cited as the primary barrier to attending sessions. Additionally, the virtual learning format, while convenient and accessible, was felt to have negatively affected engagement and meaningful connection among participants and STREAM presenters. In year 1, there was a high rate of participants who signed up and then subsequently did not attend the session. In interviews with faculty and residents, they described the challenges of attending noon time virtual sessions without protected time for them to attend the session. As a trial, we combined 2 sessions for 1 pillar into 1 longer session, but attendance challenges persisted. As another trial, 2 sessions were scheduled coincident with dedicated divisional meetings or resident professional development time blocks. For these 2 sessions, attendance was >90% of potential participants (faculty and residents) and feedback about the in person setting and opportunities to share in small group activities in person were very positive.

Year 2 Revisions

Based on the review and assessment of year 1, we made multiple revisions of the curriculum in preparation for year 2 (Table 3). We revised the original 4 pillars to strengthen the connection with the PERMA-H model and more explicitly reflect the content of the sessions: (1) optimizing mental health, (2) building resiliency, (3) collaborative engagement to improve work, and (4) connecting with joy and meaning in medicine. We transitioned from the original synchronous virtual model to an in-person session model to enhance engagement, buy-in, and meaning. We further increased time with interactive elements (ie, individual activities and small group discussions) and further limited didactic content to elevate the proportion of active learning efforts. We included an interactive activity within the first 10 min of each session to improve interaction throughout the session. We deepened content related to equity and inclusion to make it more visible in each session. We separated faculty and resident sessions to improve community-building and group dynamics, as the different needs in these groups appeared to outweigh the commonalities. Additionally, we provided the option for sessions to be delivered “a la carte,” depending on the needs of the institution and participants, rather than the expectation/requirement to complete the entire 8 session series. With the year 2 in-person revised model, we recruited faculty at the three pilot institutions and 7 additional institutions as STREAM Faculty for the delivery of in-person sessions. Ten total institutions participated in the year 2 curriculum.

Table 3.

Year 1 Feedback and Curricular Revisions for Year 2.

Curricular Characteristic	Feedback	Change for Year 2
Setting	Virtual environment decreased engagement, increased distractibility Noon sessions difficult to attend, morning clinical obligations often run over	Virtual → in-person learning environment Session times at the discretion of learning groups
Learners	Trainees have different perspectives and current lived experiences compared to faculty Content sometimes felt less relevant to one group or the other	Combined (all learners) sessions → separate sessions based on group (residency program, faculty division, etc)
Length of session	1 h sessions more desirable than 3–4 h block of time Difficult to complete work asynchronously	Sessions remained 1 h in length Only in-person live sessions, optional online resources offered but not required for sessions
Series content/structure	Participating in complete series was too difficult due to scheduling conflicts	Integrated series → A la carte sessions selection, based on learner needs Schedule several months in advance
Other feedback	Diversity, equity, and inclusion components not very visible in many sessions	Integration of explicit components into each pillar

Discussion

In effort to meet the wellbeing needs of pediatric faculty and trainees, we developed the STREAM curriculum using the PERMA-H positive psychology framework and Kern's 6-step approach to curriculum development. The curriculum's original 4 pillars (Attending to Your Mental Health, Professional Resilience, Engagement in Health Systems, and Joy and Meaning in Work) formed the foundation of our learning objectives, and active, learner-centered educational strategies guided the learning activities and implementation. Program assessment, facilitated by reflection, discussion, and participant feedback, generated important revisions and refinements to the curriculum to best meet learner needs in the real-world setting of academic medicine.

Valuable lessons emerged through our process, including the ability to be agile in response to learner needs and the balance of benefits and shortcomings of the virtual learning environment. While part of our original strategy was to utilize the virtual learning environment to maximize ease, access, and participation, in practice it had an opposite effect and decreased engagement. The COVID-19 pandemic necessitated virtual learning, and benefits of this learning environment remain,^22–24 particularly for large group didactic-style learning when participants are separated by significant distance. Studies have also highlighted disadvantages of this learning environment, especially for small group, discussion-based sessions and sessions for which interpersonal connection is the cornerstone to the subject matter.^24–26 In-person presentations to colleagues within a group or division also strengthens colleague relationships, which has been shown to contribute to improved wellbeing.^27,28 Additionally, utilizing rolling data and interval program assessment allowed for more real-time adjustments and curricular revisions compared to using only full, end-of-program assessments.

Beyond recognizing the impact of the learning environment and remaining nimble with learner needs, another important finding in the implementation process was the necessity for protected time for resident and faculty physicians alike to attend and meaningfully participate in educational sessions. Despite desire to attend sessions and favorable feedback on session content, frequent clinical and other academic demands prevented attendance. The barriers of logistics, time, and clinical demands preventing faculty from participating in professional development have been previously well-described.^29,30 Specifically, Steinert et al³⁰ found that “clinical reality and logistical issues appeared to be greater deterrents to participation than faculty development goals, content or strategies.” Having sessions scheduled by institutional leadership during protected professional development time sends a strong “value” message, makes sessions easier to attend, and feels less like an “extra” obligation being forced amid many other obligations. Additionally, the ACGME requires protected educational time for all residents.³¹ It is likely this required protected educational time is routinely dedicated to clinical education, and other professional development opportunities, such as STREAM, may not be protected. Relatedly, it was difficult from a time perspective for participants to commit to 8 sessions. The curricular transition to allow the opportunity for faculty and trainee leaders to select specific sessions based on need provides autonomy to the learner group and individualization of experience.

While healthcare systems and regions vary, a resounding theme consistent in physician wellness and burnout literature is the burden of a working environment that is overwhelming, lacks compassion, and is rife with unrealistic work demands.^32–36 Therefore, an important unifying message throughout the sessions was the acknowledgement that wellbeing is not an individual's sole responsibility and system issues play a role. With these intense systems and working environment issues, the idea of personal resilience and flourishing can inspire resentment and frustration. It is important for any physician wellbeing intervention to acknowledge the burdens of the system when addressing ideas like personal resilience. The STREAM curriculum acknowledged this throughout, and the Engagement pillar was, in part, focused on identifying parts of the system that could be changed to create a more compassionate and manageable working environment for physicians.

The primary limitation to this study was that the barriers to participation limited our ability to measure impact of this pilot curriculum. These barriers to participation reflect the relative inflexibility and onerous workload in healthcare system environments. Several other limitations, detailed above, were elucidated in the Program Evaluation component of the curriculum development process. Further, we cannot characterize the impact, if any, on objective wellbeing measures as a result of this pilot curriculum. The recognition of these limitations and their usefulness in program revisions underscore the critical importance of this 6th and final step in Kern's curriculum development framework. Our future work will include a more detailed analysis of learner outcomes, satisfaction with, and participation in the revised curriculum.

Conclusions

The STREAM wellbeing curriculum delivers skill-building workshops and is a promising model to promote positive behavior change in pediatric academic medicine. Despite a careful needs assessment and planning for educational sessions, in all faculty development, and in particular “wellness” curricular activities may require adjustment and modifications while in process to improve delivery and participation—and enhance chances of successful education/training. Continuous curriculum development should be expected to be needed and embraced, and planned review of the program should be built into the design to allow for program agility. In effort to impact the significant and widespread problem of physician burnout, we must continue to build evidence for the effectiveness of STREAM and other wellness interventions.

Supplemental Material

sj-docx-1-mde-10.1177_23821205251348515 - Supplemental material for Evolution of a Training Program for Pediatric Faculty and Trainee Wellbeing

Supplemental material, sj-docx-1-mde-10.1177_23821205251348515 for Evolution of a Training Program for Pediatric Faculty and Trainee Wellbeing by Suzanne Reed, Julie A. Young, Josephine Enciso, Emma Omoruyi, Rachel Cramton, Larry Hurtubise, Katherine Allison and John Mahan in Journal of Medical Education and Curricular Development

Footnotes

Acknowledgements

Authors would like to acknowledge the work of the Pediatric Resident Burnout-Resilience Consortium Study in defining and describing longitudinal wellbeing issues in pediatric physicians.

ORCID iD

Suzanne Reed

Ethical Considerations

IRB approval was obtained at all participating institutions prior to data collection.

Author Contributions

SR participated in project conceptualization, curriculum development, delivery, and led the preparation and revisions of all drafts of the manuscript. JAY participated in project conceptualization, curriculum development, delivery, and preparation and revisions of all drafts of the manuscript. JE participated in curriculum delivery and preparation and revisions of all drafts of the manuscript. EO participated in curriculum delivery and preparation and revisions of all drafts of the manuscript. RC participated in curriculum delivery and preparation and revisions of all drafts of the manuscript. LH participated in project conceptualization, curriculum development, and delivery. KA participated in curriculum development, delivery, and data management. JM participated in project conceptualization, curriculum development, delivery, and preparation and revisions of all drafts of the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by the United States Department of Health and Human Services Health Resources and Services Administration (grant number: 1U3NHP45413-01-00).

Declaration of Conflicting Interests

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

Consent

All participants provided consent for this curricular study.

Supplemental Material

Supplemental material for this article is available online.

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