Feasibility of a “Network of Champions” in Implementing a Program to Address Physician Well-being

The ability of physicians, and internal medicine (IM) physicians in particular, to deliver the highest quality and empathic healthcare may be limited by their “work conditions” [1]. Physicians are rushed, measured, and constrained by the combination of increasing administrative burdens with difficult-to-manage workloads and decreasing control over their work environments. The consequences of not addressing these factors have included a steadily evolving crisis of physician burnout, hours reduction and turnover, as well as concerns about the impact on care quality and patient safety [1, 2]. The toll burnout takes on physician mental and physical health is well-described [3–5]. Coordinated efforts appear to be necessary on structural and organizational levels to improve well-being and ensure sustainability of the profession [4]. The National Academy of Medicine’s (NAM) Taking Action Against Clinician Burnout consensus study calls for systems improvement to prevent burnout. Suggestions include 1) create positive work and training environments, 2) reduce administrative burdens, 3) enable technology solutions, 4) provide support to physicians and learners, and 5) invest in research [4]. The NAM report provides a framework for viewing existing interventions and assessing their value. In that report, they mention that “medical societies, state licensing boards, specialty certification boards, and medical education and health care delivery organizations all need to take concrete steps to reduce the stigma for clinicians of seeking help for psychological distress, and make assistance more easily available” [4]. Many of the factors impacting clinician well-being are due to and controlled by local environments; thus, approaches to address the issues should include a local focus. JOURNAL OF WELLNESS ORIGINAL RESEARCH

The American College of Physicians (ACP) is the largest medical-specialty society in the world with over 161,000 members. ACP's vision is to be recognized globally as a leader in promoting quality patient care, advocacy, education and career fulfillment in Internal Medicine and its sub-specialties. Integration of clinician well-being into mission, vision and values is important for organizations like ACP to lead by fostering healthy work and training environments. ACP's "Patients Before Paperwork" initiative catalyzed high-level efforts to decrease administrative burdens [6]. This effort was the beginning. It was soon recognized that the empowerment and well-being of the physician was a critical area of focus and more likely to be achieved through human connection, than access to an online toolkit (as many other organizations were employing). This paper describes ACP's development, implementation, and preliminary findings of an organization-wide well-being training strategy to foster communities of thriving physicians at the state and local level.

METHODS
In response to studies showing that physicians were experiencing high levels of work-life stress, ACP proposed a multifaceted response to physician burnout. Given ACP's reach via its 85 chapters throughout the world, a chapter-based approach was selected as the most feasible way to scale up to a world-wide program that fostered a unique human touch. In an initial effort to gather a sense of interest and engagement, ACP trained a pilot group of 20 Well-being Champions (WBC) in October 2015. Impressed with the enthusiasm of this group, ACP expanded the program to 1) understand and address more of its members' needs, and 2) transform physicians' work environments while improving their ability to cope with those environments.

Goal and Structure of the ACP Well-being Champion Program
The goal for the Well-being Champions Program was to equip Champions with knowledge, best practices, and skills to improve well-being locally. Because local needs were diverse, program directors allowed Champions discretion in terms of what they offered their chapters. Customization was a key aspect of the well-being training, as effective Champions must be prepared to customize their approach to the challenges their chapter is facing. For example, if a major stressor is the electronic health record, then offering programs on that topic would likely be well received (e.g., discussing templates and scribes), while if work-life integration challenges are primary, then emphasizing workflow redesign may be most helpful.
Each of ACP's 68 domestic and 17 international chapters planned to train one to two Well-being Champions to serve 3-year terms. Well-being Champions received travel reimbursements to attend training but were not compensated for their role. Training consisted of a one-day, in-person, initial interactive program as a pre-course to the ACP Annual Meeting, followed by virtual webinar training, mentoring, and year-long support. Complete training for the next two cohorts of 93 physicians was held in 2017 and 2018 during a one-day training experience. Training in 2019 was expanded to two full days to allow more focus on physician coaching and positive psychology (as these were needs identified by the previously trained Champions). Table 1 describes goals, objectives, and educational strategies of the curriculum.
Supplemental training, mentoring and ongoing support were provided. In 2017, ACP offered training in positive psychology to chapter leaders and a 4-hour refresher training to the original group trained in 2015. From 2018-2020, twelve virtual webinars were offered and attended by 371 people live and received 497 views through the Champions' resource center site. Champions also have access to an online community of staff and colleagues, and to resources curated by ACP staff.

Well-being Champion Training
Subject matter experts (SMEs) collaborated with ACP staff and leadership to design learning objectives to guide the curriculum and developed content to deliver on those objectives. The Champions' training was largely based on research in physician work-life and positive psychology [7][8][9]. These studies address NAM-suggested areas, such as the evidence base for burnout prediction and reduction, creating positive work and learning environments, reducing administrative burden, and providing support to physicians and learners. These findings were generalized during training for broader applicability, and clear examples of system changes within these groups were provided Learning Objectives -After the sessions, champions will be able to:

Curricular Components
Articulate the rationale for investing in improving physician well-being and professional satisfaction.
• Making the case for burnout prevention • Making the business case: $250,000 -$1,000,000 to replace a departing physician; improving quality, patient safety, physician morale and engagement (2) Conduct an environmental scan and connect with existing well-being efforts in your chapter, practice, or health system.
• Performing an environmental scan and landscape assessment of well-being efforts in your chapter Draft a well-being champion identity statement (personal mission statement as a well-being champion).
• Creating Vision Statement for Well-being Champion efforts Employ positive psychology coaching and tools with individuals or groups trying to improve well-being and satisfaction.
• Means to achieve "joy in practice" • Positive psychology and coaching techniques for physician well-being (8,9) Select an approach for measuring and analyzing physician well-being and professional satisfaction in your chapter. Recommend menu of potential interventions based on analysis of data.
• Measurement techniques: instruments and necessary infrastructure, using the Mini-Z • Practice sessions analyzing and sharing organizational data with leadership Identify key resources that can help you in your Champion work.
• In depth review of interventions that work • Conceptual models for burnout, including the demandcontrol model of job stress (1,4,7,12) • Specific, evidence-based interventions for improving satisfaction and reducing burnout (7) • "Bold suggestions" for improving work-life (floats, scribes, and customizing standard work) • Gender differences in burnout and how to mitigate them (adjusting panel sizes, encouraging part time, improving control) Employ positive psychology coaching and tools with individuals or groups trying to improve well-being and satisfaction.
• Coaching using the mini-Z 2.0 Develop a two-year physician wellbeing and professional satisfaction plan for your chapter that aligns with your mission statement.
• Vision to action: Building a chapter well-being plan • Review of ACP Resources to support Well-being Champion work • Overcoming obstacles and sustaining success for evidence-based interventions the champions could bring to their home chapters and institutions. Participants learn the conceptual models underlying the etiologies of burnout and drivers of well-being, then learn positive psychology and coaching skills in an interactive format to foster listening and reflection. The syllabus provides measurement tools alongside evidence-based interventions, including use of the Mini Z work-life measurement tool, and ways to coach to create change based on Mini Z results [10]. This curriculum is taught by two experts in physician well-being and one expert in positive psychology and well-being, and is coordinated by 3 administrative staff. Prior to their training date, Champions were asked to complete an environmental scan of their Chapter to identify existing resources, areas of greatest need, other potential collaborators in their Chapter, and potential challenges that might exist. Their prior experience with and knowledge about physician well-being were also assessed. Based on survey results, Champions were guided through the drafting of a mission statement, vision, and action plan during the training. As part of outlining the action plan, Champions identified ACP resources that would help them succeed in achieving their goals. These steps were included to ensure that the training was more than an information transfer, and that Champions felt empowered to take the next steps toward their vision of success upon completion of training.
To support the Champions, ACP developed an online toolkit housing curricular materials, resources, and links to the Mini Z. Champions were connected via an online listserv and newsletter called "IM Thriving". The listserv provided a vibrant example of how the camaraderie among Champions could be sustained with frequent sharing of new articles, techniques, and successes among participants and ACP leaders.
SMEs Mark Linzer and Sara Poplau were paid through their employer, Hennepin Healthcare, by the ACP for their work on this project. SME Kerry Palamara was paid as a consultant by ACP. SMEs' travel costs to training sessions were also supported by ACP. There were no other fees or royalties, and the Mini Z used for measurement is currently free for use and is in the public domain. The ACP had no oversight of data analysis or in the decision to publish this paper. Other funding sources for the authors are listed in the conflicts of interest statement.

Well-being Champions Training Evaluation
Well-being Champions completed baseline surveys 2-4 weeks prior to the training sessions (with one reminder e-mail sent one week prior to the deadline) including demographics, clinical practice experience, prior well-being experience, chapter well-being efforts, and level of interest in well-being. Within 1 week after training, participants were asked to complete online surveys assessing knowledge, skills, and attitudes after their training. Surveys were designed to understand WBC's comfort with specific skill sets which were aligned with the objectives and also would promote a high likelihood of being successful in reducing burnout within their Chapter / organization. In particular, information about their ability to articulate the evidence base for burnout reduction, design interventions, access resources, analyze survey data, foster a well-being community, deliver presentations, engage leadership, and use positive psychology for coaching were included. Finally, surveys assessed how ready WBC's were to begin a well-being program at their home site.

RESULTS
At present, there are 158 WBC's from 8 countries. These Champions represent over 90% of ACP domestic chapters, and 100,000 members. Champions were predominantly female, with balanced representation of inpatient, outpatient, academic, and community-based practices ( Table 2). All chapter sizes were represented, from fairly small (1-475 physicians) to very large (6,000+ physicians). While level of chapter interest in well-being was high in 58%, only 26% had a budget allocated for well-being maintenance / optimization, and most budgets were small. Initial plans for well-being efforts included program planning and utilizing or developing committees.  In terms of knowledge, skills, and attitudes ( Table 3), 85% of Champions from the 2018 and 2019 cohorts felt able to articulate the evidence base for wellness training, suggest interventions, access resources, administer a work-life and wellness survey, analyze well-being data, enhance their own well-being, foster a well-being community, deliver a program in well-being, and engage leadership. After expanding the positive psychology and coaching curriculum in year 2, those ready to use these skills increased from 76% to 91%. While 27-30% of attendees felt "ready to go" to implement programming after training, 63-64% felt "a little nervous getting started".
After training, Champions engaged in diverse activities, including organizing well-being chapter committees, planning local presentations, implementing webinars, developing online resources, and being available for 1:1 meetings with fellow physicians.  Table 5.
The following are the pre-COVID-19 pandemic activities reported by Well-being Champions as undertaken between January and February of 2020: 10 total activities in 2 months (5 per month) -6 meetings, 1 workshop, 1 webinar, and 2 newsletters. During the pandemic, there were 93 total activities undertaken in the 8 months from March to October 2020 (>10 per month), including: 67 webinar or virtual meetings/trainings, 21 newsletter or related articles, 5 surveys, as well as a socially distanced walk, a story slam, and a Bibliotherapy session (a creative arts therapy modality that involves storytelling or the reading of specific texts with the purpose of healing).

DISCUSSION
In this report of a large scale, innovative program to address work-life and well-being within the field of Internal Medicine, we have shown that: a. Recruitment of volunteer physician faculty to engage in this multi-faceted work is feasible, b. It is possible to train a large number of people with knowledge, skills, and attitudes that enable them to feel ready to enact change, and c. Compared to the annual cost of burnout, the costs of the program may be reasonable for large organizations. We anticipate this model will be exportable to other clinical or training environments to promote sustainable work-lives for physician and non-physician members. Data from 20 chapters and 1,300 internists show not only the need for the program but a mechanism for monitoring progress, with high overall burnout rates, and more challenging work environments among women internists [11].
Our main goal is to be sure that investments in local leadership and activism in well-being are felt by individual physicians who may be struggling. Our strategy, set forth by ACP's Physician Well-being and Professional Fulfillment Committee,   focuses in the areas of improving the practice and organizational environment, fostering local communities of well-being, and promoting well-being (https://www.acponline.org/practice-resources/physician-well-being-and-professionalfulfillment).
With the robust community created among Champions and chapter members, ACP leadership can learn from "boots on the ground" experiences; ACP leaders can also share what is happening at a systems level, and Champions can bring these experiences to their chapters.
To be successful, we (and other organizations that undertake such efforts) must work with Champion cohorts to leverage small budgets and grow plans for their chapters. Champion trainees can become local trainers and (with their self-reported abilities to demonstrate the evidence base for burnout prevention and perform positive psychology activities and coaching) spread the effort and enthusiasm for well-being action and activism. To better support Champions in their work, ACP began monthly group coaching for Well-being Champions in August 2020 to catalyze their efforts, further build community, troubleshoot shared challenges, and connect them with the resources needed for success. To date, 66 Champions and chapter well-being leaders from 45 chapters are involved in these sessions.
Costs for this program varied from year to year, based on the approach used. The annual direct costs of the program were well below 1% of aggregate ACP member dues and could be modified to be even less with strategic adjustments to the program (for example: adapting existing training materials and offering virtual training). Table 6 depicts key elements of the Champions Program and provides options for lower cost undertakings that organizations can tailor based on specific needs.
Several examples exist of other organizations aiming to achieve NAM's goals to take concrete steps to reduce the stigma for clinicians that seek help for psychological distress and make assistance more easily available. In 2011, the American Academy of Pediatrics developed a systematic approach to wellness, while several years later, the American Board of Family Medicine began measuring burnout for re-credentialing physicians [12,13]. The American College of Surgeons offers wellness tracking (https://www.facs.org/member-services/surgeonwell-being), while the American College of Emergency Medicine has a well-being committee, and the American College of Gastroenterology has posted a toolbox based on the American Medical Association's STEPS forward modules [14,15]. However, to our knowledge, there are few, if any, professional organizations that have instituted large-scale training programs to infuse their profession with Well-being Champions to implement training and well-being promotion activities, along with well-being measurement, aimed at changes at the local level. We hope that this manuscript can provide a model that can be readily exported to other organizations. We advise using the training framework and learning objectives in Table  1; additionally, a sample toolkit was made available on the ACP website -(https://www.acponline.org/practice-resources/ physician-well-being-and-professional-fulfillment/design-yourown-well-being-program) and is described in Table 6. • Engage with experts on creating an inclusive health care environment. Panel discussions focus diversity, equity, inclusion, and gender equity. • Perform an environmental scan to identify gaps in diversity, equity, or inclusion, and then identify short-and long-term goals and steps to achieve them. • Promote collaborations through the formation of work affinity groups based on shared interests and approaches.

Chapter/ Territory
• Projects and initiatives from this event include a podcast (The DEI Shift now running for three seasons) focused on DE&I, a book of case studies on DE&I initiatives, and a collection of video clips of DE&I perspectives in medicine. • More than 100 attendees with 14 ACP chapters represented, as well as physicians from diverse specialties and non-physician team members.  Given the work-life challenges noted for IM in the initial data collection from the 1,300 members, our plan is to continue to collect data and feedback from the Champions in a more robust and systematic manner. We hope in so doing that we can iterate the curriculum to support the areas of greatest need and monitor progress throughout the discipline of IM [11]. Refining training to promote effective system change is the main purpose of future training. Future studies will report progress in the realms of internist well-being and professional fulfillment.
Given that training was completed within the year prior to the onset of the COVID-19 crisis, the Well-being Champion network was in a unique position to offer well-being resources and approaches to promote work-life balance and sustainability during the crisis, as evidenced by the myriad ways they were able to support their colleagues during this time. Burnout prevention was at a premium as IM became immersed in the treatment of patients infected with the COVID-19 virus while developing unique models of care.

LIMITATIONS
There are limitations to this report. For one, we have few data that reflect change at the local level. Second, many of the international chapters have differing experiences and thus customization of training is required. Third, systematic measurement of well-being on the larger scale of the entire membership has not yet been performed. Finally, it is not clear if the best locus for a well-being program is at the national or local level.

CONCLUSION
With a documented crisis in physician burnout, ACP identified a need to invest in our physician members by giving them agency, data, evidence-based interventions, and ongoing support to foster local communities of well-being. This report outlines key components of that training and program infrastructure so that other organizations might reproduce relevant aspects of this approach. Additionally, we strive for internists worldwide to know that such a program exists and that a more favorable work environment is an aspirational and foreseeably achievable goal for our profession.

Abbreviations:
IM -Internal Medicine NAM -National Academy of Medicine ACP -American College of Physicians WBC -Well-being Champion SME -Subject Matter Expert