DISCUSSION

This report is the first comprehensive review of wellness activities and programs within Canadian academic EM centers. Significant activity was found across all of the evaluated domains, including formal wellness programs and leadership opportunities, shift scheduling, daily and long-term wellness measures, career transitions, and financial considerations. The most striking finding was the variability and inconsistency of wellness program availability between and within centers. This likely reflects the nature of the rapidly evolving landscape of wellness in EM. The specific example of low numbers of breastfeeding spaces and policies for returns after leaves is particularly concerning. This report would suggest that a comprehensive survey within divisions/departments may lead to some opportunities to declare a set of minimum standards for programs to decrease variability between sites or academic versus clinical appointment.

We note three tangible positive findings that were evident from the survey. First, counselling was available at the university or hospital level in a large percentage of academic sites. This is critically important given recent research showing a large bias against seeking help among doctors surveyed by the Canadian Medical Association.^{Reference Simon and McFadden14} Furthermore, the College of Family Physicians and Royal College of Physicians and Surgeons of Canada's accreditation standards mandate that academic EM residency programs establish and maintain means for resident physicians to access counselling services for support with stress, burnout, or crisis.^{Reference Taher, Hart and Dattani15–17} Despite this positive finding, there remains room for improvement as four academic centers did not have either hospital or university level support. Second, 77% of academic sites have some degree of departmental policies for physicians at the end of their careers. Given the large reliance on shift work, and the difficulties with adaptation to disruptions of circadian rhythm with aging, the progressive policies that most academic centers have adapted is encouraging. This is important as overall dissatisfaction has been shown to be a significant factor underlying intention to quit and early retirement.^{Reference Cydulka and Korte18–Reference Likourezos, Chalfin, Murphy, Sommer, Darcy and Davidson20} Likourezos et al. reported that emergency physicians who were dissatisfied with professional autonomy were more likely to seek a new position or exit the profession.^{Reference Likourezos, Chalfin, Murphy, Sommer, Darcy and Davidson20} Third, almost 60% of centers were found to hold an annual retreat. Although not much literature is available on the effect of retreats on wellness, they do provide a departmental/divisional forum for reflection and future goal setting, which is intrinsically tied to professional fulfillment and wellness.

The Institute for Healthcare Improvement introduced the Triple Aim in 2008 as a framework that describes an approach to optimizing health system performance through: (1) improving the patient experience of care (including quality and satisfaction); (2) improving the health of populations; and (3) reducing the per capita cost of health care.^{Reference Berwick, Nolan and Whittington21} Currently, many institutes now pursue the “quadruple aim” in 2014 with institutions advocating for health care team wellness as a crucial fourth aim.^{Reference Bodenheimer and Sinsky22} Our survey suggests that, if this fourth aim is included in the framework, there is currently a significant gap in top-down support/structures. In fact, it is difficult to even measure the metric of wellness. In our survey, most wellness programs were at the division/department level, not at the hospital or university level. It appears we have a long way to go before the quadruple aim can become a meaningful reality.

Our study had a 100% response rate, indicating a comprehensive assessment of Canadian academic EM programs has been achieved. The survey assessed a broad range of infrastructure consistent with career sustainability and wellness. As in prior academic scans in EM, the data obtained from this survey can be the springboard to encourage further initiatives.

There are several limitations to our study. Many wellness issues are managed at the hospital level, e.g., shifts. Due to the surveys being carried out at the medical schools and not the 60+ academic hospitals in Canada, we do not have a complete picture. The survey was based on the report of local physician champions, who are likely to be the most aware of programming and, thus, may not reflect the general awareness of all departmental/division members. In addition, wellness initiatives may stem from university, hospital, or departmental/divisional programs, and particularly so in programs with multiple sites (e.g., British Columbia). Although we delineated the source of programming, the responses best reflect the wellness champions’ local situation, and it is possible that other hospitals or groups had differing initiatives that were not included here. Although we attempted to examine gender equity, this survey was not designed to examine diversity issues in general, which would be an opportunity for future research. Finally, we did not ask about the status of the local electronic medical record (EMR) system and supports for physicians in this regard.^{Reference Melnick, Dyrbye and Sinsky23}

EM programs can use the results of this study as a framework to examine what systems are currently in place, determine their relative weaknesses and strengths, and set goals and priorities for development. National collaboration between EM programs to develop more comprehensive wellness programs may speed our specialty toward the Quadruple Aim goal. Our results may aid in discussions with hospitals, universities, and stakeholders to help gain support for these initiatives. The authors believe that the high priority areas for wellness initiatives are as follows: the development of a structured practice of critical incident debriefing; the provision of places to either sleep surrounding night shifts and/or spaces to breastfeed on shift; and the creation of programs to assist physicians with transitions, such as onboarding or returning to work following leave.