Becoming AWARE: ACGME's New Suite of Well-Being Resources.

T he Accreditation Council for Graduate Medical Education (ACGME) launched the AWARE suite of well-being resources in December 2019. This collection of resources, available in multiple media formats, is designed to promote well-being among residents, fellows, faculty members, and others in the graduate medical education (GME) community. The ACGME’s Common Program Requirements on well-being state that sponsoring institutions and programs are encouraged to review materials to create systems for identification of burnout, depression, and substance abuse. The AWARE suite, along with other materials and information on well-being, are available on the Physician Well-Being section of the ACGME website (http://www.acgme.org/whatwe-do/initiatives/physician-well-being).

T he Accreditation Council for Graduate Medical Education (ACGME) launched the AWARE suite of well-being resources in December 2019. This collection of resources, available in multiple media formats, is designed to promote well-being among residents, fellows, faculty members, and others in the graduate medical education (GME) community.
The ACGME's Common Program Requirements on well-being state that sponsoring institutions and programs are encouraged to review materials to create systems for identification of burnout, depression, and substance abuse. The AWARE suite, along with other materials and information on well-being, are available on the Physician Well-Being section of the ACGME website (http://www.acgme.org/whatwe-do/initiatives/physician-well-being).

Background
The ACGME's longstanding commitment to addressing physician well-being through raising awareness, supporting research, and identifying resources and professional development for program leaders and faculty members is reflected in the multiple initiatives the organization has undertaken since its inception.
The ACGME has been at the forefront of defining the parameters of well-being from a GME perspective, and of amplifying the community's efforts to improve it. These efforts range from ACGME President and CEO Dr. Thomas J. Nasca's leadership with the National Academy of Medicine's Action Collaborative on Clinician Well-Being and Resilience to the research team led by Dr. DeWitt Baldwin Jr that measures and analyzes the results of the Annual Resident/Fellow and Faculty Survey questions addressing well-being. Since implementation of the recent revisions to Section VI of its Common Program Requirements in 2017, the ACGME has redoubled its efforts to highlight and create opportunities for GME programs to access resources and foster dialogue on well-being. Through such vehicles as its Back to Bedside initiative and Physician Well-Being Symposia, the ACGME has increasingly taken on the role of convening key national stakeholders and members of the GME community to facilitate conversation around how to mitigate physician stress, prevent burnout, and help physicians find meaning through work at the individual, program, and system levels.
The impact of stress, depression, and burnout on physicians is profound; evidence shows it follows them from medical school through residency and continues well into their professional practice. 1 There are no one-size-fits-all solutions to the challenges GME stakeholders face in their efforts to maintain their well-being in the clinical learning environment. [2][3][4] Residents and fellows, faculty members, program directors, and coordinators face their own unique obstacles (and a few common ones) to managing the variables that contribute to their personal and professional senses of well-being. These variables include excessive workload, balancing effort and reward, and exercising control over decisions, as well as dealing with workplace harassment, microaggressions, and negotiating clinical hierarchy and culture. 2,3 Yet there is also evidence that a variety of individually focused and organizational or system interventions can help prevent burnout and/or improve burnout rates among physicians. 4 Acknowledging the numerous factors that impact well-being in the clinical learning environment, ACGME executive leadership established 2 priority goals for the organization's well-being initiatives. These included the curation of evidence-based educational resources on a variety of topics affecting well-being and, where needed, the creation of new resources that could meaningfully contribute to institutional and program efforts to improve the well-being of their communities. It is the ACGME's hope that these resources will support the well-being elements in Section VI of the Common Program Requirements and help programs and institutions identify solutions that best meet local needs. Resources can support, but cannot take the place of a local commitment to fostering well-being, and to assessing DOI: http://dx.doi.org/10.4300/JGME-D-19-00967.1 Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its Review Committees. The decision to publish the article is made by the ACGME. and assisting residents, fellows, faculty members, or others in distress.
The AWARE suite of resources emerged as a response to these goals. AWARE was designed to align with the broader ACGME commitment to developing high-quality resources that provide programs with educational tools they can use. These resources complement the collection of external resources the ACGME has compiled, including those around addressing burnout, mitigating the effects of depression, managing organizational change, changing the structure and culture of clinical learning environments, and suicide prevention. Those resources can be found on the Tools and Resources page in the Physician Well-Being section of the ACGME website (www.acgme.org/what-we-do/initiatives/ physician-well-being/resources).
The initial set of AWARE resources is a collaboration between the ACGME's Office of Distance Learning and Senior Scholar for Well-Being Dr. Stuart Slavin, using leading-edge technologies and evidencebased approaches. Strategies include concepts and frameworks from cognitive psychology-an early focus of the AWARE resources-as well as from anthropology, business, communication, and sociology. The ACGME AWARE tools, derived from multiple disciplines, are designed for use by the GME community to inform local curriculum development and support system redesign.

Cognitive Psychology, Organizational Change, and Culture
The field of cognitive psychology has proven a fruitful starting point for developing resources to support individual clinicians and community wellbeing. Slavin and colleagues' research into the effectiveness of using concepts and methods from cognitive behavioral therapy to teach medical students and residents skills for improving their resilience provides evidence that such strategies could have a positive impact at the individual and program levels. 3,5,6 The positive outcomes of programs such as the Resident and Faculty Wellness Program at Oregon Health & Science University, based largely on providing counseling using cognitive behavioral methods, reinforce the notion that the field has much to contribute to improving clinician well-being. 7,8 This framework and accompanying methods are accessible and relatively simple to implement-and the systems supporting them are feasible for replication at the institutional level. The early focus of AWARE is on disseminating both cognitive skill-building educational interventions and exemplary systems and practices to support clinician well-being developed within the GME community. Additional online (live and on demand) and multimedia resources on strategies for addressing the organizational and cultural aspects of well-being are under development and slated for release in 2020.

The AWARE Suite
The AWARE resources can be used as part of program and institutional efforts to improve faculty member, resident, and fellow well-being. They can also be used to help programs support local commitment to fostering well-being at an individual level and to addressing system-level issues, including assessing and assisting residents and fellows, faculty members, or others in distress. The AWARE suite of resources will expand over time to include tools for addressing system-level issues; for the moment, the resources released in December 2019 focus on the dissemination of strategies for cognitive skill building to improve resilience and well-being. The hope is that the methodologies and educational resources that comprise the AWARE suite, available in multiple media formats, will provide individuals, programs, and institutions with a range of tools they can access for personal use or adapt for inclusion in their local curriculum.

AWARE Cognition and Well-Being Skill Development Video Workshop
Created for designated institutional officials (DIOs) and program directors, this video workshop provides a framework for addressing well-being with residents and fellows, and a guide for leading a local workshop on the role of cognition in well-being. The workshop toolbox contains 3 short videos with slides, as well as a facilitator's guide with a workshop agenda, exercises, and guidelines for discussion. Depending on how the live workshop is conducted locally, it takes between 1.5 to 2.5 hours to run. Workshop materials can be found in the Learn at ACGME online portal (www.acgme.org/distancelearning).

AWARE App
Designed for individual physicians, particularly junior residents, the AWARE app introduces users to common cognitive routines that contribute to stress and burnout, and then directs users toward cognitive behavioral therapy and other practices that may be helpful to undoing those routines and improving wellbeing. The app can also be used by institutions and programs as part of a broader well-being curriculum. The app is available for download through the Apple Store or Google Play; the duration of play time runs 20 to 30 minutes depending on how the user navigates the available resources in the app.

AWARE Podcasts
Two podcast series with different objectives were developed.
The Cognitive Skill Building for Well-Being series is designed to teach individual clinicians, including residents, fellows, and faculty members, about common cognitive mindsets and effective strategies for enhancing their well-being.
The Systems and Research in Well-Being series is designed to connect DIOs and program directors with resources to inform their efforts to develop local systems to support their clinicians' well-being, and to provide the community with updates on evolving evidence-based knowledge.
The AWARE podcasts can be found by searching ''ACGME AWARE'' on podcast platforms including Apple Podcasts, Spotify, and Radio Public; they are also available in the Learn at ACGME online portal (www.dl.acgme.org).
For more information on the AWARE suite of resources, contact the ACGME Office of Distance Learning: de@acgme.org. All AWARE resources are available at no cost to members of the GME community and their use is governed by a Creative Commons attribution for education license.