Assessing Well-Being in Milestones 2.0: A Case for Flourishing-Focused Advising

In 2018, the Accreditation Council for Graduate Medical Education introduced “harmonized” Milestones, whereby subcompetencies for Interpersonal and Communication Skills, Practice-based Learning and Improvement, Professionalism (PROF), and Systems-based Practice were redefined to provide a shared mental model across specialties.¹  The Milestone PROF-3 (Self-awareness and Help-seeking) poses a special challenge for program leadership.¹  PROF-3 articulates the developmental progression for a trainee to “plan to optimize personal and professional well-being.”¹  Given the well-established prevalence of burnout^2,3  and depressive symptoms in residency training across specialties,⁴  as well as ongoing issues surrounding burnout in practicing physicians after training,^5,6  the development of a subcompetency centered on well-being represents an important addition to the toolbox for trainee assessment. Though not yet present in all specialties, a version of the harmonized PROF-3 Self-awareness and Help-seeking subcompetency is present in the revised milestones of over 30 different specialties.⁷ 

Physician well-being has been described as a constellation of intrinsic motivation, social connection, and autonomy.⁸  Further, some suggest viewing this construct through the lens of flourishing or thriving, in which one's well-being includes aspects of happiness, physical and mental health, meaning, character, and social connection.^8-10  The Self-awareness and Help-seeking PROF-3 Milestone is “not intended to evaluate a resident's well-being, but to ensure each resident has the fundamental knowledge of factors that impact well-being, the mechanisms by which those factors impact well-being, and available resources and tools to improve well-being.”¹¹  However, the task of assessing trainee competence in this domain will pose a challenge to program leadership and clinical competency committees. First, self-awareness and help-seeking are complex constructs that are difficult to assess by program leadership. Second, evidence-based tools and resources in these domains are lacking.

Here, we propose a framework of flourishing-focused advising as a means to assess trainee competence in the harmonized PROF-3 subcompetency.

We suggest building on the existing infrastructure of semiannual advisor and program director meetings to incorporate structured reflection on individual trainee well-being. In our model (Figure), the trainee completes a self-assessment of well-being and is prompted to consider the results through a reflective exercise before meeting with their advisor. This assessment is then used as a springboard for structured, intentional dialogue between the advisor and trainee during a semiannual review.

There are several instruments available to provide a self-assessment of individual well-being. We recommend either the Flourish Index (FI)¹⁰  or the Brief Inventory of Thriving (BIT),¹²  as both instruments move beyond unidimensional measurements of well-being—such as resilience, happiness, or life satisfaction—and provide holistic conceptualizations of well-being (Table). The FI and the BIT are short, easy to administer, and have validity evidence in diverse workplace contexts, including resident populations.^12,20-23  While these instruments provide a reliable measure of individual well-being, the primary aim of the instrument in our model of flourishing-focused advising is to be used as a tool for trainee self-reflection (Figure). These instruments serve a dual purpose. First, they provide a valuable teaching moment in which the learner reflects on their well-being amid the rigors of training. Second, these instruments provide an important launchpad for program leadership to offer resources to support the individual and the program in deficient areas.

Prior to a trainee's advisor meeting, the trainee will reflect on their self-assessment, with specific guidance to consider the factors that influence their individual well-being in each of the domains on the FI or BIT. The Table shows sample questions that can be provided to trainees to facilitate self-reflection. Programs may encourage trainees to select 1 to 2 domains they wish to discuss with their advisor. During the advisor-trainee meeting, the advisor should dedicate a portion of the meeting to an explicit discussion eliciting trainee perspectives on institutional factors that affect well-being, possible solutions to cultivate improved well-being, and next steps for engaging resources to support well-being. Prior to Milestones 2.0, one of the authors (B.D.) found a similar method of self-reflection using the Blue Zones of Happiness as a useful tool for developing individualized goals to improve resident well-being.^24,25  In our experience, a flourishing-focused advisor meeting evolves naturally from discussions about professional goals and does not require substantial time. The meeting may add depth to the conversation by going beyond typical professional goals.

It is important to emphasize that the trainee's level of well-being as measured by the FI or BIT does not equate to competence in PROF-3, nor is assessment of well-being the aim of this subcompetency.¹¹  For example, a trainee may have high levels of well-being as measured by the instrument but lack competence to identify the factors contributing to their well-being and to engage in mechanisms to sustain it. Rather, using a specialty-specific milestone worksheet as a framework, the advisor should document the trainee's level of competence in reflecting on the institutional and personal factors affecting their individual well-being and assess the amount of assistance the trainee needs in order to develop individualized goals to improve their well-being.⁷ 

In alignment with the intended goal of the Self-awareness and Help-seeking subcompetency, the purpose of completing the FI or BIT should be for self-reflection rather than evaluation of the individual's well-being. To permit genuine self-reflection by the trainee, the trainee's score on the assessment should not be provided to the advisor. Rather, we recommend either the instrument be completed by the trainee privately without any data collection or the self-assessment instrument be completed on a completely anonymized digital platform. The latter approach would allow the program to follow aggregate trends in trainee well-being without sacrificing trainee privacy; however, it should be noted the act of recording the responses may impede honest self-reflection for some trainees.²⁶ 

Our recommended approach has several strengths. First, by creating a formalized structure for the integration of reflection and dialogue concerning trainee well-being into the advising process, faculty will more likely be consistent in their approach to discussing the critical topic of well-being with their advisees. Second, using a flourishing framework moves the conversation beyond burnout and narrowly defined dimensions of wellness and creates opportunities for a strengths-based approach to foster trainee well-being. Third, allowing a safe space for trainees to reflect on institutional factors affecting their well-being provides valuable feedback to program leadership on pain points and low-hanging fruit for institutional interventions to improve trainee well-being. Notably, institution-level interventions have been shown to be more effective than individual-level interventions in improving physician well-being.²⁷ 

PROF-3, the new Self-awareness and Help-seeking subcompetency, has the potential to make an important contribution to medical education. PROF-3 may mitigate physician burnout indirectly by promoting emotional maturity and healthy coping strategies. Program leadership will be held accountable for assessing trainees' competence in self-awareness and help-seeking, as well as crafting curricula and advocating for systemic change to address professional well-being. Weaving instruments such as the FI and the BIT into the rhythm of advisor and clinical competency committee meetings can add structure to the discussion and enhance trainee self-efficacy in well-being.