Resident Perspectives on a Wellness Program: A Qualitative Analysis

Abstract

Background and Objectives

Resident physicians experience high levels of burnout and depression compared to the general population. While focus on promoting resident wellness, including required wellness programming from the Accreditation Council for General Medical Education (ACGME), has increased, research into resident perspectives on what should be included in these programs has been limited. This study aimed to evaluate resident perspectives on a wellness program at the University of Michigan Family Medicine Residency (UM FMR).

Methods

This qualitative study evaluated transcripts from a focus group and an anonymous survey of residents at UM FMR. Two authors reviewed transcripts using descriptive coding and a classical analysis strategy. All authors reached consensus on themes, which were then sent to residents for review and feedback.

Results

Six themes emerged as important to the resident wellness program: (a) program variety, (b) developing a supportive resident community, (c) workplace wellness skills development, (d) addressing basic needs, (e) options for processing difficult situations, and (f) acknowledgment of structural limitations to resident wellness.

Conclusions

This analysis of the survey revealed opportunities for improvements in this residency wellness program and also serves as a model for future studies on resident perspectives on resident wellness.

Introduction

Burnout and depression in physicians are increasingly common, particularly during residency. Though physicians are more resilient than the general population, even these resilient physicians face rising burnout rates¹. One meta-analysis found that approximately one-fourth of residents experience depression or depression symptoms annually, with rates increasing yearly.² Family physicians should strive to increase the resiliency and wellness of trainees to improve patient safety, because burnout negatively impacts care.^3,4

To combat depression and burnout, many residencies have implemented wellness programs, with mixed evidence on effectiveness.⁵ One study of family medicine residents noted that substandard wellness programs and insufficient time for self-care were associated with increased rates of emotional exhaustion, depersonalization, and depressive symptoms.⁶ Research has indicated that family medicine residents have lower satisfaction with wellness programs compared to program directors.⁷ For these programs to succeed, further research is needed to identify what residents find helpful in wellness curricula.

This study aimed to evaluate family medicine resident perspectives on a wellness curriculum and to develop a framework that can be used in other programs; an expanded study then could identify common themes across residency programs. Before this study, the wellness curriculum at University of Michigan Family Medicine Residency (UM FMR) consisted of 18 to 20 sessions of 1 to 3 hours each per academic year, with content based on Accreditation Council for General Medical Education (ACGME)⁸ requirements, residency psychologist expertise, and informal resident feedback.

Methods

Design

This study took place at UM FMR and was determined to be exempt from review by the Michigan Medicine Institutional Review Board (HUM00241909). A second-year family medicine resident in the same program, with experience in conducting focus groups, facilitated but did not participate in one focus group for all available residents using a question framework developed by the authors to elicit resident perspectives on strengths, weaknesses, and areas for development in the current wellness program (Table 1). This focus group was audio-recorded, then transcribed and de-identified by the facilitator. Questions from the focus group (Table 2) were adapted for an open-ended, anonymous survey that was sent to all residents in an attempt to capture all feedback and responses, and were compiled into two transcripts based on attendance at the focus group.

Table 1.

Questions for Focus Group

How does our residency promote resident wellness? What are limitations? What do you like about wellness sessions? What ways could we improve? What tangible skills would you like to learn from wellness sessions? What topics would you want to hear more about in wellness sessions?

Table 2.

Questions for Survey

How does our residency already promote resident wellness? What are some limitations in our residency wellness currently? What do you like about our wellness sessions? What ways could we improve wellness sessions? What tangible skills would you like to learn about from wellness sessions? What topics would you want to hear about more in wellness sessions? What other ways could the wellness committee promote wellness? What could administration do to support wellness? What could faculty do to support wellness?

Analysis

Two authors reviewed the deidentified transcript of the focus group and the compiled survey responses using electronic descriptive coding and a classical analysis strategy.⁹ All authors reviewed the codes, which were then thematically analyzed using a grounded theory informed approach.⁹ Theme consensus was reached across all transcripts, and the results were presented to residents to ensure the themes reflected resident experiences and perspectives.

Results

Out of 35 eligible residents, 21 participated in the focus group, and 16 residents completed the survey, 8 of whom participated in the focus group and 8 of whom did not participate, to achieve a response rate of 82%. Six themes, described in the following text, emerged from the data about what residents identified as important to a wellness curriculum. A selection of representative supporting quotes for the themes are included in Table 3. We found no difference in the themes between the focus group and survey responses.

Table 3.

Representative Quotes by Theme

Theme	Representative quotes
Program variety	“A balance between structured and unstructured and how unstructured time can be really nice and we don’t really have a lot of that in our wellness activities.” “We like the sessions that are more resident led.”
Developing a supportive resident community	“I find the culture to be a supportive one, which helps with wellness, as working with faculty and residents within our department is a comfortable and safe environment.” “Faculty know how to better support us when people are like really sick or you know, we watched a traumatic, we were part of like a traumatic patient experience.” “[Attending name] actually covered [inpatient adult medicine service] for an afternoon to allow me to go to wellness. And it was like the most validated I ever felt and supported as a resident.”
Workplace wellness skills development	“We learn a lot how to be well outside of work, but most of our time is spent at work and most of our stress comes from it as well. So how to manage stress at work?” “Someone asking us that question, now I feel like, something like that would be super helpful; it’s like okay, how do I, how do I get there? How do I get there in a way that like I enjoy, and I stay excited about?” “It’s more like a time issue with like the things we’ve already talked about as limitations, in-basket management, 24-hour shifts, etcetera.”
Addressing basic needs	“We also really liked wellness as like a time for all of us to be in the same place, because we don’t really work with each other at all.” “More in person meetings, with food please; outdoors is a plus.”
Options for processing difficult situations	“We’ve all experienced very traumatic things in residency, and so to have a place where we can like talk about them in an actual environment.” “For me like vulnerability is something I want to share in a safe space; and not that this isn’t a safe space, but this is a professional space and those are kind of different to me.”
Acknowledgment of structural limitations to resident wellness	“We also have [resident sick coverage system] not only as a promotion of wellness but also as a negative.” “For the admin half days, if we specifically want to use it on a half day of clinic, we have to use it like really in advance, because now they’re scheduling clinic out for like, what, 6 months? Is what they, like that’s how early they want us to know electives and like things. That’s difficult.” “We talked about all of the limitations our program has in terms of expected culture of resident work life, uh GME and ABFM requirements on hours, days off, the amount of rotations we have to do.”

Abbreviations: GME, graduate medical education; ABFM, American Board of Family Medicine

1. Program Variety

Residents appreciate when wellness programming is varied, particularly in providing options for their level of participation within an activity and facilitating resident-led activities. They also recognize that each session may not be helpful for all residents, so variety in types of wellness sessions should help more residents find benefit over time.

2. Developing a Supportive Resident Community

Residents value creating a supportive community, including support from other residents, faculty, and staff, and value being involved in developing a supportive culture. Part of a wellness program needs to be giving residents a space to develop a community.

3. Workplace Wellness Skills Development

Residents identify knowledge gaps in how to maintain wellness in the workplace and how to identify role models. They identify development of these skills along with other workplace skills, including charting efficiency and workplace boundaries, as opportunities for future wellness programs.

4. Addressing Basic Needs

When wellness sessions help address needs such as providing food and creating a space for social connection, residents find them helpful. Residents currently find focusing on wellness sessions is difficult when they have to worry about trying to eat when going to or coming from busy clinics or inpatient shifts.

5. Options for Processing Difficult Situations

Residents feel that discussion of traumatic events and ways to cope are limited, but also recognize that some may feel uncomfortable being vulnerable in the workplace. Providing options for level of involvement in processing emotions is identified as important to make sure residents feel comfortable in these spaces.

6. Acknowledgment of Structural Limitations to Resident Wellness

Resident wellness has many structural limitations, including program and ACGME requirements that limit free time, schedule control, and ability to schedule time for self-care, which contribute to burnout. These are not within the control of the individual program but affect the larger context of resident wellness.

Conclusions

Residents identified several core areas that they would like included in wellness programs, including addressing basic needs, workplace wellness skills development, and options for processing difficult or traumatic situations. They also appreciated variety in wellness sessions and opportunities to develop community. Residents also expressed that having food at wellness sessions made them more likely to engage in the session. These findings are significant because they include topics that may not be typically considered in wellness programs.

Though this study was limited by a small sample size at a single institution, it can serve as a model for other institutions to complete reviews of their wellness programs. We also aim to expand this project to other residencies to identify common themes to improve resident wellness curricula beyond the level of the individual program. While the focus group was facilitated by a resident to improve honesty of participants, this may have introduced bias; however, the facilitator did not participate in the feedback. Responses were de-identified before analysis by a paired resident and attending, who were not involved in wellness program planning, but were interested in improving resident satisfaction, which could be another potential area for bias.