Abstract
Importance
Wellness programs have become important strategies to combat burnout and depression among residents. However, the resident perspective on wellness in ophthalmic graduate medical education has not been solicited on a national level.
Objectives
To report on residents’ views of wellness initiatives in ophthalmic graduate medical education and identify potential strategies for promoting resident wellness.
Design, Setting, and Participants
In this national survey of ophthalmology residents in the United States, conducted from September 21 to November 3, 2017, all 1048 ophthalmology residents listed on the websites of ophthalmology residency programs accredited by the Accreditation Council for Graduate Medical Education were emailed an anonymous online survey consisting of 12 multiple-choice questions with options for free-text answers. Residents also received a mailed letter with a survey link and a $1 incentive, as well as 2 reminder emails. Survey responses were analyzed using descriptive statistics, and the free-text answers were categorized.
Main Outcomes and Measures
Main outcomes include residents’ reports regarding their personal experiences with wellness during residency, support systems provided by their programs, and opportunities for improving wellness in ophthalmic graduate medical education.
Results
Of 1048 residents, 241 (23.0%) responded to the survey. Most respondents (121 of 177 [68.4%]) reported that their programs faced an issue involving depression, burnout, or suicide among residents within the past year; 26.3% of respondents (61 of 232) reported being involved in a case when resident fatigue, burnout, or depression adversely affected a medical outcome or judgment. Fewer than half of the respondents (110 of 241 [45.6%]) reported that their residency programs placed moderate or major emphasis on promoting a culture of resident wellness, and only 26.7% (63 of 236) reported that their department had a formal resident wellness program. The most commonly cited barrier to resident wellness (59 of 236 [25.0%]) was a lack of time to attend wellness programs.
Conclusions and Relevance
These results suggest that there is a substantial burden of burnout and depression among US ophthalmology residents and that there are opportunities to boost wellness in ophthalmic graduate medical education by making wellness curricula more accessible to residents and ensuring that residents have time to attend wellness programs.
This survey study reports on residents’ views of wellness initiatives in ophthalmic graduate medical education and identifies potential strategies for promoting resident wellness.
Key Points
Question
What is the status of resident wellness in US ophthalmic graduate education?
Findings
In this survey of US ophthalmology residents, 68.4% of respondents reported that their programs faced an issue involving depression, burnout, or suicide among residents within the past year. The most commonly cited barrier to resident wellness (25.0%) was lack of time to attend wellness programs.
Meaning
There may be a substantial burden of burnout and depression among US ophthalmology residents, and there are opportunities to boost wellness in ophthalmic graduate education by making wellness curricula more accessible to residents.
Introduction
Persistent evidence of depression and burnout associated with residency training has driven the development of institutional guidelines and symposia intended to boost support for wellness among residents.1,2,3 However, more information is needed on the effect of these efforts in US graduate medical education. Obtaining the resident perspective on a national level is critical to achieving this goal.
To our knowledge, a national survey of ophthalmology residents on wellness has not been undertaken. One study surveyed 21 residents at a single institution; 3 of the 5 respondents (60.0%) reported experiencing burnout.4 We invited all residents from ophthalmology residency programs accredited by the Accreditation Council for Graduate Medical Education to participate in an anonymous, web-based survey on the status and sentiments regarding resident wellness initiatives in ophthalmic graduate medical education and opportunities for improvement.
Methods
We developed a 12-question survey using information from a parallel survey of US ophthalmology residency program directors (PDs),5 the Accreditation Council for Graduate Medical Education’s Clinical Learning Environment Review,3 and previous studies on wellness initiatives in medical education.6,7 We used Qualtrics Survey software (Qualtrics) and revised the survey with input from 10 ophthalmology residents. We defined resident wellness as the state in which good medical, mental, and social health contribute to resident well-being, enable residents to achieve balanced lifestyles, and provide outstanding patient care.8 The Brown University institutional review board determined that this study did not need formal review because it did not meet the definition of human participants research.
From September 1 to 21, 2017, we used residency websites and the emails of ophthalmology residency program coordinators from the American Medical Association’s Fellowship and Residency Electronic Interactive Database to compile the names of 1391 US ophthalmology residents in postgraduate years (PGYs) 2 to 4.9 On September 21, 2017, we emailed all 111 coordinators about the study and asked them to forward the survey to their residents. In addition, we mailed all residents a letter with the survey link and a $1 incentive.5 After 2 weeks, we sent 2 reminder emails, 1 week apart. We closed the survey after 6 weeks on November 3, 2017. We analyzed the responses using descriptive statistics and categorized the free-text answers. To investigate whether the results were affected by nonresponse based on training year, we compared unweighted results with weighted results by PGY. The weights (PGY 2, 0.90; PGY 3, 0.98; and PGY 4, 1.14) were calculated based on the number of PGY positions listed on the ophthalmology resident matching website (https://www.sfmatch.org)10 and the number of respondents for each PGY.
Results
Of 1048 residents, 241 (23.0%) responded to the survey. The Table displays the unweighted and weighted results; the unweighted results are presented here. Most respondents (121 of 177 [68.4%]) reported that their programs faced an issue involving depression, burnout, or suicide among residents within the past year; 26.3% of respondents (61 of 232) reported being involved in a case when resident fatigue, burnout, or depression adversely affected a medical outcome or judgment. Of 236 respondents, 63 (26.7%) reported that their department had a resident wellness program.
Table. Survey Results on US Resident Wellness Programs in Ophthalmology.
| Question | Residents, No. | Unweighted, % | Weighted by Postgraduate Year, %a |
|---|---|---|---|
| 1. As a resident, do you have access to free counseling and behavioral health services in your ophthalmology program? (n = 241) | |||
| Yes | 138 | 57.3 | 55.6 |
| No | 11 | 4.6 | 4.6 |
| Do not know | 92 | 38.2 | 39.8 |
| a. If yes (to question 1): Have you been educated on how, specifically, to access counseling and behavioral health services? (n = 137) | |||
| Yes | 101 | 73.7 | 71.7 |
| No | 36 | 26.3 | 25.3 |
| b. If yes (to question 1): If residents participate in such counseling or services, does their participation remain confidential with respect to: (Check all that apply) | |||
| The faculty (n = 94) | 91 | 96.8 | 96.7 |
| The ophthalmology department chair (n = 84) | 83 | 98.8 | 98.8 |
| The PD (n = 80) | 78 | 97.5 | 97.4 |
| c. If yes (to question 1): Do you believe residents’ participation in such counseling or services should remain confidential with respect to: (Check all that apply) | |||
| The faculty (n = 137) | 137 | 100 | 100 |
| The ophthalmology department chair (n = 133) | 132 | 99.2 | 98.4 |
| The PD (n = 121) | 116 | 95.9 | 94.9 |
| 2. How much emphasis does your residency program place on promoting a culture of resident wellness? (n = 241) | |||
| None | 35 | 14.5 | 14.8 |
| Minor | 95 | 39.4 | 37.7 |
| Moderate | 87 | 36.1 | 37.5 |
| Major | 24 | 10.0 | 10.0 |
| 3. What is the main hindrance to resident wellness in your residency program? (Please mark one) (n = 236) | |||
| Lack of wellness programming | 15 | 6.4 | 6.3 |
| Lack of time to attend wellness programming | 59 | 25.0 | 24.7 |
| Lack of access to free and confidential counseling and behavioral health services | 3 | 1.3 | 1.3 |
| Academic stressors | 31 | 13.1 | 13.2 |
| Shift times | 12 | 5.1 | 5.0 |
| Shift duration | 25 | 10.6 | 10.7 |
| Understaffing at clinical sites | 22 | 9.3 | 9.2 |
| Paperwork and administrative requirements | 25 | 10.6 | 11.2 |
| Fear of making errors that result in patient injury | 5 | 2.1 | 2.0 |
| Substance abuse concerns (for yourself or co-residents) | 1 | 0.4 | 0.5 |
| Sexism or racism in the culture of medicine | 0 | 0 | 0 |
| There are no hindrances | 23 | 9.7 | 9.9 |
| Other (please describe): Call schedule (n = 5); lack of support from administration, PD, or attending physicians (n = 4); lack of time (n = 2); workload (n = 2); wellness is high (n = 2) | 15 | 6.4 | 5.9 |
| 4. In the past 12 mo, have you or any of your ophthalmology co-residents faced any issues involving resident depression, burnout, or suicide? (n = 236) | |||
| Yes | 121 | 51.3 | 51.3 |
| No | 56 | 23.7 | 22.0 |
| Do not know | 59 | 25.0 | 26.7 |
| 5. Does your ophthalmology program provide access to a formal wellness program intended to reduce resident stress, burnout, and depression? (n = 236) | |||
| Yes | 63 | 26.7 | 26.1 |
| No | 81 | 34.3 | 34.0 |
| Do not know | 92 | 39.0 | 39.8 |
| a. If yes (to question 5): What are the components of your resident wellness program? (Check all that apply) (n = 63) | |||
| Screening for burnout or depression | 15 | 23.8 | 22.0 |
| Tracking of burnout or depression prevalence | 6 | 9.5 | 9.3 |
| Education in fatigue and stress management | 47 | 74.6 | 74.8 |
| Debriefing or support groups sessions | 14 | 22.2 | 22.3 |
| Self-care, mindfulness, or meditation training | 27 | 42.9 | 43.9 |
| Cognitive behavioral therapy (web-based or in person) | 4 | 6.3 | 6.0 |
| Other (please describe): Psychiatry (n = 1), group physical activity (eg, ultimate Frisbee) (n = 1), scheduled outings with attending physicians (n = 1), wellness day (n = 1), blank response (n = 2) | 6 | 9.5 | 7.4 |
| b. If yes (to question 5): Which of the following does your resident wellness program actively promote? (Check all that apply) (n = 63) | |||
| Psychological wellness (eg, meetings with a professional who teaches skills that improve resilience and stress management) | 32 | 50.8 | 51.2 |
| Social wellness (eg, casual gatherings that foster camaraderie) | 41 | 65.1 | 65.7 |
| Physical wellness (eg, making healthy food regularly available, including exercise as a part of the residency schedule) | 14 | 22.2 | 22.0 |
| Professional wellness (eg, mentorship pairs or teams between junior and senior residents that facilitate open dialogue about personal or work-related concerns, training to improve doctor-patient relationships) | 34 | 54.0 | 54.3 |
| Other (please describe): Activities and mentorship (n = 1); nominal wellness program provided, but it does not actively promote any of the above (n = 1); blank response (n = 1) | 3 | 4.8 | 4.2 |
| None of the above; residency does not actively promote any wellness programs | 6 | 9.5 | 8.9 |
| c. If yes (to question 5): How much has the wellness program improved your residency experience? (n = 61) | |||
| No improvement at all | 11 | 18.0 | 17.2 |
| Minor improvement | 24 | 39.3 | 40.3 |
| Moderate improvement | 14 | 23.0 | 23.3 |
| Major improvement | 6 | 9.8 | 10.0 |
| Other (please describe): Have not taken advantage of wellness program offerings (n = 4), have not taken advantage of wellness program offerings owing to lack of time (n = 1), blank response (n = 1) | 6 | 9.8 | 9.1 |
| 6. Which aspect of resident wellness programs do you think is most important? (Please mark one) (n = 233) | |||
| Screening for burnout or depression | 55 | 23.6 | 24.5 |
| Tracking of burnout or depression prevalence | 17 | 7.3 | 7.4 |
| Education in fatigue and stress management | 32 | 13.7 | 13.4 |
| Debriefing or support groups sessions | 29 | 12.4 | 12.9 |
| Self-care, mindfulness, or meditation training | 60 | 25.8 | 24.9 |
| Cognitive behavioral therapy (web-based or in person) | 9 | 3.9 | 4.0 |
| Other (please describe): Root causes of depression or burnout (overwork, understaffing, administrative workload) (n = 8), general protected time to dedicate to wellness (eg, time to attend doctor appointments) (n = 7), exercise (n = 3), retreat days (n = 4), faculty support and improvement of camaraderie (n = 2), time off (n = 2), other (n = 5) | 31 | 13.3 | 12.9 |
| 7. If one structural change could be made that could improve the wellness of you and your peers, which structural change would you suggest should be made? (Please mark one) (n = 233) | |||
| Improve shift schedules | 98 | 42.1 | 41.2 |
| Faculty attitude toward mental health issues | 25 | 10.7 | 10.9 |
| Availability of free and confidential counseling and behavioral health services | 16 | 6.9 | 7.5 |
| Additional professional counseling | 5 | 2.1 | 2.4 |
| Introduction or improvement of wellness programs | 56 | 24.0 | 24.4 |
| Other (please describe): Decrease administrative burden (n = 6); boost support from attending physicians, PD, and institution (n = 6); decrease demands on resident time (morning or nighttime lectures, after hours responsibilities) to allow for more study time and happiness (n = 5); provide protected time for wellness (n = 5); arrange social or exercise activities (n = 4); increase access to counseling that is offered only during clinic hours (n = 1); address understaffing (n = 1); make counseling sessions mandatory once per month (n = 1); none needed (n = 3) | 31 | 13.3 | 13.6 |
| 8. Which of the following issues do you think are unique to ophthalmology residents and would best be addressed by ophthalmology-specific wellness programs? (Check all that apply) (n = 233) | |||
| Curriculum design | 60 | 25.8 | 25.1 |
| Examination preparation | 93 | 39.9 | 39.7 |
| Faculty expectations of residents related to skills building | 113 | 48.5 | 48.0 |
| Clinical responsibilities | 117 | 50.2 | 49.7 |
| Surgical difficulty | 93 | 39.9 | 40.0 |
| None of the above; ophthalmology residents do not need wellness programs specific to ophthalmology | 20 | 8.6 | 8.2 |
| Other (please describe): Need more support easing into ophthalmology residency after intern year, which is very different than ophthalmology practice (n = 4); reduce administrative burden and duties outside of clinical or surgical responsibilities (eg, lecture load) (n = 2); reduce expectation to work after home call (n = 2) | 8 | 3.4 | 4.0 |
| 9. How can the Accreditation Council for Graduate Medical Education better promote resident wellness? (Check all that apply) (n = 233) | |||
| Fund research on wellness interventions | 65 | 27.9 | 28.0 |
| Provide resources for burnout or depression screening | 105 | 45.1 | 45.5 |
| Provide resources for training in resilience skills | 67 | 28.8 | 28.3 |
| Offer strategies for developing wellness programs | 90 | 38.6 | 38.0 |
| Mandate the inclusion of a resident wellness program in ophthalmology residency training programs | 104 | 44.6 | 44.5 |
| Other (please describe): Address overwork due to increased clinical volume and administrative responsibilities without increased training spots (n = 5), improve work hours and limitations on call and duty hours (specific recommendation made by 2 respondents: include home call in duty hours) (n = 5), create incentives and punishments for programs based on anonymous resident evaluations of their own programs (n = 2), offer resident retreats (n = 2), require monthly counseling sessions (n = 1), provide funding support to identify barriers to wellness (n = 1), lobby for better resident salaries (n = 1), provide protected time for wellness (n = 3), improve the culture of residency (n = 1), require programs to cover wellness center or gym costs (n = 1), involvement not necessary (n = 5) | 27 | 11.6 | 11.3 |
| 10. Have you been involved in a case when resident fatigue, burnout, or depression adversely affected a medical outcome or judgment? (n = 232) | |||
| Yes | 61 | 26.3 | 26.3 |
| No | 168 | 72.4 | 72.0 |
| Other (please describe): Poor triage on part of primary call resident (n = 1), blank response (n = 2) | 3 | 1.3 | 0.9 |
| 11. Which postgraduate year are you enrolled in? (n = 231) | |||
| 2 | 90 | 39.0 | 35.3 |
| 3 | 74 | 32.0 | 32.6 |
| 4 | 67 | 29.0 | 33.1 |
| 12. How many total residents are in your residency program? (n = 233) | |||
| ≤9 | 59 | 25.3 | 25.3 |
| 10-15 | 112 | 48.1 | 48.0 |
| ≥16 | 60 | 25.8 | 25.4 |
| If you have any additional comments you would like to share, please list them here | |||
| Summary of responses: The stigma of getting help is the greatest barrier to wellness (n = 1), residents are overextended and overworked (n = 3), more programs should have post-call days as it is unfair for clinic patients to be evaluated by someone who had little to no rest and is prone to making mistakes (n = 2), stressors come from peers and faculty (n = 2), wellness is a systemic problem (n = 2), need protected time to utilize wellness resources (n = 1), overall wellness is pretty good (n = 3), thank you for doing this survey (n = 2) | |||
Abbreviation: PD, program director.
Postgraduate years 2 to 4.
The most commonly cited barrier to resident wellness was a lack of time to attend wellness programs (59 of 236 [25.0%]). Of 233 residents, 117 (50.2%) noted that the issue of how to handle clinical responsibilities would be best addressed by ophthalmology-specific wellness programs, and 113 (48.5%) said that the issue of faculty expectations of residents related to skills-building in the clinic and operating room would be best addressed by ophthalmology-specific wellness programs. One-third of respondents (92 of 241 [38.2%]) did not know if they had access to free counseling services in their program. Among those who were aware of such services, 26.3% (36 of 137) were unaware of how to access them. Of 241 respondents, 110 (45.6%) reported that their programs placed moderate or major emphasis on promoting a culture of resident wellness; of 233 respondents, 98 (42.1%) chose “improving shift schedules” as a structural change to improve resident wellness.
The PGY distribution of respondents closely matched that of the overall resident population, so the magnitude of influence of each PGY on the results was proportional to the percentage of positions in each PGY. Hence, the unweighted and weighted results were similar (Table).
Discussion
The survey results suggest that there is a substantial burden of depression and burnout among US ophthalmology residents. Of 177 respondents, 121 (68.4%) reported that their programs faced depression, burnout, or suicide among residents within the past year. This rate is comparable with the 69% rate of burnout reported in a 2017 study of 566 general surgery residents.11 The novelty of ophthalmic examination and procedures compared with training during internship, the rapid evolution of ophthalmic technology and pharmacotherapeutics, and the technical difficulty of ophthalmic surgery are all potential stressors for ophthalmology residents.12
The survey results indicate opportunities to improve the culture of wellness in ophthalmic graduate medical education. Most respondents reported that their programs faced an issue involving depression, burnout, or suicide among residents within the past year. In comparison, in a prior survey of ophthalmic PDs, only 25% of respondents reported facing a resident wellness issue.5 Potential sources for this discrepancy include the following: (1) residents were more forthcoming than PDs when reporting issues concerning depression, burnout, and suicide; (2) residents who experienced or witnessed depression, burnout, or suicide were more likely to participate in the survey; or (3) PDs were unaware of a sizable proportion of wellness issues among residents. Consistent with the third explanation, only 39% of respondents in a survey of ophthalmic PDs reported that their programs screened for burnout or depression among residents.5 One-fourth of residents who participated in our survey also reported being involved in a case when fatigue, burnout, or depression among residents adversely affected a patient’s outcome or clinician judgment. These findings suggest the need for more effective wellness strategies to protect residents and their patients.
Our survey results also highlight potential strategies to bridge the gap between the resident experience and program requirements. One strategy would be to ensure that local graduate medical education leaders inform residents of wellness programming and provide residents the opportunity to suggest additions or modifications to existing support systems. In one survey of ophthalmic PDs, 98% of respondents reported that counseling services were available in their residency programs.5 However, more than half of our resident respondents were unaware of the availability of counseling services or how to access them. Since one-fourth of residents reported a lack of time to attend wellness programs as the main hindrance to resident wellness, another strategy would be to encourage residents to attend wellness events and provide them time off to do so. Otherwise, residents may hesitate to take time off, as that may pose a burden to other faculty and residents when work schedules need to be rearranged. Designating faculty wellness champions and promoting resident-faculty dialogue on topics such as work-life balance may also be beneficial.
Limitations
While the 23.0% response rate in the present study is in the midrange of national resident surveys (10%-34.3%),13,14 the generalizability of the results may be limited by the response rate and nonresponse bias unrelated to PGY. For example, the mental health status of the residents may have influenced the results. On one hand, residents who faced depression or burnout in the past may have been more likely to respond relative to those who had not. On the other hand, residents currently facing depression or burnout may have been less likely to participate. Therefore, it is unclear whether our study’s observed rate of depression and burnout is higher or lower than the true rate among all ophthalmology residents.
Conclusions
In July 2017, the Accreditation Council for Graduate Medical Education released a revised set of ophthalmology program requirements that mandate residency programs to provide activities and curricula that encourage resident well-being, encourage residents to pay attention to work intensity, and permit residents to attend personal health appointments.15 It is hoped that these new requirements will help PDs implement wellness strategies and reduce resident burnout.
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