Exploring Resident Physician Wellness at an Allopathic Medical School in West Virginia: A Qualitative Study

Abstract

Introduction:

Social support is key to wellness, especially during times of stress and uncertainty. The working climate, including the multidisciplinary medical community provides opportunities for both positive and negative wellness experiences. The purpose of this study is to explore residents’ concepts of wellness and the influence of programs, faculty, peers, and nursing and ancillary staff.

Methods:

An email with a link to the REDCap survey was sent to each resident (n=450) in the school of medicine at West Virginia University asking them to give examples of ways their wellness has been supported (or not) by faculty members, their program, co-residents, and nursing and ancillary staff. The residents returned 51 completed surveys (11% response rate). Seven residents participated in a face to face interview. A content analysis using Hale’s adaptation of resident wellness (based upon Maslow’s Hierarchy of Needs) as the theoretical framework was conducted on the data.

Results:

Positive wellness elements frequently focused on time, supportive actions, and social connection. Negative examples impacting wellness included feeling disrespected, not being included in decision making, conflicts, and feeling unappreciated. Suggestions from the residents often described low cost interventions such as being” included” and feeling part of the team.

Conclusion:

The participants described how all members of the healthcare team can support resident wellness in a variety of domains. Peers, support staff in the hospital environment, faculty supervisors, and the program overall can contribute to the basic physiologic needs, safety, belonging, esteem, and self-actualization of resident learners through social support.

Introduction

Wellness is a broad term consisting of the multi-dimensional aspects of one’s life that in combination lead to optimal levels of physical and emotional health and social functioning. Wellness is not a passive individual state, but rather an active lifelong process influenced by intentions, choices and actions that allows one to flourish in all aspects of life.¹ Resident physician wellness is heavily influenced by a learning environment that includes overlapping physical, social and psychological contexts. In this fluid environment, residents are in a constant process of transformation as they cultivate their professional identity.² This evolving identity is formed in part by how residents interpret and process their experience within the medical community. These experiences include interactions with mentors, teachers, role models, and others, and communication in formal and informal settings as they carry out their job as a resident physcian.²

Burnout syndrome is described as a psychological response to chronic interpersonal stressors on the job.³ Maslach and Leiter describe a three- dimensional model of burnout which includes 1) overwhelming exhaustion, 2) cynicism and detachment from the job, and 3) a lack of accomplishment and ineffectiveness on the job.³ This model highlights how burnout is experienced by an individual within a social context and influenced by understanding of self and others.³ There is a high prevalence of burnout in residents, with many specialties reporting a rate of over 50%.⁴ Burnout has been linked to decreased quality of care⁵ and negatively impacts relationships with others in the workplace.⁶

In a systematic review and meta–analysis of physician burnout, authors identified 2,617 articles examining interventions to mitigate and reduce burnout in practicing physicians.⁶ This review highlighted effective interventions which can be individually focused or organizational in nature; however, studies combining the foci are lacking. Most commonly studied are those interventions that are individually oriented such as mindfulness, stress management, and small group discussions. Recently, scholars have adapted Maslow’s framework to identify a hierarchy of needs as it applies to resident physician experiences.^7,8 Hale et al expanded on Maslow’s basic needs to include fundamental health determinants for residents such as sleep, physical health and safety, and mental health. The authors identify a gap in the literature evaluating organizational or structural interventions to address the issue of physician burnout. The current study builds upon the individualistic study of wellness to explore how the greater community of the clinical learning environment and other health care team members influence the wellness of resident physicians. The purpose of this study is to explore how programs, faculty, peers, nursing, and ancillary staff can support and foster a culture of wellness for residents, through the analytical lens of Hale’s expanded theory of Maslow’s framework.

Methods

This study was approved by the West Virginia University School of Medicine Institutional Review Board. WVU SoM is an allopathic medical school with its main campus located in north central West Virginia supports more than 75 residency and fellowship training programs. No compensation or course credit was offered for participation. The protocol consisted of a sequential mixed-methods design, with the first phase being a survey, and the second phase being in depth, semi-structured interviews. The researchers include three medical educators consisting of two physicians and a staff member from the graduate medical education office (GME) involved in wellness initiatives, and a research nurse with experience in qualitative research. Because two of the investigators are involved in resident evaluation and may have perceived conflict of interest, they were not involved in participant selection, did not have direct contact with participants, and only reviewed blinded results of the surveys and interviews.

Survey –

A survey assessing wellness techniques and challenges was developed by the authors. An email with a link to the REDCap survey was sent to all residents at WVU SoM (n=450) asking for their examples (short answers) of ways in which their wellness has been supported or inhibited by faculty members, their program, co-residents, nursing, and ancillary staff. In addition, the residents were asked about their own techniques to foster wellness and about negative wellness experiences. The respondents could choose to return an anonymous survey or self-identify as willing to participate in a face to face interview.

Interviews-

The survey also asked for volunteers to participate in a face to face interview about their wellness experiences. Because of a paucity of possible enrollees, all potential participants were included. After written informed consent, all interviews were conducted in a private office or via telephone by a trained research nurse (PD), audio recorded, and professionally transcribed. The interviews lasted 30–60 minutes each. See Table 1 for interview guide. The interview guide was informed by the role based survey responses aiming to understand how they fit into Hale’s modified framework. All transcripts were checked for accuracy with the audio recordings by investigators. The transcribed interviews were deidentified and uploaded into NVivo⁹ for organization. Content analysis was utilized as the methodological orientation underpinning the analysis. Two co-investigators preliminarily reviewed the interviews and constructed a codebook based upon Hale’s framework.⁷ Memo-writing and group discussion were utilized to verify coding and expand themes. An audit trail was maintained throughout. Methodological rigor was enhanced by triangulation back to the survey results as well as investigator triangulation. To strengthen the reliability of results, two researchers coded the transcripts independently before comparing codes and assigning labels within the framework. The analysis team included two researchers, both with qualitative research experience (PD and CS). Methods were compared against the consolidated criteria for reporting qualitative research checklist.¹⁰

Table 1:

Semi-structured Interview Guide

	Semi structured interview guide
1.	Can you tell me what factors make your residency easier for you?
2.	How has it been for your families, significant other, or close friends dealing with you being a resident?
3.	How do you deal with the demands of residency versus those of your personal relationships? How do you deal with them when they are in direct conflict?
4.	How do you deal with the demands of residency versus those of your personal relationships? How do you deal with them when they are in direct conflict?
5.	Have you ever felt that you needed a break from you medical training? How did you deal with this?
6.	Can you tell me about any strategies you currently use to self-manage your own wellness?
7.	What barriers prevent you from effectively managing your wellness?
8.	How do you feel the experience of internship (residency) has changed you?
9.	If you could change one thing in your day-to-day clinical or educational environment that you feel would benefit your overall wellbeing, what would that one thing be?
10.	If you could change one thing in your day-to-day clinical or educational environment that you feel would benefit your overall wellbeing, what would that one thing be?
11.	If you could change one thing in your day-to-day clinical or educational environment that you feel would benefit your overall wellbeing, what would that one thing be?
12.	Have you ever used any of the resources offered? If so, which ones? Did you find them helpful? Why or why not?
13.	Are you aware of the WVU SOM’s GME Well-being Program? What are your thoughts on this program?
14.	Is there anything else you would like to share with me about your experiences as a resident that I have not asked about?

Results

Participants

The response rate was 11% (N=51). Although twenty residents indicated they would be open to being interviewed and provided their contact information, seven semi-structured interviews were completed. The participants included four men and three women from seven different program specialties, which included residents in their second through fifth post-graduate years of training (See Table 2).

Table 2.

Participant Demographics.

Participant	M/F	Specialty	PGY
01	M	Otolaryngology	5
02	M	Radiation Oncology	3
03	M	Orthopedics	2
04	M	Anesthesia	4
05	F	Psychiatry	2
06	F	Emergency Medicine	3
07	F	Medicine/Pediatrics	3

PGY: postgraduate year; M-male, F-female

Survey

The write-in results for the email survey were reviewed and categorized in terms of role-specific interventions; similar and duplicate answers were removed. A summary of these results are presented in Table 3 and Table 4.

Table 3.

Summary of Write in Survey Questions Supporting Wellness

Group	An example of how your wellness was supported
Program	Institute a “wellness day” Provide support for conferences, other educational opportunities, and career development Involve residents in decision making, for example, design of new call room. Flexible scheduling Access to FSAP and time to go if requested.
Faculty	Be willing to listen to challenges during residency and provide good reassurance. Be flexible with time and recognize when someone needs a break or to eat. Ask how you can help. Provide encouragement, even if things are not going so well. Communicate and encourage interactions with other residents through a Facebook group or study group
Co-residents	Cover time for each other if needed for personal reasons. Listen to each other Socialize through outings or dinners. Stay late to help even when you are not on the team Support each other through text threads or group chat online Recognize if someone is struggling
Nursing or Ancillary Staff	Include residents in events on your unit or floor, share food. Provide supportive feedback Assist with questions and tasks and communicate plan of care Be patient Anticipate orders and be efficient team member Share knowledge/teach new residents

FSAP: Faculty and Staff Assistance Program

Table 4.

Summary of Negative Impact to Wellness Question

Negative impacts	Feeling disrespected
	Not getting time off when requested
	Not being included in decision making
	Forced to work extra hours
	Poor pay
	Feeling scrutinized constantly
	Too much paperwork
	Institutionally imposed activities of little value
	Feeling unappreciated
	Conflicts with other residents
	Gossip

Interviews

Interview data was analyzed using Hale’s adapted framework as the theoretical framework for the qualitative analysis. Representation was found across all the major categories of these themes as follows:

Basic Physiologic Needs

Time is discussed as a basic need for residents and is referenced in many physiologic needs such as sleeping, exercise and mental health. Many residents described how a lack of time was a primary concern and a most valued resource. Control over time was often discussed in terms of inability to attend to self-care activities such as exercise, or activities to de-stress because of educational requirements.

Example of a response concerning time:

“If I had an extra hour every day to study, I would feel less like-- If all my days ended an hour earlier and I studied for that hour, I could then go home and not feel pressure to study.” (3^rd year orthopedic surgery resident)

Food was discussed as an important part of overall wellness. The residents recognized the value of nutritious food and appreciated efforts to make high quality food available.

Example of a response concerning food:

“A couple of different people brought up having healthy lunches and having bottles of water instead of just the soda. I think that they’re actively working on that right now, so there’s the nutrition part. “(3^rd year internal medicine/pediatrics resident)

Physical health was identified as important by the residents; however, the demands of their schedules did not always allow them to exercise as they would like. Having facilities that are free and convenient assisted them in their physical wellness.

Example of a response concerning physical health:

“They have opportunities for us to join the hospital gym that can help in terms of physical wellness.”(4^th year anesthesiology resident)

All the residents recognized the stress they experience as a result of their program and schedules. Mental health resources access such as a faculty and staff assistance program was important. Additionally, participants described how family and fellow residents helped them stay focused and supported their mental health.

Example of a response concerning mental health:

“Probably the one thing that myself and my co-residents have been exposed to is the FSAP across the street from here, for counseling about basic for evaluation.” (1^st year otolaryngology resident)

Safety

Hale’s adaptation of Maslow’s Hierarchy of Needs for resident wellness includes contemporary concerns such as personal and financial security; thus expanding on the original concept of physical safety.⁷ Financial concerns including debt were rarely mentioned. Two of the residents mentioned student debt as a barrier to activities but not as an actual stressor for them. None of the residents expressed any concerns for their physical safety.

Example of a response concerning safety:

“Just a significant amount of resident debt from student loans. The resident salary doesn’t always keep up.” (4^th year anesthesiology resident)

Love and Belonging

The residents often spoke about how love and belonging were important to them. They wanted to feel part of larger group and drew from the support of others to feel secure and valued. Conversely, being alone or feeling alone was detrimental to their overall sense of wellness. The importance of a spouse and family as well as spending time outside of work was discussed in terms of feeling love and as part of a supportive network. The residents also discussed how relationships with others can suffer and can be strained as a result of the demands of residency.

Example of a response concerning love and belonging:

“At home I have a wife who I think loves me and an infant. The day-to-day of life would be much harder without her. I am lucky to have in-laws in town that are also very supportive.” (5^th year otolaryngology resident)

Esteem

Esteem includes feeling respected, a sense of fairness, and control over their lives. Residents talked about how the program could support them with scheduling and the impact of faculty on their esteem.

Example of a response concerning esteem:

“Then, having people above you, so senior residents and staff that you feel are trying to help you as opposed to always like nitpicking. If you feel stressed that everything you’re doing is always being critiqued and criticized, it makes you on edge more.” (2^nd year orthopedic surgery resident)

Self-actualization

The highest order need, self-actualization included feeling accomplished and competent to provide care as a physician and progressing towards a goal. Wellness was described as an overall sense of happiness.

Example of a response concerning self-actualization:

“Everyone always told me growing up, once you find what you love that you’ll never work a day in your life. I never believed them. I always thought work was work until now. I found this and I can’t imagine being away from here more than for a small period of time. I won’t say that my wellness is tied to my career, but it certainly helps me feel fulfilled that I’ve reached my potential and that what I do makes a difference.” (4^th year anesthesiology resident)

Discussion

In the current study, residents were asked to discuss wellness and to describe how their wellness was supported by others in the GME environment. The residents’ examples of positive wellness elements frequently focused on time (e.g. time off, flexible scheduling), support (e.g. patience, sharing knowledge, and encouragement), and social connection (e.g. being invited to events on the floor, sharing food, socializing through outings, social media connections). Examples of program wellness elements included career development and flexibility with time and schedule. Negative examples that impacted the residents’ wellness included feeling disrespected, not being included in decision making, conflicts, and feeling unappreciated.

It is generally understood that the nature of resident education is stressful and demanding. As a result, vulnerable residents can experience significant threats to wellness, such as poor mental health and burnout ⁴, which can carry over to their personal and professional lives.¹¹ In addition, even fundamental human needs such as sleep, eating, and exercise are often negatively impacted because of the demands of residency training.⁷ The multi-dimensional aspects of resident wellness are recognized by the American Medical Association as outlined in their six aspects that are key for resident well-being.¹² The six elements include nutrition, fitness, emotional health, preventative care, financial health, and mindset and behavior adaptability. It is important to foster a culture of wellness during medical education by facilitating these basic needs especially since negative experiences can lead to burnout and have a lasting effect on a resident’s education and career.

Maslow’s Hierarchy of Needs is often depicted as a pyramid of human needs in which higher order needs are dependent on baser needs, and all can be relevant to wellness. The most basic physiologic needs such as food, water, shelter etc. form the bottom of the pyramid followed upwards by safety, love and belonging, esteem and self-actualization. Recently, scholars have adapted Maslow’s framework to identify a hierarchy of needs as it applies to resident physician experiences.^7,8 Hale et al., expanded on Maslow’s basic needs to include fundamental health determinants for residents such as sleep, physical health and safety, and mental health. Additionally, they changed the pyramidal orientation of wellness needs to be circular, thereby recognizing the importance of all needs simultaneously.⁷ The participants in our study illustrate the ways in which all members of the healthcare team can support resident wellness in a variety of domains. Peers, support staff in the hospital environment, faculty supervisors, and the program overall can provide support of the basic physiologic needs, safety, belonging, esteem, and self-actualization of resident learners.

The relationship between wellness and resident education is well studied.^{4,5,7,8,13–15} However, the current study is one of few to consider the impact of social connectedness in resident education. In a systematic review of the literature, Raj, reviewed 26 articles examining the predictors and factors associated with well-being, as well as barriers and success of interventions aimed to enhance resident wellness. Three main factors emerged as key to resident wellness: autonomy, competence building and strong social connection.¹⁵ Less studied is the impact of contextual social connections, such as relationships with other team members, on resident wellness. Pham et al. considered these social connections by including people who might influence a resident’s wellness, through formal or casual interactions throughout the day.¹⁶ They utilized a story based feature of those people whom residents encounter throughout the clinical learning environment. Individuals from faculty members to newspaper vendors discussed the aspects of learning and patient care environment on resident’s wellness and shared their stories in the resident’s weekly newsletter. Qualitative results of this study highlighted how others can foster a sense of contextual social attachment for the residents leading to a healthier learning experience. Conversely, a sense of disconnect or distance, or a lack of communication could lead to feeling detached. This is one of few studies to highlight the importance of community and social connectedness on resident wellness and focus from the outside (community) in and not from the resident (individual) outwards.

Social connectedness is key to wellness, especially during times of stress and uncertainty. During stressful times, such as the recent pandemic, researchers found that people who reported a stronger sense of social connectedness, had lower levels of stress, worry and fatigue.¹⁷ It is generally understood that resident education is also unpredictable, and stressful and a sense of social connectedness could help buffer against negative experiences and boost resilience. Feeling connected to others such as peers or staff in the health care setting could be associated with increased health and wellness. For example, the residents indicated that sharing experiences such as events, or activities with peers, nursing and ancillary staff resulted in positive reports of wellness. Examples that suggest non-connectedness such as feeling unappreciated or disrespected were associated with threats to the wellness of the residents. Figure 1 illustrates the contextual, role-specific social connectedness model of wellness.

Figure 1.

Contextual social connectedness concept model of resident wellness

Although individual traits heavily influence wellness, the working environment can be a key contributor to negative experiences, such as burnout.¹⁸ The Accreditation Council for Graduate medical Education (ACGME) addresses importance of this environment on resident wellness in the Clinical Learning Environment Review (CLER). The CLER outlines expectations for graduate medical education and can be used to evaluate programs and teaching institutions for medical education. The CLER also requires that programs address workload/working environments and create programs to address resident burnout and fatigue. Individually focused interventions such as self-care and resilience training programs can be effective in combatting burnout.¹⁹ However, these programs should be done in coordination with systemic considerations such as improving the workplace for residents.²⁰

Over 900 residents in approximately 85 training programs provide essential care to the people of WV.²¹ The health and wellbeing of this physician cohort should be a priority for all members of the healthcare system. Results from the current study identify the influence of the greater community and how the workplace can contribute to, and support (or detract from) resident wellness within Hale’s framework. Suggestions from the residents often include low-cost interventions such as being “included” and feeling part of the team. Social support from co-residents and faculty, feeling respected and appreciated were common. Figure 2 illustrates the external environment (program, faculty, co-residents and nursing/ancillary) as an integrated framework encircling Hale’s revised Maslow’s hierarchy of need for residents. ⁷

Figure 2.

Hale’s modern revision of Maslow’s original work* with additional integrated framework extension.⁸

*Reproduced and revised with permission from Andrew Hale MD

Limitations

This study has some limitations. Firstly, all the participants were from one institution which may limit the generalizability of the results. Secondly, the relatively low response rate to the survey, the limited number of participants in the face to face interview, and the lack of representation of every specialty will also limit generalizability. The residency demands and encroachment on personal wellness vary among specialty and therefore wellness levels may vary along specialty lines. Future research could explore resident wellness from the broader medical community’s perspective through interviews or survey methods.

Conclusion

Although response rate was low for our study, the residents who did participate provided their valuable insight into the concepts of wellness of physicians in training. This study is one of few to consider the relationships within the learning environment and how these interactions can support or negatively impact resident wellness. Despite the focused interest in resident wellness, the prevalence of burnout remains high. The proposed model expanding on Hale’s revised Maslow’s hierarchy of needs could be useful to inform programs aimed at the greater graduate medical education community to support and encourage residents during their education. A healthy workplace that encourages social connectedness and support between the multidisciplinary health care team members will create a better workplace for everyone and contribute to a better of sense of wellness for the residents who are working and learning there.