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Well-being in residency: Effects on relationships with patients, interactions with colleagues, performance, and motivation
Patient Education and Counseling 72 (2008) 194–200 www.elsevier.com/locate/pateducou
Well-being in residency: Effects on relationships with patients, interactions with colleagues, performance, and motivation Neda Ratanawongsa *, Scott M. Wright, Joseph A. Carrese Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States Received 8 February 2008; received in revised form 16 April 2008; accepted 27 April 2008
Abstract Objective: Previous studies about resident well-being have focused on negative aspects of well-being. We conducted this study to explore residents’ conceptions of well-being and how it affects their work. Methods: One investigator conducted semi-structured interviews with residents at two hospitals during February–June 2005. Through random sampling stratified by program and gender, we invited 49 residents from internal medicine, psychiatry, surgery, emergency medicine, anesthesia, obstetrics/gynecology, and pediatrics. Using an editing analysis style, three investigators independently coded transcripts. Results: 26 residents participated in 45-min interviews. Residents acknowledged that well-being affected four elements of their work: relationships with patients, interactions with colleagues, performance, and motivation. Residents described higher quality discussions with patients when their well-being was high and inappropriate exchanges when well-being was low. Residents attributed conflict with colleagues to lower states of well-being. Residents felt they had improved decision-making when their well-being was higher. Residents’ motivation in their daily work and career varied with fluctuating well-being. Five residents initially denied that their well-being affects their work, voicing concerns that this would be unprofessional. Conclusions: Most residents felt that both high and low levels of well-being affected their work, particularly their work relationships. Practice implications: The educational and patient care goals of residency training may be enhanced through interventions that promote resident well-being. # 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Medical education; Residency; Physician well-being; Professionalism; Patient–provider communication
1. Introduction The graduate medical education of physicians may be stressful and difficult [1–3]. The well-being of trainees may affect their potential for professional growth and development. Recent studies have suggested that negative aspects of wellbeing – such as burnout – may be associated with a lower capacity for empathy and suboptimal patient care [1–3]. The Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour guidelines to improve both patient safety and resident well-being [4]. In one study, 84% of
* Corresponding author at: Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Suite 2300, Baltimore, MD 21224, United States. Tel.: +1 410 550 1862; fax: +1 410 550 3403. E-mail address: [email protected] (N. Ratanawongsa). 0738-3991/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2008.04.010
internal medicine residents felt that work hours had enhanced their well-being, but many residents felt they led to worsened patient care (37%) and education (47%) [5]. A systematic literature review found inconsistent evidence about the effects of work hour limits on residents’ quality of life and suggested that further evidence is needed to support the link between resident well-being and patient outcomes [6]. A study by Papp et al. suggests a possible relationship between resident well-being – mediated by sleep deprivation and fatigue – and professionalism [7]. Although professionalism has been promoted as a core competency in medical training [8,9], some have suggested that reducing the stressors of residency may be a necessary step to facilitate professional behavior [7,10]. Research about resident well-being and its consequences on residents’ work have primarily focused on negative aspects of well-being, such as burnout, depression, or fatigue [3,11–13].
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However, the breadth of well-being during residency and the impact of positive well-being on work have not been delineated fully. We conducted this qualitative study for two objectives: to explore more completely residents’ perceptions of well-being and to understand their beliefs about how their well-being affects their work. In a recent paper, we reported that residents defined well-being as a balance among multiple parts of their personal and professional lives, including professional, family, social, physical, mental, spiritual, and financial domains [14]. In this paper, we focus on the second objective, reporting residents’ descriptions of how fluctuations in their well-being – as defined above – affect their relationships with patients, interactions with colleagues, performance in patient care, and motivation.
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higher numbers representing higher well-being. The interview then included open-ended questions about the components of resident well-being, factors related to its promotion or reduction, the impact of well-being on work, perceptions of how training programs may enhance resident well-being, and the definition of well-being (see Appendix A for the interview guide). The results in this paper focus on responses to the question: ‘‘How does your well-being affect your work?’’ The interviewer (NR), trained in qualitative interviewing techniques, used reflective probes to encourage respondents to clarify and expand on their statements. The interviewer did not know residents at seven of the nine programs, but did interact with residents in the continuity clinic for two programs. 2.4. Data analysis
2. Methods 2.1. Study design We chose a qualitative interview design to explore the phenomenon of physician well-being from the informants’ perspectives. A qualitative methodology allows the emergence of themes that researchers may not anticipate. One-on-one interviews permit exploration in greater depth than is possible with closed-ended scales, surveys, or even focus groups. 2.2. Study sampling Through purposive sampling, we recruited residents from nine residency programs at two university-affiliated medical centers in Baltimore, Maryland. Our goal in purposive sampling was to target a diverse set of respondents currently in training in multiple training programs at each stage of residency. The largest training programs were selected for recruitment, and a variety of clinical disciplines were represented. We used stratified random sampling to obtain approximately equal proportions by gender from each program. Recruitment e-mails and letters emphasizing the confidential and voluntary nature of participation were sent to 49 residents. Following accepted qualitative methodology, we discontinued sampling when we determined that new interviews yielded confirmatory rather than novel themes, a process called achieving ‘‘thematic saturation’’ [15]. We discontinued sampling after 26 interviews, a sampling size consistent with other qualitative studies [16–19]. Enrollees received a $50 Amazon gift certificate as compensation. A Johns Hopkins School of Medicine Institutional Review Board approved the study. 2.3. Data collection From February to June 2005, one investigator (NR) conducted audiotaped, semi-structured interviews with participants in private settings within or outside the hospital. The interview began by asking residents to rate their wellbeing using words or a numerical rating from 1 to 10, with
We analyzed transcripts using an ‘‘editing organizing style,’’ a qualitative analysis method in which researchers search for ‘‘meaningful units or segments of text that both stand on their own and relate to the purpose of the study’’ [15]. With this process, we derived a coding template from the data itself, rather than applying a pre-existing template. Each investigator independently analyzed six randomly selected transcripts and generated codes to represent the subjects’ statements. The three investigators compared codes and negotiated discrepancies to create a coding template. Two investigators independently coded each remaining transcript with this template. Although a third investigator was available to mediate in cases of discrepant coding, the two original investigators successfully reached consensus after reviewing and discussing each other’s coding. All coding was completed between March and July 2005. For this paper, the investigators selected the themes encompassing the relationship between well-being and work. The authors agreed on representative quotes for each theme. Atlas.ti 5.0 software (Atlas.ti GmbH, Berlin, Germany, 2005) was used for data management and analysis. We compared demographic characteristics of participants and nonparticipants with Fisher’s exact test using STATA Intercooled version 9.0 (Stata Statistical Software: Release 9.0, Stata Corporation, College Station, TX, 2005). 3. Results 3.1. Respondent demographics and overall ratings of well-being Twenty-six of the 49 invited residents (53%) participated in 45-min interviews. The average age was 28.7, with a range of 26–33. Five participants (19.2%) were interns, and just over half (53.8%) were women (see Table 1). Participants did not differ significantly from non-participants in gender, postgraduate year, or program (all p > 0.05). In describing their overall well-being, 14 residents (53.8%) rated their well-being as excellent or 8–10, 8 residents (30.8%) as good or 5–7, and 4 residents (15.4%) as low or <5.
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Table 1 Characteristics of 26 residents interviewed about resident well-being at two university-affiliated hospitals Characteristic Age, mean (S.D.) Women, n (%) Married/partnered, n (%) Children, n (%) Prior careers, n (%) Interviewed during rotation with overnight call, n (%)
28.5 (2.2) 14 (53.8) 14 (53.8) 2 (7.7) 5 (19.2) 12 (42.2)
Program, n (%) Internal medicine, categorical program #1a Internal medicine, categorical program #2a Internal medicine, general internal medicinea Psychiatry Surgery Emergency medicine Anesthesia Obstetrics/gynecology Pediatrics
4 2 4 4 3 3 2 2 2
(15.4) (7.7) (15.4) (15.4) (11.5) (11.5) (7.7) (7.7) (7.7)
Post-graduate year, n (%) 1 2 3 4
5 9 9 3
(19.2) (34.6) (34.6) (11.5)
Overall ratings of well-being, n (%) Excellent/8–10 Good/5–7 Low/<5
14 (53.8) 8 (30.8) 4 (15.4)
a
Categorical internal medicine programs #1 and #2 are based at different affiliated hospitals. The general internal medicine program is based in the same hospital as categorical program #1.
3.2. Results of qualitative analysis
in patient care; and (4) motivation in their daily work and overall career (see Fig. 1). Table 2 presents the total number of times each theme was stated in all interviews and the percent of respondents stating each theme. This table refers to responses to the question: ‘‘How does your well-being affect your work?’’ 3.2.3. Relationships with patients A significant effect of well-being on work involved residents’ relationships with patients and their families. Residents revealed stories about how lower well-being affected the quantity and quality of interactions. In the words of a third-year internal medicine resident: ‘‘If you are not feeling well and completely stressed out, you don’t have all the tools to deal with patients the way you should . . . [During intern year] I would not have been able to give patients as much as I could now. If you are down yourself, it’s difficult to give someone else strength, or help somebody to cope . . .’’ Conversely, when residents had higher well-being, they felt more compassionate in their interactions with patients. An emergency medicine intern valued his conversations with patients about the psychosocial aspects of their illnesses: ‘‘The whole preventive focus – talking to people about weight, smoking cessation . . . Some days you are just too tired and that leads to frustration and you just don’t have that conversation. ‘Aw, that person’s not going to quit anyway. It doesn’t really matter what I tell them.’ But when you feel better about yourself, you’re just more giving.’’
3.2.1. Definition of well-being Residents described well-being as a balance among multiple parts of their personal and professional lives: family, friends, physical health, mental health, spiritual health, financial security, and professional satisfaction. However, residents voiced a willingness to accept a temporary imbalance during residency, sacrificing aspects of their personal lives in order to promote their professional development. At times, stressors such as sleep deprivation or emotionally intense work demands led to dissatisfaction with the imbalance and fluctuations between higher and lower levels of well-being. Residents coped with these stressors using resources such as supportive personal relationships, camaraderie with colleagues, physical exercise, and hobbies. When these supports were adequate, they were more successful in maintaining their well-being. When stressors overwhelmed coping strategies, well-being sagged. Finally, if residents began to lose their sense of themselves as individuals outside of medicine, residents’ well-being suffered. Further description of the respondents’ conception of wellbeing is reported separately [14]. 3.2.2. Effects of well-being on work Residents described ways in which both low and high levels of well-being affected four areas of their work: (1) relationships with patients; (2) interactions with colleagues; (3) performance
Fig. 1. Conceptual model representing the effects of resident well-being on work, from interviews with 26 residents at two university-affiliated hospitals.
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Table 2 Total number of times and percent of respondents stating major themes about the effects of resident well-being on work, from interviews with 26 residents at two university-affiliated hospitalsa Theme
Total number of times theme stated in all interviews
Percent of respondents stating theme
Relationships with patients Interactions with colleagues Performance in patient care Motivation in daily work and overall career
48 37 50 53
84.6 73.1 80.8 80.8
a This table refers to responses to the question: ‘‘How does your well-being affect your work?’’ Respondents were not queried specifically in each subcategory, and these counts represent spontaneous and unsolicited responses in each subcategory.
3.2.4. Interactions with colleagues Residents expressed how their sense of well-being influenced their relationships with colleagues and staff. Residents noted that a low sense of well-being on their part or the part of their colleagues led to interpersonal conflict. One internal medicine PGY-3 regretted her impatience with her intern: ‘‘Somehow my tolerance for [my intern’s] mistakes was just much, much lower . . . And I was very quick to point out things she missed and in a quite a harsh way. I feel bad about it because when I kind of lose my balance and don’t feel that well, then I just lose perception of how other people feel . . .’’. An emergency medicine PGY-2 recounted the difficulties she had experienced with consultants: ‘‘I don’t know how to judge people’s well-being except for what they say, and some people get very toxic about situations . . . How people respond or how toxic they are – it’s one measure of their well-being . . . I think most people could respond more with patience or with kindness if they were feeling okay themselves.’’ Residents felt that they possessed greater collegiality towards other residents when they had higher well-being themselves. An internal medicine PGY-2 declared: ‘‘I think when I’m feeling good and I’m not so stressed out, I am . . . a lot more patient with colleagues.’’
3.2.5. Performance in patient care Residents commented on how diminished well-being made them less attentive or efficient in their work performance. An emergency medicine PGY-2 acknowledged lapses in performance when feeling fatigued in the intensive care unit: ‘‘When I was starting to get really tired, I would just let things slide – if I knew it wasn’t that critical for the patient at that point in time. We had a patient who a history of pulmonic stenosis, and the team asked me several times to get cardiology consult. And I knew that wasn’t critical for her management in the ICU, and so I shoved it towards the back burner . . . I didn’t want to do it because I didn’t want to deal with having to call the consult and the follow-up that
they’d want. Maybe in the beginning of the month I probably would have done it.’’ Residents also noted that higher well-being led to improved medical decision-making. An anesthesia PGY-2 declared that, by renewing her wellbeing during her days off, she was able to provide higher quality patient care: ‘‘I need to be fully rested, mentally and physically, in order to function adequately and also make competent decisions when I take care of patients.’’ An internal medicine PGY-2 expressed similar sentiments: ‘‘I think when I’m feeling good and I’m not so stressed out . . .I’m probably more likely to take the time to get a thorough history, do a more thorough exam, more likely to call the primary care provider, and do those things that are extra but really should be part of what you’re always doing.’’
3.2.6. Motivation in daily work and overall career Residents’ well-being affected their feelings about their daily work and their career in medicine. Lower levels of wellbeing led to feelings of ambiguity about whether medicine was the right choice. A pediatric intern admitted: ‘‘And now I don’t like going to work. I don’t get up in the morning and say, ‘‘Wow, I get to go into work at 6:00 in the morning and round on 8 patients before I get to schedule these tasks. And oh gee, maybe I get to do some admissions.’’ I don’t. It’s not fun. I don’t enjoy it. I don’t look forward to it. What’s wrong with this? If this was a job in the real world, you’d quit and find something else to do. And not every month is like that. You know there are months I feel better than others.’’ An internal medicine PGY-3 reflected back to his intern year, when he had similar doubts: ‘‘Patients became more of a source of work and burden than somebody sick and in need of my care . . . I just had more of a cynical viewpoint of it because the workload was high.’’ Alternatively, residents suggested that higher well-being enabled them to feel greater zeal towards their purpose in medicine.
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One surgical resident said: ‘‘When things are better in your personal well-being, you actually derive even more satisfaction from working and interactions at work.’’ Some residents specifically observed that higher well-being allowed them to rediscover their intrinsic passion for their work through their relationships with patients. An internal medicine intern recently refreshed from vacation remarked: ‘‘It’s nice to remember the reason you do everything that you do . . .[Before vacation] I really didn’t want to have to see my patients or their families. And now since I’ve been back, I’m so much more happy and comfortable to talk to people and to see how they’re doing and just stop in. I’ve enjoyed myself more in the last few days than I have in a long time.’’
3.2.7. Denying that well-being affects work Five of the 26 residents stated that their well-being did not affect their work. Importantly, these residents all acknowledged the potential for a low sense of well-being to affect the quality of their work. However, at least in their initial comments, they claimed that they successfully guarded against this because they felt it would be unprofessional. One third-year surgical resident explained why she felt her well-being should not affect her work: ‘‘I don’t think it does very much because I know how important my work is, and so I feel sometimes like I have to suspend my well-being because at work it doesn’t necessarily matter how I feel. It matters how I’m taking care of my patient and am I getting my job done. It probably affects my attitude about how I see [work], but I’d like to think it doesn’t affect the end product.’’ However, this same resident later acknowledged that lapses have occurred, supporting the relationship between well-being and work reported in the first four themes: ‘‘[The patient] needed a Foley catheter and he didn’t want one . . . He was angry and scared, and I had twenty other things to do and the last thing I needed was this patient to argue with me . . . ‘This is what we want to do, if you say no fine, but you know we’re going to do it when you’re asleep.’ This wasn’t the appropriate way to handle it, and he said that he didn’t appreciate my tone and I can see his point. But at the time I just didn’t have the patience to sit down and actually find out why he was so worried about it. I just needed to cross off that box and move on.’’ Other residents also felt that maintaining quality patient care in spite of low personal well-being was important, but acknowledged that it was difficult to know when quality of care began to decline. One obstetrics/gynecology resident said: ‘‘There have been times when I’ve caught myself. You just have to snap out of the phase and be a little more attentive.
Every once in a while, a nurse will call you on it or say, ‘‘What’s wrong with you?’’ But most of the time, you just kind of have to be self-aware of how you’re acting. It’s not always easy though.’’ 4. Discussion and conclusion 4.1. Discussion In this qualitative study, most residents acknowledged times when lower levels of well-being negatively affected their relationships with patients, interactions with colleagues, and performance in patient care. Conversely, they noted that higher levels of well-being enhanced their capacity for these aspects of their work. Trainees also described how their well-being affected their motivation and enthusiasm for medical careers, leading them to question whether the sacrifices were worth the potential professional gain. Our findings support previous studies that suggest a relationship between residents’ wellbeing and their perceptions about the quality of their patient care and their career satisfaction [3,7,11]. Our study contributes to this literature by exploring in a broader sense how positive and negative aspects of well-being – as defined by residents themselves – affect their work. Our respondents’ narratives illustrate how well-being may affect some of the core competencies expected of residents, including patient care, interpersonal and communication skills, and professionalism [8,9]. A primary goal of medical training is to inculcate future physicians with the tenets of medical professionalism that encompass commitments to patients and colleagues [9]. Our informants expressed a willingness to endure personal sacrifice for the sake of professional development [14]. However, their commentaries illustrate how professional development and professionalism may be facilitated by higher levels of well-being, while sacrificing well-being may be counterproductive. These narratives exemplify potential challenges for resident physicians attempting to reconcile the relationship between their well-being and their professionalism. A subset of residents felt that felt that professional physicians should be able to block out negative states of well-being at work, putting the patient’s interests first. However, most residents in this study did feel that their well-being – whether low or high – has a significant impact on the quality of their communication and care at work. This relationship between well-being and work is increasingly acknowledged in the business sector and occupational health literature [20–23]. By promoting the notion that the welfare of patients supersedes that of the physician, the formal and informal curricula of medical training may suppress acknowledgement of this connection between physician well-being and work. This denial may prevent physicians-in-training from exploring the specific ways in which their well-being affects their own work, which may differ from resident to resident. Medical educators may be able to enhance professional learning and practice by promoting greater self-awareness in residents about their own well-being and its effects on their work. Mindful practice enables physicians to examine honestly
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their feelings and how they affect relationships with patients and colleagues [24]. In one study, only 32% of residents felt that self-awareness was frequently taught in their residency training or easy to incorporate in their daily lives [25]. A prerequisite for effective training in professionalism is ‘‘a safe venue for students and residents to share their experiences and enhance their personal awareness’’ [26]. Such venues may allow residents to understand more fully how their well-being affects their work and to delineate strategies to enhance both their wellbeing and their professionalism [27,28]. While this article focuses on the effects of well-being on work, this qualitative data highlights the dynamic interplay in both directions, with work affecting well-being and well-being affecting work in a potential loop or spiral pattern. During the interviews, when asked how their well-being affected their work, residents returned to descriptions of how work affected their professional development, maintenance of self, and overall sense of balance, which lies at the heart of the residents’ definition of well-being [14]. Organizational changes to maximize resident well-being – such as forums for providing feedback, flexible work schedules, and supportive faculty advising systems [14] – may not only improve resident wellbeing, but also mitigate downward spirals or potentiate upward spirals. Several limitations of this study should be considered. First, this qualitative study is limited to residents at two affiliated medical centers, and as such our findings may not apply to residents in other programs. However, our study design included residents from a variety of disciplines and postgraduate years. Second, 47% of potential participants declined participation, which was expected given the 45-min duration of the interview and the personal subject matter. However, our enrollment rate is comparable to other published interview studies with residents [17]. Our participants did not differ significantly from non-participants in measurable demographic characteristics, but non-respondents may have had different degrees of well-being – lower or higher – which may have yielded different perspectives on how well-being affects work. Third, residents in two of the nine programs did know the interviewer prior to data collection, which may have affected the candor or nature of their responses. Fourth, this crosssectional study cannot demonstrate causality in the relationship between resident well-being and work performance, but rather represents the informants’ perspectives about how they believe well-being affects their work. As some authors have suggested, the delivery of suboptimal patient care may actually precede resident distress, in addition to the converse [29]. Fifth, we did not aim for theoretical saturation by training level, and thus cannot make meaningful comparisons among training years. Although our respondents alluded to fluctuations in their wellbeing and how their well-being affected their work over the course of residency, their recollections of particular problems during internship may be limited by recall bias. Another study found that declines in mood and empathy during internship did not recover in all domains over the course of residency [12]. Finally, our study was restricted to self-report by residents of their behavior and may be subject to biases in characterizing
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their relationships and their work. Our data collection did not allow us to explore the perspectives of patients, colleagues, or faculty. 4.2. Conclusion In this qualitative study, residents described how both higher and lower levels of well-being affected their work in areas integral to core competencies of medical training, particularly interpersonal and communication skills, professionalism, and patient care. 4.3. Practice implications Training programs may wish to assess and promote the wellbeing of their trainees to help them achieve their full potential in their work. Acknowledgements Funding for this project was provided through a grant from the Osler Center for Clinical Excellence at Johns Hopkins and by the Health Resources and Services Administration, Grant #5 D55HP00049-06-00. The funders had no involvement study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. Dr. Wright is an Arnold P. Gold Foundation Associate Professor of Medicine and a Coulson-Miller Family Scholar. Dr. Carrese is supported by the Morton K. and Jane Blaustein Foundation, Inc. as a Blaustein Scholar of the Johns Hopkins Berman Institute of Bioethics. Appendix A Interview guide used in semi-structured interviews with residents about resident well-being at two university-affiliated hospitals
How would you rate your overall level of well-being? What helps you maintain your well-being? What makes it hard for you to maintain your well-being? How does your well-being compare with others around you at work? How does your work affect your well-being? How does your well-being affect your work? What exists now in your residency to help you maintain your well-being? What improvements could be made to help you or others maintain well-being? After talking about this topic, how would you summarize what ‘‘well-being’’ means to you? Do you have any other comments or suggestions?
Conflict of interest The authors have no conflicts of interest to disclose.
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Well-being in residency: Effects on relationships with patients, interactions with colleagues, performance, and motivation Neda Ratanawongsa *, Scott M. Wright, Joseph A. Carrese Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States Received 8 February 2008; received in revised form 16 April 2008; accepted 27 April 2008
Abstract Objective: Previous studies about resident well-being have focused on negative aspects of well-being. We conducted this study to explore residents’ conceptions of well-being and how it affects their work. Methods: One investigator conducted semi-structured interviews with residents at two hospitals during February–June 2005. Through random sampling stratified by program and gender, we invited 49 residents from internal medicine, psychiatry, surgery, emergency medicine, anesthesia, obstetrics/gynecology, and pediatrics. Using an editing analysis style, three investigators independently coded transcripts. Results: 26 residents participated in 45-min interviews. Residents acknowledged that well-being affected four elements of their work: relationships with patients, interactions with colleagues, performance, and motivation. Residents described higher quality discussions with patients when their well-being was high and inappropriate exchanges when well-being was low. Residents attributed conflict with colleagues to lower states of well-being. Residents felt they had improved decision-making when their well-being was higher. Residents’ motivation in their daily work and career varied with fluctuating well-being. Five residents initially denied that their well-being affects their work, voicing concerns that this would be unprofessional. Conclusions: Most residents felt that both high and low levels of well-being affected their work, particularly their work relationships. Practice implications: The educational and patient care goals of residency training may be enhanced through interventions that promote resident well-being. # 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Medical education; Residency; Physician well-being; Professionalism; Patient–provider communication
1. Introduction The graduate medical education of physicians may be stressful and difficult [1–3]. The well-being of trainees may affect their potential for professional growth and development. Recent studies have suggested that negative aspects of wellbeing – such as burnout – may be associated with a lower capacity for empathy and suboptimal patient care [1–3]. The Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour guidelines to improve both patient safety and resident well-being [4]. In one study, 84% of
* Corresponding author at: Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Suite 2300, Baltimore, MD 21224, United States. Tel.: +1 410 550 1862; fax: +1 410 550 3403. E-mail address: [email protected] (N. Ratanawongsa). 0738-3991/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2008.04.010
internal medicine residents felt that work hours had enhanced their well-being, but many residents felt they led to worsened patient care (37%) and education (47%) [5]. A systematic literature review found inconsistent evidence about the effects of work hour limits on residents’ quality of life and suggested that further evidence is needed to support the link between resident well-being and patient outcomes [6]. A study by Papp et al. suggests a possible relationship between resident well-being – mediated by sleep deprivation and fatigue – and professionalism [7]. Although professionalism has been promoted as a core competency in medical training [8,9], some have suggested that reducing the stressors of residency may be a necessary step to facilitate professional behavior [7,10]. Research about resident well-being and its consequences on residents’ work have primarily focused on negative aspects of well-being, such as burnout, depression, or fatigue [3,11–13].
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However, the breadth of well-being during residency and the impact of positive well-being on work have not been delineated fully. We conducted this qualitative study for two objectives: to explore more completely residents’ perceptions of well-being and to understand their beliefs about how their well-being affects their work. In a recent paper, we reported that residents defined well-being as a balance among multiple parts of their personal and professional lives, including professional, family, social, physical, mental, spiritual, and financial domains [14]. In this paper, we focus on the second objective, reporting residents’ descriptions of how fluctuations in their well-being – as defined above – affect their relationships with patients, interactions with colleagues, performance in patient care, and motivation.
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higher numbers representing higher well-being. The interview then included open-ended questions about the components of resident well-being, factors related to its promotion or reduction, the impact of well-being on work, perceptions of how training programs may enhance resident well-being, and the definition of well-being (see Appendix A for the interview guide). The results in this paper focus on responses to the question: ‘‘How does your well-being affect your work?’’ The interviewer (NR), trained in qualitative interviewing techniques, used reflective probes to encourage respondents to clarify and expand on their statements. The interviewer did not know residents at seven of the nine programs, but did interact with residents in the continuity clinic for two programs. 2.4. Data analysis
2. Methods 2.1. Study design We chose a qualitative interview design to explore the phenomenon of physician well-being from the informants’ perspectives. A qualitative methodology allows the emergence of themes that researchers may not anticipate. One-on-one interviews permit exploration in greater depth than is possible with closed-ended scales, surveys, or even focus groups. 2.2. Study sampling Through purposive sampling, we recruited residents from nine residency programs at two university-affiliated medical centers in Baltimore, Maryland. Our goal in purposive sampling was to target a diverse set of respondents currently in training in multiple training programs at each stage of residency. The largest training programs were selected for recruitment, and a variety of clinical disciplines were represented. We used stratified random sampling to obtain approximately equal proportions by gender from each program. Recruitment e-mails and letters emphasizing the confidential and voluntary nature of participation were sent to 49 residents. Following accepted qualitative methodology, we discontinued sampling when we determined that new interviews yielded confirmatory rather than novel themes, a process called achieving ‘‘thematic saturation’’ [15]. We discontinued sampling after 26 interviews, a sampling size consistent with other qualitative studies [16–19]. Enrollees received a $50 Amazon gift certificate as compensation. A Johns Hopkins School of Medicine Institutional Review Board approved the study. 2.3. Data collection From February to June 2005, one investigator (NR) conducted audiotaped, semi-structured interviews with participants in private settings within or outside the hospital. The interview began by asking residents to rate their wellbeing using words or a numerical rating from 1 to 10, with
We analyzed transcripts using an ‘‘editing organizing style,’’ a qualitative analysis method in which researchers search for ‘‘meaningful units or segments of text that both stand on their own and relate to the purpose of the study’’ [15]. With this process, we derived a coding template from the data itself, rather than applying a pre-existing template. Each investigator independently analyzed six randomly selected transcripts and generated codes to represent the subjects’ statements. The three investigators compared codes and negotiated discrepancies to create a coding template. Two investigators independently coded each remaining transcript with this template. Although a third investigator was available to mediate in cases of discrepant coding, the two original investigators successfully reached consensus after reviewing and discussing each other’s coding. All coding was completed between March and July 2005. For this paper, the investigators selected the themes encompassing the relationship between well-being and work. The authors agreed on representative quotes for each theme. Atlas.ti 5.0 software (Atlas.ti GmbH, Berlin, Germany, 2005) was used for data management and analysis. We compared demographic characteristics of participants and nonparticipants with Fisher’s exact test using STATA Intercooled version 9.0 (Stata Statistical Software: Release 9.0, Stata Corporation, College Station, TX, 2005). 3. Results 3.1. Respondent demographics and overall ratings of well-being Twenty-six of the 49 invited residents (53%) participated in 45-min interviews. The average age was 28.7, with a range of 26–33. Five participants (19.2%) were interns, and just over half (53.8%) were women (see Table 1). Participants did not differ significantly from non-participants in gender, postgraduate year, or program (all p > 0.05). In describing their overall well-being, 14 residents (53.8%) rated their well-being as excellent or 8–10, 8 residents (30.8%) as good or 5–7, and 4 residents (15.4%) as low or <5.
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Table 1 Characteristics of 26 residents interviewed about resident well-being at two university-affiliated hospitals Characteristic Age, mean (S.D.) Women, n (%) Married/partnered, n (%) Children, n (%) Prior careers, n (%) Interviewed during rotation with overnight call, n (%)
28.5 (2.2) 14 (53.8) 14 (53.8) 2 (7.7) 5 (19.2) 12 (42.2)
Program, n (%) Internal medicine, categorical program #1a Internal medicine, categorical program #2a Internal medicine, general internal medicinea Psychiatry Surgery Emergency medicine Anesthesia Obstetrics/gynecology Pediatrics
4 2 4 4 3 3 2 2 2
(15.4) (7.7) (15.4) (15.4) (11.5) (11.5) (7.7) (7.7) (7.7)
Post-graduate year, n (%) 1 2 3 4
5 9 9 3
(19.2) (34.6) (34.6) (11.5)
Overall ratings of well-being, n (%) Excellent/8–10 Good/5–7 Low/<5
14 (53.8) 8 (30.8) 4 (15.4)
a
Categorical internal medicine programs #1 and #2 are based at different affiliated hospitals. The general internal medicine program is based in the same hospital as categorical program #1.
3.2. Results of qualitative analysis
in patient care; and (4) motivation in their daily work and overall career (see Fig. 1). Table 2 presents the total number of times each theme was stated in all interviews and the percent of respondents stating each theme. This table refers to responses to the question: ‘‘How does your well-being affect your work?’’ 3.2.3. Relationships with patients A significant effect of well-being on work involved residents’ relationships with patients and their families. Residents revealed stories about how lower well-being affected the quantity and quality of interactions. In the words of a third-year internal medicine resident: ‘‘If you are not feeling well and completely stressed out, you don’t have all the tools to deal with patients the way you should . . . [During intern year] I would not have been able to give patients as much as I could now. If you are down yourself, it’s difficult to give someone else strength, or help somebody to cope . . .’’ Conversely, when residents had higher well-being, they felt more compassionate in their interactions with patients. An emergency medicine intern valued his conversations with patients about the psychosocial aspects of their illnesses: ‘‘The whole preventive focus – talking to people about weight, smoking cessation . . . Some days you are just too tired and that leads to frustration and you just don’t have that conversation. ‘Aw, that person’s not going to quit anyway. It doesn’t really matter what I tell them.’ But when you feel better about yourself, you’re just more giving.’’
3.2.1. Definition of well-being Residents described well-being as a balance among multiple parts of their personal and professional lives: family, friends, physical health, mental health, spiritual health, financial security, and professional satisfaction. However, residents voiced a willingness to accept a temporary imbalance during residency, sacrificing aspects of their personal lives in order to promote their professional development. At times, stressors such as sleep deprivation or emotionally intense work demands led to dissatisfaction with the imbalance and fluctuations between higher and lower levels of well-being. Residents coped with these stressors using resources such as supportive personal relationships, camaraderie with colleagues, physical exercise, and hobbies. When these supports were adequate, they were more successful in maintaining their well-being. When stressors overwhelmed coping strategies, well-being sagged. Finally, if residents began to lose their sense of themselves as individuals outside of medicine, residents’ well-being suffered. Further description of the respondents’ conception of wellbeing is reported separately [14]. 3.2.2. Effects of well-being on work Residents described ways in which both low and high levels of well-being affected four areas of their work: (1) relationships with patients; (2) interactions with colleagues; (3) performance
Fig. 1. Conceptual model representing the effects of resident well-being on work, from interviews with 26 residents at two university-affiliated hospitals.
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Table 2 Total number of times and percent of respondents stating major themes about the effects of resident well-being on work, from interviews with 26 residents at two university-affiliated hospitalsa Theme
Total number of times theme stated in all interviews
Percent of respondents stating theme
Relationships with patients Interactions with colleagues Performance in patient care Motivation in daily work and overall career
48 37 50 53
84.6 73.1 80.8 80.8
a This table refers to responses to the question: ‘‘How does your well-being affect your work?’’ Respondents were not queried specifically in each subcategory, and these counts represent spontaneous and unsolicited responses in each subcategory.
3.2.4. Interactions with colleagues Residents expressed how their sense of well-being influenced their relationships with colleagues and staff. Residents noted that a low sense of well-being on their part or the part of their colleagues led to interpersonal conflict. One internal medicine PGY-3 regretted her impatience with her intern: ‘‘Somehow my tolerance for [my intern’s] mistakes was just much, much lower . . . And I was very quick to point out things she missed and in a quite a harsh way. I feel bad about it because when I kind of lose my balance and don’t feel that well, then I just lose perception of how other people feel . . .’’. An emergency medicine PGY-2 recounted the difficulties she had experienced with consultants: ‘‘I don’t know how to judge people’s well-being except for what they say, and some people get very toxic about situations . . . How people respond or how toxic they are – it’s one measure of their well-being . . . I think most people could respond more with patience or with kindness if they were feeling okay themselves.’’ Residents felt that they possessed greater collegiality towards other residents when they had higher well-being themselves. An internal medicine PGY-2 declared: ‘‘I think when I’m feeling good and I’m not so stressed out, I am . . . a lot more patient with colleagues.’’
3.2.5. Performance in patient care Residents commented on how diminished well-being made them less attentive or efficient in their work performance. An emergency medicine PGY-2 acknowledged lapses in performance when feeling fatigued in the intensive care unit: ‘‘When I was starting to get really tired, I would just let things slide – if I knew it wasn’t that critical for the patient at that point in time. We had a patient who a history of pulmonic stenosis, and the team asked me several times to get cardiology consult. And I knew that wasn’t critical for her management in the ICU, and so I shoved it towards the back burner . . . I didn’t want to do it because I didn’t want to deal with having to call the consult and the follow-up that
they’d want. Maybe in the beginning of the month I probably would have done it.’’ Residents also noted that higher well-being led to improved medical decision-making. An anesthesia PGY-2 declared that, by renewing her wellbeing during her days off, she was able to provide higher quality patient care: ‘‘I need to be fully rested, mentally and physically, in order to function adequately and also make competent decisions when I take care of patients.’’ An internal medicine PGY-2 expressed similar sentiments: ‘‘I think when I’m feeling good and I’m not so stressed out . . .I’m probably more likely to take the time to get a thorough history, do a more thorough exam, more likely to call the primary care provider, and do those things that are extra but really should be part of what you’re always doing.’’
3.2.6. Motivation in daily work and overall career Residents’ well-being affected their feelings about their daily work and their career in medicine. Lower levels of wellbeing led to feelings of ambiguity about whether medicine was the right choice. A pediatric intern admitted: ‘‘And now I don’t like going to work. I don’t get up in the morning and say, ‘‘Wow, I get to go into work at 6:00 in the morning and round on 8 patients before I get to schedule these tasks. And oh gee, maybe I get to do some admissions.’’ I don’t. It’s not fun. I don’t enjoy it. I don’t look forward to it. What’s wrong with this? If this was a job in the real world, you’d quit and find something else to do. And not every month is like that. You know there are months I feel better than others.’’ An internal medicine PGY-3 reflected back to his intern year, when he had similar doubts: ‘‘Patients became more of a source of work and burden than somebody sick and in need of my care . . . I just had more of a cynical viewpoint of it because the workload was high.’’ Alternatively, residents suggested that higher well-being enabled them to feel greater zeal towards their purpose in medicine.
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One surgical resident said: ‘‘When things are better in your personal well-being, you actually derive even more satisfaction from working and interactions at work.’’ Some residents specifically observed that higher well-being allowed them to rediscover their intrinsic passion for their work through their relationships with patients. An internal medicine intern recently refreshed from vacation remarked: ‘‘It’s nice to remember the reason you do everything that you do . . .[Before vacation] I really didn’t want to have to see my patients or their families. And now since I’ve been back, I’m so much more happy and comfortable to talk to people and to see how they’re doing and just stop in. I’ve enjoyed myself more in the last few days than I have in a long time.’’
3.2.7. Denying that well-being affects work Five of the 26 residents stated that their well-being did not affect their work. Importantly, these residents all acknowledged the potential for a low sense of well-being to affect the quality of their work. However, at least in their initial comments, they claimed that they successfully guarded against this because they felt it would be unprofessional. One third-year surgical resident explained why she felt her well-being should not affect her work: ‘‘I don’t think it does very much because I know how important my work is, and so I feel sometimes like I have to suspend my well-being because at work it doesn’t necessarily matter how I feel. It matters how I’m taking care of my patient and am I getting my job done. It probably affects my attitude about how I see [work], but I’d like to think it doesn’t affect the end product.’’ However, this same resident later acknowledged that lapses have occurred, supporting the relationship between well-being and work reported in the first four themes: ‘‘[The patient] needed a Foley catheter and he didn’t want one . . . He was angry and scared, and I had twenty other things to do and the last thing I needed was this patient to argue with me . . . ‘This is what we want to do, if you say no fine, but you know we’re going to do it when you’re asleep.’ This wasn’t the appropriate way to handle it, and he said that he didn’t appreciate my tone and I can see his point. But at the time I just didn’t have the patience to sit down and actually find out why he was so worried about it. I just needed to cross off that box and move on.’’ Other residents also felt that maintaining quality patient care in spite of low personal well-being was important, but acknowledged that it was difficult to know when quality of care began to decline. One obstetrics/gynecology resident said: ‘‘There have been times when I’ve caught myself. You just have to snap out of the phase and be a little more attentive.
Every once in a while, a nurse will call you on it or say, ‘‘What’s wrong with you?’’ But most of the time, you just kind of have to be self-aware of how you’re acting. It’s not always easy though.’’ 4. Discussion and conclusion 4.1. Discussion In this qualitative study, most residents acknowledged times when lower levels of well-being negatively affected their relationships with patients, interactions with colleagues, and performance in patient care. Conversely, they noted that higher levels of well-being enhanced their capacity for these aspects of their work. Trainees also described how their well-being affected their motivation and enthusiasm for medical careers, leading them to question whether the sacrifices were worth the potential professional gain. Our findings support previous studies that suggest a relationship between residents’ wellbeing and their perceptions about the quality of their patient care and their career satisfaction [3,7,11]. Our study contributes to this literature by exploring in a broader sense how positive and negative aspects of well-being – as defined by residents themselves – affect their work. Our respondents’ narratives illustrate how well-being may affect some of the core competencies expected of residents, including patient care, interpersonal and communication skills, and professionalism [8,9]. A primary goal of medical training is to inculcate future physicians with the tenets of medical professionalism that encompass commitments to patients and colleagues [9]. Our informants expressed a willingness to endure personal sacrifice for the sake of professional development [14]. However, their commentaries illustrate how professional development and professionalism may be facilitated by higher levels of well-being, while sacrificing well-being may be counterproductive. These narratives exemplify potential challenges for resident physicians attempting to reconcile the relationship between their well-being and their professionalism. A subset of residents felt that felt that professional physicians should be able to block out negative states of well-being at work, putting the patient’s interests first. However, most residents in this study did feel that their well-being – whether low or high – has a significant impact on the quality of their communication and care at work. This relationship between well-being and work is increasingly acknowledged in the business sector and occupational health literature [20–23]. By promoting the notion that the welfare of patients supersedes that of the physician, the formal and informal curricula of medical training may suppress acknowledgement of this connection between physician well-being and work. This denial may prevent physicians-in-training from exploring the specific ways in which their well-being affects their own work, which may differ from resident to resident. Medical educators may be able to enhance professional learning and practice by promoting greater self-awareness in residents about their own well-being and its effects on their work. Mindful practice enables physicians to examine honestly
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their feelings and how they affect relationships with patients and colleagues [24]. In one study, only 32% of residents felt that self-awareness was frequently taught in their residency training or easy to incorporate in their daily lives [25]. A prerequisite for effective training in professionalism is ‘‘a safe venue for students and residents to share their experiences and enhance their personal awareness’’ [26]. Such venues may allow residents to understand more fully how their well-being affects their work and to delineate strategies to enhance both their wellbeing and their professionalism [27,28]. While this article focuses on the effects of well-being on work, this qualitative data highlights the dynamic interplay in both directions, with work affecting well-being and well-being affecting work in a potential loop or spiral pattern. During the interviews, when asked how their well-being affected their work, residents returned to descriptions of how work affected their professional development, maintenance of self, and overall sense of balance, which lies at the heart of the residents’ definition of well-being [14]. Organizational changes to maximize resident well-being – such as forums for providing feedback, flexible work schedules, and supportive faculty advising systems [14] – may not only improve resident wellbeing, but also mitigate downward spirals or potentiate upward spirals. Several limitations of this study should be considered. First, this qualitative study is limited to residents at two affiliated medical centers, and as such our findings may not apply to residents in other programs. However, our study design included residents from a variety of disciplines and postgraduate years. Second, 47% of potential participants declined participation, which was expected given the 45-min duration of the interview and the personal subject matter. However, our enrollment rate is comparable to other published interview studies with residents [17]. Our participants did not differ significantly from non-participants in measurable demographic characteristics, but non-respondents may have had different degrees of well-being – lower or higher – which may have yielded different perspectives on how well-being affects work. Third, residents in two of the nine programs did know the interviewer prior to data collection, which may have affected the candor or nature of their responses. Fourth, this crosssectional study cannot demonstrate causality in the relationship between resident well-being and work performance, but rather represents the informants’ perspectives about how they believe well-being affects their work. As some authors have suggested, the delivery of suboptimal patient care may actually precede resident distress, in addition to the converse [29]. Fifth, we did not aim for theoretical saturation by training level, and thus cannot make meaningful comparisons among training years. Although our respondents alluded to fluctuations in their wellbeing and how their well-being affected their work over the course of residency, their recollections of particular problems during internship may be limited by recall bias. Another study found that declines in mood and empathy during internship did not recover in all domains over the course of residency [12]. Finally, our study was restricted to self-report by residents of their behavior and may be subject to biases in characterizing
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their relationships and their work. Our data collection did not allow us to explore the perspectives of patients, colleagues, or faculty. 4.2. Conclusion In this qualitative study, residents described how both higher and lower levels of well-being affected their work in areas integral to core competencies of medical training, particularly interpersonal and communication skills, professionalism, and patient care. 4.3. Practice implications Training programs may wish to assess and promote the wellbeing of their trainees to help them achieve their full potential in their work. Acknowledgements Funding for this project was provided through a grant from the Osler Center for Clinical Excellence at Johns Hopkins and by the Health Resources and Services Administration, Grant #5 D55HP00049-06-00. The funders had no involvement study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. Dr. Wright is an Arnold P. Gold Foundation Associate Professor of Medicine and a Coulson-Miller Family Scholar. Dr. Carrese is supported by the Morton K. and Jane Blaustein Foundation, Inc. as a Blaustein Scholar of the Johns Hopkins Berman Institute of Bioethics. Appendix A Interview guide used in semi-structured interviews with residents about resident well-being at two university-affiliated hospitals
How would you rate your overall level of well-being? What helps you maintain your well-being? What makes it hard for you to maintain your well-being? How does your well-being compare with others around you at work? How does your work affect your well-being? How does your well-being affect your work? What exists now in your residency to help you maintain your well-being? What improvements could be made to help you or others maintain well-being? After talking about this topic, how would you summarize what ‘‘well-being’’ means to you? Do you have any other comments or suggestions?
Conflict of interest The authors have no conflicts of interest to disclose.
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