The obstetrics and gynecology community is mobilizing to develop interventions to improve wellness and to reduce burnout for our residents. Among all specialties, obstetrician–gynecologists have especially high burnout rates,1,2 and the Council on Resident Education in Obstetrics and Gynecology (CREOG) and the American College of Obstetricians and Gynecologists have prioritized physician well-being as a core focus area.3
Addressing the complex issues of resident physician wellness and burnout will require interventions targeted to both systems and individual factors.4–9 Numerous interventions have been described6,8,10–13; however, there is very little published describing the learners' perspectives on this type of programming. Furthermore, there is a striking gap of available evidence about which activities residents prioritize as effective interventions. A thorough understanding of residents' perspectives will be essential for the implementation of effective, evidence-based solutions to this complicated epidemic.
In 2015, CREOG established the Wellness Task Force to better understand wellness and burnout affecting residents during training, and to develop evidence-based interventions. The task force developed a survey with the goal to examine residents' perceptions of wellness, burnout, and perceived effectiveness of wellness programming, and to investigate the role of the learning environment on wellness and burnout. We believe the results of this survey offer the most comprehensive data set to date of residents' views of wellness problems.
Members of the CREOG Educational Committee and the CREOG Wellness Task Force developed a six-item survey that queried attitudes and practices related to wellness (Appendix 1, available online at http://links.lww.com/AOG/B268). We based the survey content on a review of the literature and a prior survey of obstetrics and gynecology resident wellness.14 To determine perceptions of how wellness was prioritized in their residency programs, we asked respondents whether wellness was not a priority, somewhat of a priority, a priority, or unknown. We assessed symptoms of burnout with the question “During your residency training, have you personally experienced any of the follow issues?”—respondents selected all that applied from a list of six possibilities, which included a space to fill in “other” issues. For wellness interventions, respondents rated the efficacy of 11 programs and activities currently offered in their residency programs with a 4-point Likert scale (Not Effective, Effective, Very Effective, or Not Applicable if the activity was not available in their residency program). Respondents then selected the one activity they believed that all residency programs should provide to promote wellness in residency training and how wellness education in residency training should be promoted. Respondents could provide free text descriptions of what they believed all residency programs should provide to promote resident wellness. Lastly, respondents also reported how often they engaged in activities that helped to maintain wellness in their lives.
We distributed this survey to all U.S. obstetrics and gynecology residents who took the January 2017 CREOG in-training examination. Participation was voluntary, and respondents provided consent before answering the survey questions. Respondents completed the survey electronically before starting the in-training examination. Survey responses were anonymous and linked only to residency year. Participants who did not consent, or who did not indicate their residency year, were excluded from data analysis. The Institutional Review Board of the American College of Obstetricians and Gynecologists approved the survey.
We performed descriptive statistics using Microsoft Excel 2010 and calculated a comparison between years of residency training using IBM SPSS Statistics 23. The primary outcome for the study was differences in burnout by residency year level. A priori sample size calculation using a baseline burnout rate of 50% confirmed that 64 was the minimum number of participants necessary to detect 10% differences between residency year groups at a significance level of 0.05. We used Kruskal-Wallis tests to examine differences by residency year for Likert scale items (priority of wellness programming, level of effectiveness of interventions) and conducted post hoc pairwise comparisons for significant responses. We used χ2 tests for reports of depression, burnout, and other wellness issues and examined differences between groups and attitudes towards wellness with Wilcoxon Mann-Whitney U tests.
Of the 5,855 residents who participated in the 2017 CREOG in-training examination, 5,376 were U.S. participants and were offered the survey. Of these 5,376, 5,061 started the survey (94%). Of these, 61 respondents did not consent to be included or did not include their training year, leaving 4,999 (93%) who we included in the data analysis. Table 1 lists the participant demographics by residency year.
Many residents reported personal experience with problems of wellness (Table 2): more than half (51.2%, 2,592) of all respondents claimed burnout, and nearly one third (32.0%, 1,602) reported depression. In addition, 12.6% (628) reported binge drinking, 4.7% (233) reported an eating disorder, 1.1% (56) reported drug use and 0.4% (19) reported a suicide attempt. It is also noteworthy that 3.9% (197) indicated “other” problems, with free text responses that included a range of issues including anxiety (33), fatigue (18), suicidal ideation (16), sleep deprivation and disorders (13), marital and relationship strife (11), weight gain and disordered eating (8), exhaustion (4), and posttraumatic stress disorder (4). Of note, more than 500 respondents did not answer this question regarding personal experience, with 7.7% (381) indicating that they preferred not to answer the question, and 3.7% (184) reporting that they did not know whether they had experienced a wellness issue or burnout during their training.
We identified significant differences among the year of residency. Wellness issues and burnout increased after the first year (Table 2) and remained elevated throughout training. Post hoc pairwise comparisons using the Mann-Whitney U test for outcomes with a large enough response to have power to detect differences between groups. Second-, third-, and fourth-year residents more likely (compared with first-year residents) to have had experiences with burnout (χ2=145.9, P<.001), depression (χ2=40.0, P<.001), binge drinking (χ2=25.9, P<.001), and any wellness problem (χ2=104.6, P<.001). Overall, the number of residents reporting any problem with wellness increases significantly between the first year (49.8%) and second year (63.7%, P<.001) with marginal rates of difference between the advanced-level residents (second, third, and fourth years).
Overall, most (88.4%) of respondents reported that wellness was a priority in their residency program. When asked about their perception of the importance placed on resident wellness in relation to other aspects of the residency program, 36.8% (1,777) responded that it was a priority, 51.6% (2,490) somewhat of a priority, 9.6% (465) not a priority, 1.9% (91) didn't know, and 3% (155) did not respond. Post hoc pairwise comparisons using the Mann-Whitney U test demonstrated that first-year residents were more likely to state that wellness was a priority (compared with second-year residents, P<.001; compared with third-year residents, P=.003; compared with fourth-year residents, P=.069). For all residents, those who responded that wellness was not a priority in their program were more likely to report wellness issues and burnout (χ2=227.3, P<.001).
When asked which of the activities currently offered by their programs was “very effective,” organized extracurricular activities received the highest percentage (41.1%, 1,236), followed by retreat (36.9%, 1,182) and resident wellness day (33.7%, 578) (Table 3). For organized extracurricular activities, 34.0% (1,699) reported that it was not offered, retreat was not offered for 30.6% (1,529), and resident wellness days were not offered for 59.9% (2,994). When asked about what single interventions that all residency programs should provide, 41.2% (2,059) of residents felt that dedicated time for wellness maintenance was the most important intervention, followed by annual resident retreat (21.2%, 1,059) and facilitated exercise (15.6%, 778) (Table 4). When asked to select one modality for how wellness education in residency training should be promoted, 47.9% (2,197) selected program retreats, followed by 24.3% (1,113) team-building exercises, 12.3% (565) didactics, and 9.9% (455) off-site workshops. Very few respondents (1.0%, 47) selected online modules, or podcasts (1%, 48), and multiple free-text responses expressed concern about the potential addition of these modalities as residency requirements. The exhaustion of “required relaxation” is explained by one respondent: “please do not add further requirements like didactics, podcasts, modules are the worst…just give us half a day every once in a while to fix our car, clean our teeth, go grocery shopping or take a hike in the outdoors.”
This national survey of obstetrics and gynecology residents identified a high prevalence of wellness problems. Our findings that nearly half (51.2%) of residents reported burnout, and nearly one third (32.0%) endorsed depression are consistent with existing literature9 and we also found significant associations between the learning environment and these issues. This data can guide the development of interventions to combat resident burnout, both for our specialty and others.
The observation that wellness problems increase between the first and later years of training should prompt efforts to closely examine the experiences of our learners at the onset of training. Recently, Slavin et al15 described a targeted program to prevent burnout, depression, and anxiety for pediatric interns, and the authors reported a significant improvement in mental health compared with historical controls. In addition, further work needs to be done to describe effective interventions for advanced-level learners.
Residents desire time and autonomy to care for themselves, as evidenced by the high priority that respondents gave to wellness days and resident retreats. It has already been reported that residents find wellness days to be helpful,16,17 and that retreats can provide opportunity for team-bonding and bonding17,18; however, it is striking that our residents rated these two interventions so highly. It is important to note that both of these interventions require buy-in from faculty and administrators, because residents need to be released from clinical responsibilities. This buy-in will be an essential aspect of the paradigm and systems shifts necessary for transforming institutional cultures to create a more supportive environment for learners.16–19
The misalignments between current system-level solutions and what residents find helpful highlight opportunities for the development of effective interventions for this epidemic. For example, fatigue education is a core Accreditation Council for Graduate Medical Education program requirement20; however, only 11.4% (382) of our respondents reported that this was a very effective program, whereas 42.2% (1,408) believed that it was not effective. Promoting health through basic behaviors such as healthy nutrition, sleep, and exercise, and cultivating appropriate coping mechanisms for dealing with stressors are simple steps that may be more efficient than dealing with wellness issues and burnout when they arise. Individual action is important, but it is important to recognize that this epidemic highlights that there are also collective problems that can only be solved with larger-scale cultural and organizational change.
There were several limitations to our study. We used a self-reported survey to assess burnout and depression, rather than a validated tool. Because our survey was intentionally designed with few questions to be administered immediately before the in-training examination, we decided not to use a standard inventory for assessing burnout, such as the 22-item Maslach Burnout Inventory.21 This limits the type and volume of data that we were able to obtain. A second limitation was that we administered the survey before an in-training examination, and this may have contributed to a particularly stressful survey environment. The exam also takes place in January, and we know that seasonal affective disorder peaks in winter months,22 which presents an additional element of increased stress and potential burnout. A third limitation was that we did not capture demographics such as gender, family, and marital status. This limits our ability draw conclusions about the small number of residents who chose not to participate in the survey, because we do not know whether that group differed significantly from those who participated. We intentionally made these decisions to protect the confidentiality of responses given the high-stakes nature of the in-training exam setting. Lastly, we did not link our wellness responses to residents' in-training performance. Individually tailored interventions to improve wellness will need to consider multiple aspects of an individual's personal and professional portfolio to be effective.
In conclusion, this CREOG study provides strong evidence of the need to engage trainees in developing effective strategies to improve the learning environment and improve physician wellness. We hope that the findings from this study may provide the impetus to start exploring concrete and collaborative solutions to improve this pressing situation for the future health of our profession.
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