A Systemic Approach to Trainee Physician Wellness: Using the Theory of Change to Restructure a Pediatric Residency Program

doi:10.21203/rs.3.rs-616145/v1

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A Systemic Approach to Trainee Physician Wellness: Using the Theory of Change to Restructure a Pediatric Residency Program

https://doi.org/10.21203/rs.3.rs-616145/v1

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Background: Resident well-being leads to better patient care practices, but a systematic approach is needed to achieve the wellness agenda. The Theory of Change was used for developing an interventional model for wellness in our study, after identifying the causes of burnout and attrition in a pediatric residency program.

Methods: This was a quality improvement project where residents were asked about their main stressors in an anonymous open-ended feedback form. Workload (n=63, 37.5%) was identified as the main source of dissatisfaction. A database of 43 residents who quit in the past ten years was examined to find 40.0% of residents left after the first year of training and the main cause was marriage and/or family concerns (28.9%). Then literature was reviewed to build a wellness intervention's framework. Finally, the Theory of Change was applied focusing on restructuring the residency core, accountability and communication, and stress management. The final theory of the change model included the assumptions that the program needed restructuring because of high attrition, low first pass exam rate, and decreased patient satisfaction. The goal was to increase resident wellness and performance, while keeping patient care at the core.

Results: The short-term outcomes were drop in attrition rate from an average of 8.67% to 1.75%, decrease in FCPS exam attempt from 3.3 to almost 1, and an increase in patient satisfaction.

Conclusion: Using the Theory of Change, it was possible to address residents’ concerns, increase their retention and improve patient satisfaction by reconstructing the wellness program.

Health Economics & Outcomes Research

attrition

burnout

systemic change

the theory of change

trainee physician well-being

patient experience

Balancing the demands of a career in medicine and maintaining a healthy personal life, is a struggle for any trainee physician, which ends in the compromise of well-being (1). The topic of well-being in residency programs has been quite popular in recent years (2). Well-being can be defined as a level of positive energy, satisfaction, and sense of purpose in life (3). It has been correlated positively with professionalism in healthcare and leads to better patient care practices (4)(5). That is mainly due to the inverse relationship between wellness and burnout (6). Burnout can be used interchangeably with the word stress, or also defined as heightened emotional fatigue, low self-esteem, and increased depersonalization associated with a workplace environment (5). Burnout rates among trainee physicians or residents are also higher than medical students, practicing physicians, and agematched college graduates across other professions (7).

In some instances, burnout leads to attrition of residents. The word attrition has a double meaning in the Cambridge dictionary; one meaning is the loss of trainees before completion of training and the other meaning is the destruction of something by weakening it (8). One might say that these two definitions could be linked together, as can be seen in the case of residency programs. Attrition is a major concern for any residency program, as it not only hinders the process of training but also negatively affects all those involved (9, 10, 11). Some of the side effects of attrition include disruption of schedules, add-on workload on the remaining trainees, compromised service provision, and the greater problem of hiring a replacement (12). This wastage of time, money, and resources creates an overall weakness in the residency program.

To prevent such a weakness in the residency program, the well-being of residents is necessary to address via combating burnout (13). Thus, early identification of risk factors for burnout and targeted interventions to improve wellbeing should help achieve these outcomes and improve resident satisfaction (14). Existing literature explores various ways programs have adopted wellness activities such as implementing workshops, out-door activities, mindfulness sessions, and more, and noted their beneficial impact on resident's mental health, resident performance, and patient interactions (15, 16, 17). But every program is different in the aspect of resident performance, resident, work hours, workload, etc. so the change to achieve resident wellness must come from within the individual program; setting their own goals depending on their extent and type of burnout (18). To uncover the individualized wellness agenda for a program, a systemic approach starting from the residents themselves should take place, to achieve the required outcomes by designing a framework using robust implementations, which describe not just what and how, but also why a change was required in the intervention (18).

The Theory of Change (TOC) model is one such framework employed as a blueprint for planning an intervention. It promotes social change using development, involvement, and assessment analogies (19). A strong analysis of a TOC model can be extremely useful, for designing or assessing an intervention, as well as for monitoring solutions and evaluations (20). Using the Theory of Change model, we discovered the areas of improvement needed in the pediatric residency program and took the initiative to revamp the training program, keeping resident well-being and patient care at the core. Our study aimed to develop a wellness protocol in our Pediatric residency program using the Theory of Change model.

Objective: To design and test the feasibility of a wellness program using a systems approach for reduced trainee physician stress and burnout.

Study Setting

The Pediatrics and Child Health program at Aga Khan University Hospital (AKUH) was started in 1989. In 2000, AKUH became the first teaching hospital in Pakistan to be Joint Commission Accreditation International (JCIA) certified. Postgraduate Medical Education (PGME) at AKUH strives to instill critical thinking and analysis into its graduates to promote evidence-based health care and research abiding by the principles of ethics and professionalism. This postgraduate training program comprises four years of intense training to provide every resident with a comprehensive and broad-based foundation in Pediatrics, and so that they graduate as highly competent pediatricians, well equipped to begin a career in general Pediatrics or join a subspecialty or academic fellowship.

CPSP is a fellowship certifying body in Pakistan that recognizes certain core competencies which need to be developed in trainee doctors during the training process which includes, knowledge and critical thinking, technical skills, communication skills, research, and teamwork. All of these competencies have patient care as the core. It is necessary to complete 4 years of training to be eligible, so candidates that have completed one or more years of training elsewhere only need to reach a total of 4 years and can graduate from the program prematurely if so.

Study design

This quality improvement project was designed as a feasibility study.

Developing the TOC

1. Conceptualization

Academic program directors and coordinators were given specialized training on Compassion in healthcare, organized by the Pediatric Service line at Aga Khan University. This training platform helped in bringing like-minded people together. The point was then raised that compassion of residents towards themselves was necessary for them to also be compassionate towards colleagues and patients. The idea of revamping the academic program based on patient experience was taken well and this was the point where individual effort started.

2. Creation of working group

Service Line Chief, Director Patient Experience of Care, Postgraduate Program Director, and Coordinator, and Chief resident were taken on board. Closed-loop meetings with the leadership: The idea was discussed and approved by the departmental chair, service line chief, program director, and educational director.

3. Literature review/framework

A literature review was done through Google Scholar and PubMed, and several articles related to the process of initiating a wellness program were identified. One such study described that achieving resident wellness is a significant challenge, and to implement effective strategies resident-led continuous feedback and leadership cooperation is a must (21). A collection of ample literature on wellness depicted strategies for identifying the problem in the program and individual system-level interventions have shown improvement in resident wellness (22). The promotion of resident wellness requires a multi-level approach involving the residents and the leadership, with systematic support to wholly address burnout and enhance well-being, which became the framework of our TOC model (23).

4. Needs assessment

Data was collected from the residents on an anonymous feedback form with open-ended questions and from a pre-coded proforma through departmental and human resources databases. Qualitative analysis was done for the anonymous feedback form. The information from the database included the total number of residents selected per year, gender, causes of burnout among residents, number of residents who left the program, year of training in which they left, and the reasons for leaving. The data were stratified according to gender and the year of training (year I to IV), to see its impact on our outcome variable. Descriptive statistical analysis was done using SPSS software version 19.0. Frequencies and percentages were calculated for the categorical variables. Correlation statistics were applied to see the effect of gender and level of training on resident attrition.

The initial anonymous open-ended feedback from residents in training was collected and coded into sub-themes and themes. It showed that even though workload (n = 63, 37.5%) was the main source of the issue, disrespect (n = 20, 11.9%) and lack of leaves (n = 19, 11.3%) were also main factors for dissatisfaction. (Table 1)

Table 1: Resident qualitative feedback from an anonymous survey

Original Sentence	Subthemes	Themes
“...The system is not entirely paperless – file work is time-consuming and inefficient. Spending time coordinating administrative issues which should ideally be dealt with by nursing, for eg: getting a patient moved for the procedure, coordinating with radiology, EEG, etc”.	Administration issues	Stress
*“...Long Working hours less time for rest, increase workload…too much documentations..”*	Workload
*“ Pay is not sufficient enough for someone who has a family..”*	Salary
*“...degrading behavior of fellows ( few), disrespectful behavior of some staffs with the resident as they think they are permanent or working since years, behavioral issues..”*	Disrespect	Lack of emotional support
“I have learned pediatrics from this program which is better than a lot of programs. But I felt that this program has taken a lot from me than the much I learned. Lack of encouragement/ appreciation to the patient or caretaker”	Lack of appreciation
*“No leaves despite 23 earned leaves and 15 sick leaves/annum and when alternate/ 1:3 calls once residents come back from leaves”*	Lack of leaves
*“.. Low quality academic activities, Low-quality clinical round.. Lack of support for international paper/poster presentation from the dept., Lack of access to online resources remotely”*	Lack of resources	Academic
*“Delayed answering of queries, lack of teaching in rounds..”*	Lack of teaching
*“Incoordination among team members and ineffective teamwork..”*	Team issues

A total of 168 residents were present between the years 2010 to 2018, and a total of 149 were inducted. 79.8% (n = 134) of the all the residents were females and 20.2% (n = 34) were males. The greatest number of residents were inducted in the year 2010 (n = 22), and the least (n = 11) in 2017. The attrition rate peaked in the year 2018 (n = 8/62, 12.90%) and was lowest (n = 2/52, 3.85%) in 2013. The total number of residents, who dropped out from the program over the ten years, was forty-three (21.3%). Gender was not reported to have a significant impact on drop out (p > 0.1), even though attrition was greater in females (n = 33, 76.7%). But a resident's year of training was found to have a significant correlation with attrition (p-value < 0.05).

The majority of residents (n = 18, 40.0%) left after their first year of training, except in 2018 where 7 (15.6%) residents left in their last year due to early completion of training (CPSP requirement complete). Those that left in early training claimed workload (n = 7/18, 41.2%) and adjustment (n = 7/18, 41.2%) as the main causes. But the overall main cause of attrition was marriage and/or family concerns. (n = 13, 28.9%) (Table 2)

Table 2

Causes of attrition of pediatric residents (N = 43)
Cause of resident drop out	Number of residents (N = 43)
Marriage/Family issues	12 (27.9%)
Couldn’t adjust/Poor performance	9 (20.9%)
Workload	8 (18.6%)
CPSP requirement completed	6 (13.9%)
Better prospects	4 (9.3%)
Health issues	4 (9.3%)

Theory of Change Model

The Theory of Change (TOC) model was utilized to identify the processes which linked the problems in the residency program with the effective solution points. The main challenges were to identify the existing resources and establish a system by integrating innovative approaches which facilitate achieving the outcome.

For this, we took a three-tier approach (Fig. 1):

TIER I- RESTRUCTURING THE RESIDENCY CORE

Residents selected our academic program based on the opportunities of learning provided at this institution. Better training leads to enhanced trainee engagement, which thereby facilitates keeping the residents in the program. We focused some efforts on communication skills workshops as there is a key association between resident communication and patient satisfaction (24). Simulation-based training is the most effective way for teaching residents (25), hence we introduced simulation-based teaching sessions as part of the training, and also introduced monthly assessments and mock exams to boost exam-taking skills and confidence among the residents. This was to target the increased number of attempts residents took to pass their FCPS exam.

TIER II- ACCOUNTABILITY AND COMMUNICATION

The mentorship program between faculty and residents was re-structured to have more regular meetups and a supervisor-supervisee guide was developed to strengthen the relationship between the two. We also established a communication pyramid with three main areas: The Departmental residency committee, the Program director meeting, and the Quarterly academic appraisal meeting. Defined criteria and terms of references were developed for the committee to establish smooth communication between all parties involved. Along with that, people with positions were made accountable for the one below (i.e., the program director is accountable for resident’s performance and the educational director is accountable for the support extended towards the residency committee, etc.)

TIER III- STRESS MANAGEMENT

To tackle burn-out and emotional exhaustion, professional appreciation is essential to keep one surrounded with positivity (26). So, for stress management and to increase resident satisfaction, group activities such as mindfulness sessions for self-reflection and buddy bonding amongst peers were implemented to improve the residency experience and work environment, and ultimately, result in better patient care (27). We also initiated "resident of the week" on social media and an certificate awarded to residents based on feedback. We integrated the patient experience of care in the curriculum (i.e., outcome-based approach) by also making patient feedback an integral part of the trainee’s evaluation.

Data collection and analysis

Patients who were admitted to the hospital between January 2019 and February 2019 were approached at the end of their hospital stay and given a short feedback form to fill. It included the following three questions: 1. “During the hospital stay, how many times did the resident doctor addressed your concerns effectively?”, 2. “During the hospital stay, how many times did the resident doctor treat you with respect?”, and 3. “During the hospital stay, how many times did the resident doctor pay attention to you?”.

The human resources database was utilized to collect and analyze data on the residents that left the program after the intervention, and also on the number of FCPS exam attempts by residents over the years.

Patient Experience

Patients were asked to evaluate the residents, to get an understanding of the impact the wellness activities had on the resident patient care practices (Fig. 2). The questions were about residents addressing their concerns effectively, giving them attention, and being respectful. Patients were given the option of choosing from a scale of 0–3, where 0 = Never and 3 = Always. The majority of the patients responded with "always" to each of the questions asked about the residents. A few patients gave a lower rating to how many times they were given attention. This feedback was incorporated into the resident's evaluations.

Attrition rate

Preliminary analyses indicated a reduction in the attrition rate in 2018 from 12.9–1.7% in 2019. (Fig. 3)

Examination pass rate

The Fellowship exam attempts to pass is an average of 3.3 times (28), but after the intervention, it came closer to an average of 1 attempt. The graph in Fig. 4, shows that a greater number of trainees were able to pass the FCPS exam in their first attempt after the intervention in 2018.

The success and stability of a residency program lie in the process of balancing burnout with resident wellness. Evaluating the causes of burnout and attrition, and using them to increase the wellness in the Pediatric residency programs was the focus of our study.

Choosing a career in Pediatrics, which is considered a more likable field, is possibly influenced by an interest in multidisciplinary medicine and a friendly atmosphere (29). If a trainee has compromised their mental health to achieve their training goals, receiving the education of medicine and the friendly environment, then the program directors and front-runners must direct their efforts in preventing this deterioration of mental health that eventually leads to resident burnout and attrition (30). To explore resident burnout, attrition, and wellness, of our Pediatric residency program, we opted for the method of using the Theory of Change (TOC) model.

Weiss (1995) (31) defines a Theory of Change as an explanation of how an initiative works. He asks that participants not only be honest about their problems and the outcomes they hope to achieve but also how they expect to achieve them. Applying this model to the dot, we asked our residents to pin-point their stressors and reasons for leaving to help in formulating the solutions. A theory of change specifies how certain activities will lead to short-term and long-term outcomes and identifies the circumstances that may affect them (32). Similarly, our model was also successful in doing a root-cause-analysis of our program structure and setting up interventions across the whole department.

The majority of residents who joined our Pediatric training program were females (79.7%). The American Physician Specialty Data Report of 2018 showed that Pediatrics has the highest proportion of female doctors (63.3%) compared to other specialties in medicine (35.2%) (33). An article on Women in Pediatrics stated that the nurturing quality of women is the key factor in choosing pediatrics as a career (29). Despite this increased interest in females for applying for this position, it is also their population who had a greater rate of attrition. 76.7% (n = 33) of the residents in our study that quit the program were females. A variation is seen in the relation of gender and attrition in other specialties. For example, some programs have shown a higher rate of attrition among females (33, 34), while others have shown predominantly males who quit their residency program (12, 35). There was no statistical significance in the rate of attrition between males and females reported in our study and was also observed in a literature review of surgical residencies from 1980 to 2016 (37). But alongside there are numerous other individual studies that report gender being a significant determinant of resident attrition. (32, 33, 34, 37). A recent study found women have a lack of support from their program and a lack of female mentors which might be the lead cause of them quitting the program (39). One of the areas of emphasis in our intervention was on the mentorship program and communication from faculty leadership to show support to the female residents in the program.

Significant attrition was also noted in the first year of training (p < 0.05) in our study. This finding aligns with the majority of studies that have also shown higher rates of attrition among women, ethnic minorities, and junior residents, mainly due to increased stress and burnout on their part (33, 37, 39, 40). Junior position in training is the main risk factor for attrition because they are most vulnerable and inexperienced. Attrition of a junior resident depicts that they have expectations before beginning residency which are not met (36, 37). Sullivan et al (38) suggested that junior residents should be asked about their thoughts of quitting and it could serve as a warning for the residency program before possible attrition. Considering this information while forming our TOC model, more efforts were directed into supporting the younger trainees. Buddy bonding, Mentorship Program, and ‘Resident of the week' to name a few efforts made to meet the expectations of junior residents.

The residents present in our program stated that excessive workload (37.5%) was the main cause of burnout. The workload is what defines a resident's lifestyle and a survey by Viola et al (42) reported that residents specified lifestyle as the most important factor in pursuing specialty training. A majority of residents transfer into other specialties that might have a comparatively lesser workload and are more adjustable, most commonly radiology and anesthesiology (9, 33, 43). In addition to workload, lack of leaves (11.9%) and disrespect (11.3%) were also main stressors. With our TOC model, we aimed to improve on these issues by making the program more flexible and open to feedback for change. The matter of workload and lack of leaves was tackled through addressing program leadership and focusing on communication between the accountable parties and reevaluating schedules and introducing yearly leaves. Improvements in mindfulness amongst physicians have proven to be correlated with improvements in mood disturbance and burnout (44). Hence to address the feelings of disrespect, mindful sessions and formal appreciation from attendings, seniors, and patients were incorporated into resident evaluations.

The main cause of attrition in our study was marriage and/or family concerns (28.9%). Baldwin et al, at the Office of Educational Research at the American Medical Association, published one of the first surveys of resident attrition and claimed that causes of attrition were related to family/spouse concerns (45). Marriage and family commitment are linked with increased role conflict and work overload (46). Resident families in particular have always been troubled due to the timings, lack of leaves, and lack of support in the resident trainee's life (30). A lack of uniform residency policies regarding the balance between work and home seems to affect residents’ well-being consistently (47). Better peer-guidance, mindfulness sessions, and feedback incorporated into our program via TOC helped address the work-life imbalance, and time was given to residents to focus on their holistic well-being.

Before the interventions were implemented, our data showed the average attrition rate over the 9 years of the Pediatric residents to be 8.67%. This attrition rate seemed to be more than expected, especially compared to other programs. A study conducted in 2013 by Kathleen A et al (48) reported the annual attrition rate in pediatrics as 2.9%, which was found to be much lesser compared to other specialties i.e., General surgery (5.1%), Family medicine (4.7%), Anesthesiology (3.6%), Psychiatry (7.9%), and Obstetrics and Gynecology (4.2%). Other studies (17, 21, 23, 49) have also depicted a lower average attrition score. This would suggest that an intervention was highly needed in our program to bring down the attrition rate, and indeed after applying all changes focusing on wellness using the TOC model, the average attrition rate came down to a shocking 1.75%. We still need to follow this rate over the years and observe if we can sustain it.

Post-intervention a significant improvement in FCPS exam attempts was noted, depicting that resident education had been given more priority and helped residents clear the exam in one sitting. Patients also seemed to be more satisfied with residents and their care-giving skills after the intervention. Compromised wellbeing can lead to difficulties with academics and building relationships (50). Studies have shown how self-care practices are linked with the ability to perform better at work, and that residents that are in a better state of health, both physically and mentally, project that in their communication and patient-care skills (5, 44). Well-being affects relationships with patients and with colleagues, and residents stated that they had higher-quality interactions with patients when their well-being was better because they approached patient care with more energy and that may indirectly also help in training for FCPS exam as they were less likely to make clinical mistakes (16, 51).

Upgraded residency database and online resident information system helped in accurate retrieval of information related to our study minimized the chances of recall bias to almost nil and is the biggest strength of our study. Being a single-center study with variability in the pre- and postintervention data collection period can add to the limitation of this study for which we recommend a longitudinal follow-up.

A great fall in attrition rate, an improvement in resident performance, and more satisfied patients, were the main outcomes of our study. To revamp the pediatric residency program, we used the Theory of Change to address the concerns and improve the retention of residents, decrease their exam attempt numbers and increase patient satisfaction, by reconstructed mentoring, improvement in evaluations and feedback, appraisal of residents, and time spent on well-being activities as part of the training

Ethical approval, Consent and Permissions: Ethical approval was taken from Aga Khan University Ethical Review Committee (Number: 4743-Ped-ERC-17) and consent was taken from the patients and residents before their surveys.

Consent to publish: We obtained consent to publish from the participants to report the data.

Data and Materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Conflicts of Interest: The authors declare that they have no competing interests.

Funding: None

Author’s contribution: Raza M wrote the entire manuscript and made the tables, Rahman J A and Humayun K helped in conceptualizing the TOC model, Gulamani S helped with obtaining all the data, Rasheed M Ahelped with organizing and editing the paper and Saeed Sconceptualized the TOC model and overlooked the entire study.

Acknowledgments: None

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Introduction

Material And Methods

Study Setting

Study design

Theory of Change Model

TIER I- RESTRUCTURING THE RESIDENCY CORE

TIER II- ACCOUNTABILITY AND COMMUNICATION

TIER III- STRESS MANAGEMENT

Data collection and analysis

Results

Patient Experience

Attrition rate

Examination pass rate

Discussion

Strengths And Limitations

Conclusion

Declarations

References

Status:

Version 1