Effects of Clinic First Educational Interventions on Resident Wellness and Engagement

The majority of family medicine clinicians provide care primarily in outpatient settings,1 yet most family medicine residencies use rotation-based models favoring inpatient care. This comes at the expense of outpatient training, which often occurs in underfunded, dysfunctional clinics.2-4 Furthermore, most programs lack structured outpatient curricula and fail to deliver skills necessary to thrive in evolving primary care models.5 These tensions between inpatient and outpatient training result in clinic being the least favorite part of training for some residents.4

Inadequate training and dysfunctional practices are risk factors for burnout, which disproportionally affects family physicians.6 Cumbersome geographic and mental transitions from inpatient to outpatient settings can further add to learner stress.4 Models prioritizing quality resident outpatient training are needed to improve wellness.7

Bodenheimer, et al describe a Clinic First model that provides steps programs can take regarding resident scheduling, engagement, and work-life balance to emphasize quality ambulatory training in high-functioning clinics.4,8,9 While studies have examined alternative scheduling models, few have evaluated comprehensive Clinic First educational interventions.3, 10-16 Most studies focus on clinic metrics, leaving the effects on resident wellness and engagement largely unstudied.

We hypothesized that adopting a Clinic First model to make outpatient clinic training a cornerstone would positively affect resident wellness and clinic engagement.9 This study describes our interventions and their effects within the Oregon Health & Science University (OHSU) Family Medicine 4-year Portland residency program.

We conducted a mixed-methods cross-sectional study of 47 residents enrolled in our residency program from July 2017 to February 2019 (Figure 1). Seven scheduling and curricular interventions were made (Table 1) in July 2017.

Eighteen months after intervention implementation, family medicine department research associates conducted focus groups without evaluative roles within the residency (Table 2). Primary outcomes were resident wellness and clinic engagement. To encourage a wide range of responses, outcomes were not predefined.

The study team developed a series of open-ended questions that asked residents to reflect on how the curricular interventions affected their wellness and engagement (See Appendix). Third- and fourth-year residents (PGY-3s and PGY-4s) were asked to compare their experiences before and after the interventions. Second-year residents (PGY-2s) had no preintervention reference point so were not asked to compare. First-year residents (PGY-1s) were not included, given their limited time in the program at the time of study. A third party transcribed the interviews.

We used grounded theory and immersion-crystallization approaches to transcript analysis. For the purpose of analysis, we defined wellness as performing well at work and gleaning meaning or enjoyment from work while maintaining physical and mental health. We defined clinic engagement as residents’ enjoying clinic, being present for a patient panel, and being involved in clinic operations. Independent analysis and coding by each member of the research team was followed by in-person meetings to develop themes by consensus.17

We administered an online survey to two classes of PGY-1s (n=24 total) in August 2017 and August 2018 at the end of the clinic immersion month(s). We used open- and close-ended questions to understand residents’ perceived preparedness for work in their continuity clinics and rotations after the intervention. Close-ended questions used a 5-point Likert scale.

The OHSU Institutional Review Board approved this study.

We convened five focus groups December 2018 through February 2019. Participants included 6 of 12 PGY-2s (50%), 9 of 12 PGY-3s (75%), and 8 of 14 PGY-4s (57%). Emergent themes around wellness and clinic engagement included control and predictability in one’s schedule, transitions within the day and between rotations, duration and intensity of rotations, continuity, connection, work/life balance, and clinic operations (Table 3).

Completion rate for the survey was 70% (17/24); 88% of residents reported feeling prepared for rotations and managing continuity patients. Residents reported they would feel more prepared with increased clinical sessions, electronic health record inbox training, and community activities. They also recommended fewer didactic lectures.

This study provides early data on the potential effects of Clinic First interventions on resident wellness and clinic engagement. Themes suggest the 2+2 model, decreased daily transitions, reduced inpatient time, and the clinic immersion month are associated with improved perceptions of multiple factors known to contribute to wellness.4,6,7,11 Increased transitions between rotations inherent to 2+2 scheduling are perceived as mostly positive with some caveats that appear to be based on learning style differences.

Clinic engagement themes suggest residents may feel more comfortable and present with their patients while in clinic, but continue to struggle with asynchronous patient care tasks and being involved in clinic operations. Specifically, clinician meeting attendance has not improved, likely due to the need to physically transition to clinic at noon without adequate travel time. Additionally, resident engagement in QI project meetings has not improved. While the ability and expectations of residents to attend these meetings has not changed, residents perceive that the 2+2 scheduling creates barriers to attendance and meaningful group work because it creates two separate cohorts of residents. These findings highlight the importance of evaluation and continual process improvement when undertaking curricular changes.

This study has a number of limitations. As a single training site testing one approach to Clinic First implementation, our results may not be generalizable to other programs. Further, lack of a comparison group inhibits us from attributing causality to interventions. Bias among the analysis group is a possibility, as they created the study interventions. Measurement bias is also possible as our clinic immersion month survey measured resident preparedness, which we viewed as a surrogate for wellness and engagement.

This study focused on the scheduling aspects of our Clinic First transition. It will be important to further study optimal Clinic First scheduling models and curricular interventions and methods for blending inpatient and outpatient care responsibilities.

Nationally, many programs have interest in moving towards a Clinic First model.18 The implication that this model could improve resident perception of wellness and clinic engagement can give educators a sense of hope when tackling these difficult and important issues.