Well-being in Residency: Impact of an Online Physician Well-being Course on Resiliency and Burnout in Incoming Residents

Resident well-being is at the forefront of national graduate medical education initiatives. Medical students often enter residency with high levels of burnout.1 Burnout is a well-established residency problem; rates range from 27% to 75% across specialties.2,3 The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to address resident well-being and provide structure, environment, and resources to support physician well-being.4

Individual-focused interventions and organizational strategies decrease burnout.⁵ Work hour restrictions, self-care workshops, and a meditation intervention improve burnout.⁶ Resilience^7,8 and mindfulness⁹ are associated with decreased burnout. However, burnout is not a phenomenon that occurs in isolation. Systemic factors including clerical burden, inefficient clinical practices, and electronic health record challenges contribute. Work-life imbalance, poor morale, challenging patient populations, and unrealistic expectations also contribute.¹⁰ Wellness behaviors¹¹ and wellness-promoting activities¹⁰ can be implemented to reduce burnout. These factors cannot be ignored when developing a comprehensive plan to improve physician well-being and must be approached collaboratively within the system.¹² The Andrew Weil Center for Integrative Medicine (AWCIM) created and investigated the impact of an online, interactive, self-paced, well-being course (https://integrativemedicine.arizona.edu/education/physician_wellbeing.html). As course creators, we hypothesized that 4.5 hours of well-being curriculum distributed online, to multiple residencies in a single health care system at residency start, could improve resiliency, offering residents tools to prevent future burnout.

The AWCIM Physician Well-being Course (PWC) was offered to all incoming PGY-1 residents at the University of Arizona, College of Medicine Tucson in June 2018.

Residents were enrolled in PWC 1 month prior to orientation, with support from the designated institutional officials and graduate medical education well-being subcommittee. Participation was voluntary. The 4.5-hour online course teaches foundations of well-being (sleep, nutrition, exercise, resiliency, and mindfulness), and includes a 2-week daily, self-selected, 10-minute, resiliency activity. Participants complete precourse self-assessments, reflecting on their results. Strategies for building resilience, managing stress, preventing burnout, and developing mindfulness practices are explored.

After completing the coursework, residents select a resiliency activity (meditation, gratitude journaling, or finding meaning journaling). Weekly emails remind them to continue their daily activity, returning after 2 weeks for postcourse self-assessments. Participants view their pre- and postcourse self-assessments. We requested completion by July 1, 2018, with a 30-day grace period. The University of Arizona Institutional Review Board approved the study.

Validated burnout,13,14 resiliency,15-18 and gratitude19 measures were administered pre/postcourse. We administered wellness behavior and course evaluation surveys developed by AWCIM postcourse (Table 1). We deidentified measures for analysis.

Descriptive statistics are presented for completion, wellness behaviors, and course evaluation results. We conducted paired t tests to assess pre/post changes on burnout, resiliency, and gratitude measures. We conducted χ2 analyses on the demographic, categorical resiliency (hardiness), and burnout measures. We conducted analyses using IBM SPSS Statistics Desktop V25.0 (Armonk, New York).

Eighty-seven residents from 15 specialties (Table 2) were enrolled and 53 completed the course (61%). There were no differences in demographic characteristics between completers and noncompleters.

We observed statistically significant improvements in emotional exhaustion, depersonalization, and resiliency (Table 3). Resiliency increased while emotional exhaustion, depersonalization, and personal accomplishment decreased. At posttest the number of participants in the high/very high hardiness categories increased, while participants in the average/low categories decreased. The number of participants in the low-risk burnout group increased. Participants in the moderate and high-risk groups decreased. The most frequently selected resiliency activity was meditation (n=36/53, 68%). The most frequently reported wellness behavior was sleep.

Smoothness of technology, free of commercial bias, and met objectives received the highest ratings (Table 5); while course delivery and usefulness ratings were between neutral and helpful/useful. One-half thought the course should definitely/maybe be incorporated into mandatory material (n=29/53, 55%), with most (n=39/52, 75%) indicating that less time could have been devoted to activity.

This brief, online course teaching foundational well-being and resiliency skills increased self-reported resiliency and decreased burnout inventory scores in incoming residents. PWC provides introductory knowledge about personal well-being, burnout, and resiliency skills. Positive preventive skills learned in this course can be employed with challenging experiences during training.

Course completion was high (61%). Massive open online course completion rates tend to be low (1%-52%, median 13%).20 Very few students (22%) who intended to complete an online course actually completed one.21 One key strategy for our high completion rate was offering PWC prior to residency. Previously, we offered PWC to all resident years during fall 2016; despite having strong programmatic interest and high enrollment, completion was low. Offering the course during onboarding captures trainees in transition during a period when they have additional time and energy. Timing may have adversely affected perceived usefulness of the course as residency training brings up different sources of stress and increased burnout. While offering the course to incoming interns is a limitation, fourth-year medical students and incoming interns demonstrate significant burnout rates.22

Residents self-reported incorporating wellness behaviors, suggesting a possible impact extending beyond well-being knowledge. Personal accomplishment scores declined. It may be difficult for new residents to answer questions regarding personal accomplishment prior to starting residency. Gratitude scores did not change significantly, likely due to the high pretest scores.

Study limitations include the lack of control group or comparison intervention and the inability to confirm the extent to which participants adhered to their resiliency activity. Also, there is no follow-up data to assess whether the reported behaviors and resiliency gained were maintained under the stress of residency. The study results are guiding PWC review to include content regarding the systemic aspects of burnout in health care and methods to capture follow-up assessments to determine if benefits are sustained.

An online course designed to teach residents about well-being and resiliency skills was distributed to all incoming PGY-1 residents. Participants scored higher on resiliency and lower on burnout scales upon completion. Limitations include the lack of control group, timing, and absence of follow up. While cost may be a barrier for some institutions, PWC is a scalable, asynchronous online course, making it an accessible strategy to meet ACGME well-being requirements.