Faculty and Resident Perspectives of the Complexity of Wellness Program Implementation: A Qualitative Exploration

The impact of burnout on the physician workforce and the quality, safety, and satisfaction of patient care is well documented^1,2 and especially salient to family medicine, given the influence of increasing workforce demands and burnout reducing capacity.³ The Accreditation Council for Graduate Medical Education (ACGME) inclusion of wellness in the common program requirements⁴ codifies trainee well-being as essential.

The literature to date has focused on skills such as mindfulness, self-compassion, and cognitive behavioral therapy^5-9 that have been found successful, but there are also some noted cases of failures of these interventions to decrease burnout.¹⁰ Systemic drivers of burnout¹¹ are also being explored but often are outside of programs’ control, leaving programs mostly focusing on the wellness curricula. The Society of Teachers of Family Medicine (STFM) Task Force on Resident Wellness developed a standard for programs¹² but with little evidence published around the details of implementation. Recent literature suggests that having a champion, protected time, and a budget for wellness were associated with improved program director satisfaction in wellness curricula.¹³ However, there is little evidence on what residents find important.

The Family Medicine Residency at the University of Michigan Medical School developed an innovative curriculum in 2016 with three guiding principles: (1) allocate resources, (2) use evidence-informed interventions, and (3) respond to feedback. Our former curriculum emphasized momentary wellness (shared exercise, unstructured walks) and was shifted to structured elements centered on evidence-informed protective skills.^5-7

Our research aim was a qualitative exploration of wellness program implementation from the perspective of residents and curricular faculty with an emphasis on barriers to successful implementation. 

Our curriculum focused on the skills of mindfulness, self-compassion, cognitive behavioral therapy,^5-7 and process-oriented relationship building time. Delivery occurred through three 4-hour sessions for interns starting in 2016-2017 increased to quarterly sessions for 2017-2019. Second- and third-year residents received 2-hour sessions starting in 2017 and continued through 2019. In addition, all residents received 1-hour monthly sessions (Table 1) beginning in 2016. All sessions were required. 

Using a qualitative descriptive design relying on purposive sampling and thematic analysis and interpretation of the data,¹⁴ we collected data for 3 years (2016-2019) through three qualitative sources. We collected voluntary anonymous surveys of all residents through software. The first-year surveys were sent three times to interns alone, followed in subsequent years by quarterly surveys to the interns and twice yearly to the second- and third-year residents. We sent 1-month reminders to nonresponders. Additional data sources included resident and faculty feedback as detailed in Table 2. This study was granted a Category One exemption from review for research regarding educational curricula by the Institutional Review Board of the University of Michigan.

The open-ended survey responses were analyzed initially by three of four authors independently conducting qualitative thematic analysis, using immersion/crystallization, which is an iterative process of collecting, analyzing, reflecting and returning to the data to identify themes.^15,16 Using this iterative immersion/crystallization, our four-member team returned to the data after the initial theme identification for further interpretation and through repeated group discussion identified thematic patterns described below.

Of 183 survey invitations sent, 122 responded (66.7% response rate). Of the responses, 48 unique residents completed at least one survey out of 56 who participated in the curriculum. Our initial thematic analysis of the surveys resulted in themes both positive and negative that spoke to improvements in our curriculum but also the complexity of implementation (Table 3). Our deeper analysis of all the qualitative data identified three broad themes highlighting differences between resident and faculty perspectives.

The first theme involved use of time, specifically, the balance between structured (skill focused) and unstructured (processing/connecting) time and the balance between didactic and experiential elements. For example, one resident stated that “I appreciate them trying to teach techniques we can use all the time,” and a second resident reflected this theme in stating, “Maybe an over concentration on…the formal, a lot of talking at rather than practicing.” An additional component identified by faculty members was the need for safety within the unstructured time. One faculty member observed during the initial year that “While there was a growing openness and comfort with each other, there also appeared to be a level of guardedness in sharing struggles and challenges.” However, this contrasted with an observation by a different faculty member referring to a later year, with

 “very intense personal discussion…several residents expressed feeling very burned out... The support from resident group was strong…at the end we asked them to write one word that summed up their experience of these sessions and every word was a variation on connection.”

The second theme extends the first, and is centered around the locus of control. Residents expressed desire for increased input as exemplified by this quote from a resident asking to “give us a few half days to orchestrate our own wellness activities.” Simultaneously, another resident noted a lack of enthusiasm for the planning when they expressed that “Brainstorming how to make the wellness curriculum better was useful, but not invigorating or refreshing…felt sort of like work.”

The third theme involved differing definitions of wellness with residents making statements that equated wellness with time to “do our work” or with time that “should be focused on social events.” This contrasted with the curriculum focus on evidence-informed skill-building activities.

These results explored a single residency’s design and delivery of a wellness curriculum highlighting challenges in implementation. There was tension around what elements should be given emphasis with faculty designing the curriculum focusing on skill development^5-7 sessions and residents desiring less-structured relationship building^17,18 and processing time.⁶ Faculty leaders noticed that smaller, more bonded groups could tolerate more vulnerability that resulted in greater benefit from the less-structured time but required attention to emotional safety and trust.

The second theme extends a known phenomenon that increased control tends to decrease stress and improve well-being.¹⁹ Evidence suggests greater efficacy in wellness curriculum with resident participation,¹⁹ therefore encouraging meaningful resident participation should be a goal. Residents’ perception that they had little control over curricular elements while at the same time admitting to less interest in engaging makes this a difficult balance to navigate. 

The third theme pertains to differing definitions of wellness^20,21 with our residents wanting time away from work to be included in the skill-focused wellness curriculum. Our qualitative data show resident preference for focus on systemic factors and work compression over skill development.¹¹ Broadening the perspective of what is included is necessary, yet the larger systemic issues are better addressed outside of a curriculum by leadership. Our curriculum now begins with the development of a shared definition of wellness and agreement on common goals.

Major weaknesses of this study are its small size and scope as well as potential for bias. A path forward lies in ongoing research with larger pools of residents and the development of curricula that incorporate a majority of “essential elements,”¹² achieve balance between relational time, skill building, and process-oriented sessions, and continued efforts to impact the larger systems that influence wellness.