Cedfeldt, Andrea S. MD; Bower, Elizabeth A. MD, MPH; Grady-Weliky, Tana A. MD; Flores, Christine; Girard, Donald E. MD, MACP; Choi, Dongseok PhD
Dr. Cedfeldt is assistant dean, Division of Graduate Medical Education, and assistant professor, Department of Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon.
Dr. Bower is assistant dean, Division of Continuing Medical Education, and assistant professor, Department of Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon.
Dr. Grady-Weliky was associate dean of undergraduate medical education for the School of Medicine and professor, Department of Psychiatry, School of Medicine, Oregon Health & Science University, Portland, Oregon.
Ms. Flores is administrative director, Division of Graduate Medical Education, School of Medicine, Oregon Health & Science University, Portland, Oregon.
Dr. Girard is associate dean, Divisions of Graduate Medical Education and Continuing Medical Education, J.S. Reinschmidt Professor of Medical Education, and professor, Department of Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon.
Dr. Choi is associate professor, Department of Public Health and Preventive Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon.
Please see the end of this article for information about the authors.
Correspondence should be addressed to Dr. Choi, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, CB669, Portland, OR 97239; telephone: (503) 494-5336; fax: (503) 494-4981; e-mail: email@example.com.
First published online January 25, 2012
Purpose: Residents are a unique subpopulation of physicians, training in a complex work and educational environment that may create barriers to accessing preventive and illness-related health care. This study was designed to investigate residents' utilization of personal health care services and compare with those of demographically similar peers.
Method: All 675 residents in a large, urban, tertiary care U.S. academic medical center were invited to participate in a confidential, Web-based, cross-sectional survey in January 2008. Survey responses to questions addressing personal health care were compared with those of a demographically similar group using the 2008 survey from the Behavioral Risk Factor Surveillance System (BRFSS). The final weights in BRFSS were used for a post hoc stratified adjustment in analysis. Logistic regression was employed to compare subgroups.
Results: Sixty-six percent of residents completed the survey. A significantly lower percentage of residents reported having a primary care provider (44%) or dentist (65%) or having routine health and dental care visits (39% and 53%, respectively) within the past year than those in the demographically similar group of 2008 BRFSS. In that group, 83% reported having a primary care provider, and 63% and 79% reported having routine primary and dental health care visits, respectively.
Conclusions: The residents were significantly less likely than demographically similar peers to have a primary care provider or dentist or to participate in routine health maintenance. Further research into barriers preventing residents from accessing health care, and opportunities to address them, is needed.
Health care institutions have good reason to focus on their physicians' health. Physicians do not reliably take care of themselves, and when they suffer physical or emotional stress, their patients may suffer as well.1–3 What is true for physicians in general may be especially true for resident physicians; their taxing training and complex work and educational environment put them at risk for not getting the preventive and illness-related health care they may need.4
In a study of U.S. internal medicine residents, 37% responded that they did not have a primary care physician, and 12% described serving as their own primary care physicians.5 A study examining health practices among family medicine residents in Canada found that 38% had a local family physician, but 25% of those with chronic illnesses and 40% of those who use prescription medications did not have a primary care provider. Alarmingly, 41% had received prescriptions from, or written prescriptions for, their colleagues. Few residents recognized or sought treatment for mental health problems. Reported barriers to accessing health care in this study included no need for a primary care physician, no time to see a physician, no physicians available to see, and concerns over confidentiality.6
Neither of these (or any previous) studies have asked whether residents access personal health care at rates different from those of demographically similar peers in the general population. The Division of Graduate Medical Education at Oregon Health & Science University (OHSU) used a validated resident survey instrument to investigate this important question.
OHSU's Division of Graduate Medical Education annually surveys its residents, asking questions on four topics: (1) career choice, satisfaction, and perceived stress, (2) positive and negative training experiences, (3) emotional wellness, which includes 19 adjectives about positive or negative emotional states, and (4) hours worked and hours of sleep. Survey results are kept anonymous and confidential. In January 2008, with approval from OHSU's institutional review board, we added a personal health care section comprising 20 yes/no and multiple-choice questions asking about residents' access to primary and illness-related health care. These questions were developed in a focus group of residents and then pilot-tested in a larger group. The survey instrument has been published previously and can be accessed online.7
This 2008 survey was distributed to all 675 residents then in OHSU's 65 Accreditation Council for Graduate Medical Education (ACGME)-accredited residency programs. We compared the survey responses with those of a demographically similar group also surveyed in 2008 by the Behavioral Risk Factor Surveillance System (BRFSS).8 The BRFSS, administered by the Centers for Disease Control and Prevention's Office of Surveillance, Epidemiology, and Laboratory Services, is the largest annual telephone-based health survey system in the world and has tracked health conditions and risk behaviors in the United States since 1984. The questionnaire and annual survey data are freely accessible from the BRFSS Web site.8 The demographically similar group consisted of the entire set of 26- to 40-year-old respondents with college degrees and health insurance. The data were weighted using the final weight variable provided in the BRFSS data file for a post hoc stratified adjustment.
We initially analyzed the data using descriptive statistics, cross-tabulations, and graphics. The chi-square goodness-of-fit test evaluated whether respondents were representative of the entire resident cohort at OHSU. We used the Fisher exact test or chi-square test for comparisons between the OHSU residents and the demographically similar BRFSS group. Our multivariate analyses, which employed logistic regression, explored potential associations between the residents' demographic variables and their health care utilization. After doing the logistic regression both with and without age as a variable and finding that it did not change odds ratio (OR) estimates for other variables, we omitted it from the final models. We defined statistical significance as a P value <.05 and primary care as internal medicine, pediatrics, and family medicine. All computations were done in R Project for Statistical Computing software (www.r-project.org).
Of the 445 residents who responded to the survey (66% of the 675 OHSU residents), 54% (239) were male, 79% (353) were Caucasian, and 94% (438) were between the ages of 26 and 40 years old. Of the responding residents, who were demographically similar to OHSU's entire resident cohort (Table 1), 44% (193/443; 2 nonresponses) reported having a primary care provider. This proportion is significantly lower than that of the BRFSS group, in which 83% reported having a primary care provider (P < .001, chi-square test). Female residents were significantly more likely than male residents to report having a primary care provider (58% [119/204] and 31% [74/239], respectively). A comparable gender difference was seen in the BRFSS group; 88% of women and 78% of men reported having a primary care provider.
Residents were also much less likely than the BRFSS group to report having seen their primary care providers within the last year (39% [173/443] versus 63%; P < .001, chi-square test). When analyzed by gender, 56% (115/204) of female residents and 24% (58/239) of male residents had seen their primary care provider within the last year compared with 71% of women and 55% of men in the BRFSS group. Figure 1A illustrates these data.
Results for accessing dental care revealed a similar pattern. Of the residents, 65% (286/443) reported having a dentist, and 53% (237/443) reported a routine dental visit within the last year. Female residents were more likely than their male counterparts to report having a dentist (70% [143/204] versus 60% [143/239]) and to report having a routine dental visit within the last year (61% [124/204] versus 47% [113/239]). These proportions were again significantly lower than those of the BRFSS group, in which 79% (82% of women and 76% of men) had visited their dentist during the last year (P < .001, chi-square test; Figure 1B).
Using multivariate logistic regression analyses, we estimated ORs for accessing various health care resources among subgroups of residents. Gender was the most significant contributor to differences in accessing health care. Women were more likely both to identify that they had health care providers and to have seen their providers for routine health care within the last year (Table 2). Specifically, they were almost twice as likely to have a dentist and to have seen their dentist for a routine checkup in the last year (OR 1.7 and 1.8, respectively). The odds for having a primary care provider and having seen their primary care provider or gynecologist for a routine checkup were even higher (OR 3.3 and 4.1, respectively). Not surprisingly, female residents were more likely to see their health care providers more promptly when they did have physical health needs. Among residents reporting that they needed to see a care provider for reasons other than routine checkups, women were much less likely than men to report having had the health need for longer than a year (OR 0.30).
Interestingly, the number of years in training was not related to the likelihood of seeking routine health care; however, a greater number of years in postgraduate training was positively associated with an increased likelihood of seeking out nonroutine health care. With each year of training, residents were almost twice as likely to have seen their dentist, eye doctor, primary care doctor, or gynecologist for health needs outside of routine preventive care (OR 1.7, 1.7, and 2.0), and they were less likely to have health needs for which they had not scheduled appropriate appointments (OR 0.70). Compared with residents training in other specialties, residents in primary care training programs were almost twice as likely to have a physical health need requiring a visit to a health care provider for which they had not scheduled an appointment (OR 1.8). Training specialty was not associated with other differences in the ORs of accessing health care resources (Table 2).
Just as previous studies have demonstrated that physicians in general do not reliably pursue their own health care,2,3 we have found in this study that residents in particular are significantly less likely than their demographically similar peers to have primary care providers or seek routine health care, including dental care. This is of considerable concern, especially if one believes that preventive health care is important to overall wellness. Because the literature also suggests that physical or emotional stress in physicians contributes to poorer patient outcomes, we propose that intervention early in the education of physicians is necessary to promote physician wellness and to improve patient care.1
Literature on residents' self-reported health status is limited,9 but both our residents and the demographically similar BRFSS cohort rated their overall health as very good to excellent. Methodological differences make direct comparisons between the groups impossible; however, the two data sets reveal no obvious differences in health status that might explain the disparity in seeking health care. Even had we found differences in health status, this would not have explained the residents' lower rates of accessing routine preventive health care, which one should seek no matter one's health status—something that physicians, more than other groups, should know. Another possible explanation for this discrepancy in using health care services is that the “hidden curriculum” of medical training discourages physicians themselves from meeting the standard of care they set for their patients.4 Another influential factor may be the culture of postponement that pressures residents to put health care “on hold” during their training years.5 Other barriers suggested in the literature include individual perceptions of a lack of need for a primary care provider, lack of time, dearth of available providers, concerns over confidentiality, and fear of stigmatization.4,6,9
Both the women in the BRFSS cohort and the female residents in our study were more likely than their male counterparts to have primary care providers and to have obtained routine medical and dental care within the last year. Female residents were also more likely to have received nonroutine health care than were male residents. They were, in general, of child-bearing age and may have sought more care related to reproductive health; however, this is an unlikely explanation for their greater frequency of dental care. Further studies to clarify the reasons for the observed gender differences would be helpful. We also found a positive correlation between residents' years of training and their likelihood of seeking nonroutine health care. We found no such correlation with the likelihood of seeking routine health care. Additional years of training at an institution plausibly allow residents more time to establish a relationship with a primary care provider, but our data suggest that this does not translate into increased utilization of routine and preventive health care services.
The cross-sectional design of our study and our results from a single institution may limit its generalizability, but, according to ACGME data, the age and gender of our cohort are similar to those of all residents training in the United States.10 We also expect the training environments of U.S. residency programs to be similar to ours because all must meet ACGME's accreditation standards. It is unclear, however, whether our results are applicable to non-U.S. training programs. An additional limitation of our study is that our survey did not include questions related to health status or barriers to accessing health care.
If, however, our results are generalizable, we seem to be training another generation of physicians who do not value their own health and wellness. To prevent the continued training of physicians who do not prioritize their own health care, both policy and cultural changes are needed. Institutional GME divisions and residency programs must develop policies and procedures to provide and promote residents' access to personal health care.
Several institutions are addressing barriers to resident health care and wellness through structured curricula focused at faculty and residents.11,12 OHSU's GME division has attempted to address the obstacles of time availability, provider access, and stigmatization by implementing a policy that requires programs to assign residents four half-days off per academic year for health care and wellness (physical and mental well-being). The number of wellness days was chosen after informed negotiations with stakeholders. These days are set at the beginning of the academic year so that the residents can make routine health and dental care appointments well in advance. The GME division has also helped coordinate a network of easily accessible primary care providers who are not teaching faculty. In addition, OHSU has three mental health providers—two psychologists and one psychiatrist—who are available to residents free of charge and who do not document care in the system's electronic medical record. We are in the process of evaluating the effectiveness of these programmatic efforts.
Changing the culture is a longer-term challenge. Promoting a culture that values health care and wellness will require strong institutional and individual leadership and effective role models. At OHSU, additional efforts to change the culture include confidential wellness counseling for faculty, as well as program-wide educational sessions to provide strategies for the maintenance of health and wellness. It is imperative that we continue to work toward identifying and eliminating barriers to resident self-care and improving the culture within academic health centers. In this time of turmoil in medical education and health care reform, it is more important than ever that these measures be taken with expedition.
The authors wish to thank the residents of OHSU for their participation, with special thanks to those who participated in developing questions on personal time.
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8. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System survey data. Atlanta, Ga: U.S. Department of Health and Human Services; 2008. http://www.cdc.gov/brfss/
. Accessed November 28, 2011.
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12. Eckleberry-Hunt J, Van Dyke A, Lick D, Tucciarone J. Changing the conversation from burnout to wellness: Physician well-being in residency training programs. J Grad Med Educ. 2009;1:225–230.
Oregon Health & Science University's institutional review board approved this study (approval number 00001711).
Demographic data were reported by the authors in a previously published article.7