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Promoting Resident Wellness

Evaluation of a Time-Off Policy to Increase Residents’ Utilization of Health Care Services

Cedfeldt, Andrea S., MD; Bower, Elizabeth, MD, MPH; Flores, Christine, MPH; Brunett, Patrick, MD; Choi, Dongseok, PhD; Girard, Donald E., MD

doi: 10.1097/ACM.0000000000000541
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Purpose To evaluate awareness and utilization of a new institutional policy to grant residents time off to access personal and family health care.

Method In 2012, two years after policy implementation, an electronic survey was sent to all 546 residents and fellows at a tertiary care academic medical center in the United States. Residents were asked questions regarding awareness of the time-off policy, use of the policy, health care status, reasons for policy use, and barriers to use.

Results A total of 490 (90%) residents responded. Eighty-nine percent of those surveyed were aware of the policy. Of those who were aware, 49.7% used the policy to access health care. Top reasons for policy use were for personal routine or preventive health care, dental care, and urgent health care needs. The most commonly reported barrier to policy use was concern about the impact the resident’s absence would have on colleagues.

Conclusions Implementation of policies to prospectively schedule residents’ time off during business hours to address health care needs is an important means to promote resident wellness. Such policies remove one commonly cited barrier to residents’ access to health care. However, residents still reported concerns about impact on peers and patients as the main reason they were reluctant to take the time off to address their health care needs. More work is needed on both wellness policy implementation practices and on refining the systems that will allow seamless and guiltless transitions of care.

A.S. Cedfeldt is education consultant, Division of Graduate Medical Education, and associate professor, Department of Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon.

E. Bower is associate professor, Department of Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon.

C. Flores is associate director, Division of Graduate Medical Education, School of Medicine, Oregon Health & Science University, Portland, Oregon.

P. Brunett is associate dean, Division of Graduate Medical Education, and associate professor, Department of Emergency Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon.

D. Choi is professor, Department of Public Health and Preventive Medicine, Department of Ophthalmology, School of Medicine, and Department of Community Dentistry, School of Dentistry, Oregon Health & Science University, Portland, Oregon.

D.E. Girard is senior consultant, 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.

The authors have informed the journal that they agree that both D. Choi and D.E. Girard completed the intellectual and other work typical of the senior author.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: This study received institutional review board (IRB) approval through the OHSU IRB.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A242.

Correspondence should be addressed to Andrea S. Cedfeldt, 3181 SW Sam Jackson Park Rd., Portland, OR 97239; mail code L579; telephone: (503) 494-8652; e-mail: cedfeldt@ohsu.edu.

Most of the literature pertaining to resident wellness focuses on burnout identification and prevention and the identification and management of depression.1,2 What have been less well studied are the evaluation and success rates of institutional interventions to promote resident wellness and access to health care.3,4 Our institution introduced its Resident Wellness Time-Off Policy after data from an internal survey of residents and from focus groups identified that the inability to take time off during business hours was the major barrier preventing residents’ access to personal health care, which corroborated findings of an earlier study at another institution.5 In our institution’s survey, whose findings were not published, 90% of residents cited the inability to get off of work during business hours as the major barrier to seeking care.

Recently published work from our institution6 demonstrates that residents who are aware of a time-off policy are more likely to find time to address personal needs. In addition, residents who are aware of time-off policies report more positive experiences and emotions, fewer negative experiences and emotions, higher levels of career satisfaction, relatively less perceived stress, fewer work hours, and more sleep time, compared with residents who are not aware. Further, a second recently published study from our institution7 found that residents are significantly less likely than their demographically similar peers to have primary care providers or to seek routine health care, including dental care. Taken together, these findings suggest that efforts aimed at formalizing and communicating policies that support residents’ ability to take time off to attend to health care appointments may be one mechanism to improve residents’ access to health care and wellness. In July 2010, the Oregon Health & Science University (OHSU) Division of Graduate Medical Education implemented the Resident Wellness Time-Off Policy mentioned earlier, including a protocol requiring training programs to assign residents four half-days off per academic year for health care and wellness (physical and mental well-being). In this report, we review the outcomes of that effort. (For policy details, see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A242.)

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Method

In 2012, we developed a 16-item survey to assess residents’ awareness and utilization of the Resident Wellness Time-Off Policy, which had been implemented two years earlier. The survey was reviewed and revised by a group of experienced educators in residency and graduate medical education leadership positions at our institution. The survey instrument was distributed electronically to all 546 OHSU residents and fellows when each of them attended one of the eight annual sessions to renew his or her employment contract for the next academic year. These sessions occurred between April 1 and June 30, 2012. Because these were contract renewal sessions, trainees who were in programs of one year’s duration were not included in the sample. To also assess program leadership’s perception and implementation of the policy, we developed a 12-item survey for residency and fellowship program directors, which was reviewed by the same educational leadership group. The survey was distributed electronically to 83 program directors during August and September 2012. The study received institutional review board approval through the OHSU IRB.

Descriptive statistics and cross-tabulation were produced for the survey data. Chi-square tests were employed to test a difference of a question item by a factor (e.g., awareness of the time-out policy by gender). For multivariate analyses, logistic regression was used to assess differences in questions between subgroups and demographic factors. A P value less than .05 was considered statistically significant. All computations were done in SPSS version 19 (IBM/SPSS, Chicago, Illinois) or R Project for Statistical Computing programs version 3.0.2 (Foundation for Statistical Computing, Vienna, Austria).

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Results

Survey of residents

Four hundred ninety returning trainees (90%) completed the survey. Table 1 presents the number of men and women respondents, by residency year. Four hundred thirty-six (89%) of the surveyed residents were aware of the wellness time-off policy, and 216 (50%) of that group reported using it. The majority (379; 78%) reported their health as excellent or very good (see Table 2). There was no significant correlation between perceived health status and awareness or use of the policy for those self-reporting their health status as excellent/very good versus those reporting their health status as good/fair. Although first- and second-year residents were more aware of the policy than those in more advanced training years (P < .01), the percentages of respondents who used it were not significantly different across years of training. Three hundred sixty-nine (75%) of the responding residents reported plans to use the policy the following academic year.

Table 1

Table 1

Table 2

Table 2

Reasons for taking time off, barriers to using the policy, and reasons for not using the policy were assessed by check-all-that-apply questions. Of the 216 respondents (50%) who used the policy at least once, the most commonly reported reasons were preventive or routine health care (158; 73%), dental care (119; 55%), and urgent health care needs (57; 26%); see Table 3. Barriers to use included the perceived negative impact the resident’s absence would have on resident colleagues (68; 31%) and patient care (33; 15%); see Table 4. A similar proportion of the residents who were aware of the policy but did not use it (219; 50%) reported concerns about the negative impact of their absence on patient care (40; 18%), but a significantly larger percentage of these residents expressed concerns about the adverse effects of their absence on their peers (93; 42%; P < .02). Ninety-five residents (43%) in the group that did not use the policy reported that they did not need to use it.

Table 3

Table 3

Table 4

Table 4

The majority of residents who used the Resident Wellness Time-Off Policy for any reason reported that it was very easy (86; 39%) or easy (54; 25%) to use. Female respondents reported significantly higher awareness—232 (93%) versus 204 (86%; P = .014)—and utilization—129 (56%) versus 87 (43%; P < .01)—than did their male counterparts (see Table 2). Among those who used the policy, there were no significant differences in reported ease of use by gender. Only 19 (15%) female residents reported using time off for counseling services; even fewer male residents (2; 2%) did so (P = .01). Among those who did not use the policy, 61 (52%) men reported not needing the policy as compared with 34 (33%) women (P < .01). Use of the policy to obtain time for family health care needs did not differ by gender.

Among residents in the large programs (defined as 20 or more returning trainees), there were significant differences in awareness (P < .01) and utilization (P < .01) of the policy (see Table 5). Three resident groups are of special note. Respondents from orthopedic surgery and general surgery had lower levels of both awareness and utilization and lower reports of plans to use the policy. Whereas 369 (75%) respondents reported planning to use the policy the next training year, less than half of the orthopedic surgery residents (8; 42%) and general surgery residents (22; 44%) reported plans for future use (see Table 5). In contrast, those in emergency medicine reported a very high level of awareness of the policy, but a very low level of utilization and an even lower level of use planned in the future (see Table 5).

Table 5

Table 5

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Survey of program directors

Sixty-three directors (76%) responded from the 83 postgraduate training programs surveyed. Fifty-one (81%) were aware of the Resident Wellness Time-Off Policy, and of those who were aware, 48 (94%) communicated the policy to their trainees, most commonly during orientation. More than a third (18; 37%) tracked which residents used the policy. Of those, the majority (83%) reported collecting residents’ names and number of days used, whereas only a small number (2; 11%) tracked the reason for use. Nearly half (24 out of 51) of all program directors scheduled the time off only when contacted by the house officer, and a minority (19; 37%) reported having no set protocol for scheduling the days off.

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Discussion

The primary goal of the Resident Wellness Time-Off Policy was to provide a mechanism for residents to take time off to attend to personal and family health care needs. Twenty-four months after the policy was implemented, the vast majority of residents were aware of the policy’s existence, and slightly less than half of the residents who knew about the policy had used it.

Although awareness of the policy was very high (436; 89%), and nearly one-half of those aware used the policy, it is difficult to know what the optimum usage should be. Ninety-five (43%) residents who were aware of, but did not use, the policy reported that they did not need to use it. Among the users, 158 (73%) reported using the policy to seek preventive health care. Further study will be needed to determine whether increased use of the policy would further increase the number of residents obtaining preventive health care. It is encouraging that 73% of our cohort used the policy for preventive health care while only 63% of a demographically similar subgroup of the 2011 Behavioral Risk Factor Surveillance System had a routine checkup within the past year.8

In terms of ease of use and barriers to use, the majority of residents found the policy easy to use, and the majority of program directors were both aware of the policy and communicated it to their trainees. Only a very small number of residents reported their program’s being unsupportive of the policy as a barrier to its use. Another potential barrier to use could have been concerns over a loss of privacy through program administrative tracking; however, many programs did not track use of the policy at all, and the majority of those that did tracked only names and number of days used. Only a small number of programs acted inappropriately by tracking the reason for using the policy. This was strongly discouraged so that residents could confidentially use these half days for counseling services. Although the intent of the policy was to have program directors assign four half days to all residents in advance, similar to the prospective assignment of vacation time, 47% of program directors scheduled time off only when a request was made by the resident. It is unclear how much the mechanics of this process interfered with use. Given that all residents take their assigned vacation time without concern about the effects on peers, perhaps aligning this policy with the philosophy and scheduling approach to vacation use and insisting that this approach be adhered to would increase use.

One of the most important barriers to and concerns about use was residents’ apprehension about the impact of their absence on their peers and, to a lesser degree, on patient care. These are similar to barriers preventing resident health care access previously reported in the literature.7,9,10

The persistence of this barrier suggests that despite the existence of a policy, both real and perceived workload and time pressures remain problematic, as well as cultural obstacles that impede residents from delegating “their” work to colleagues. This raises the concern that systems that allow residents to easily transfer patient care to coworkers are not in place. In this era of streamlined health care and the push to constantly improve efficiency, it is difficult to design systems that have enough redundancy to allow sufficient personnel to cover for a resident who is absent from the team. Prospectively scheduling these half days at the beginning of the academic year was designed as a way to avoid this impact on scheduling. Some programs prohibited taking these half days off during specific rotations, where the impact on the rest of the team would be higher.

Women were more aware of the policy and used it more frequently. This finding parallels data documenting that women obtain routine and preventive health care more frequently than men do.11 Although only a minority of residents used their time off for counseling, women were more likely than their male counterpoints to do so. These results align with data reported by our institution’s Resident Wellness Program (RWP),12 showing that women were more likely than men to seek counseling services from the RWP and were more likely to report perceived difficulties in taking the time for these appointments.

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Limitations

There are limitations to our study. Results are from a single institution in the United States, although they may be generalizable to other U.S. academic institutions with similar programs.13 Also, our survey instrument had not been externally validated, nor was it designed to investigate why residents responded as they did. In accordance with the policy, we did not verify that residents used their time off for health care access, nor did we ask residents to report specifics of how they used that time. We did observe some differences in use by program; however, the numbers are too small to draw reliable conclusions. The policy does not address the issue of availability of primary health care providers, which is another potential barrier to preventive health care. Although our data indicate a high level of awareness of the policy, interpretation of the use data is more complex and somewhat inconclusive. We hope that continued follow-up will confirm that the policy is effective in increasing the frequency with which residents see their health care providers so that they see those providers as often as their demographically similar peers do.

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Conclusions

We are encouraged by the high level of awareness of the Resident Wellness Time-Off Policy and the effective communication policies of the program directors. The intent of the policy was to remove the time-off and scheduling barriers that can prevent residents from accessing health care; however, other barriers remain and prevent higher use. The perceived impact a resident’s absence has on his or her peers is the biggest reported barrier limiting this policy’s use, and further efforts are needed to mitigate this phenomenon. It is a slow process to change cultural and administrative norms; nonetheless, our policy targeting time off for personal health care is an initial step in normalizing appropriate self-care. Although these early results of policy awareness are encouraging, longer-term follow-up is needed. Given the large percentage of residents reporting plans to use the policy in the next academic year (over 75%), we are optimistic that this policy will achieve its ultimate aim of improving their health.

Acknowledgments: The authors would like to acknowledge the residents, fellows, and program directors of Oregon Health & Science University (OHSU) for their participation in this research and the OHSU Graduate Medical Education Office for help in administering the survey instrument.

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References

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8. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Survey Data. 2008 Atlanta, Ga U.S. Department of Health and Human Services, Centers for Disease Control and Prevention
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