Postgraduate medical training confers a set of significant professional and personal stressors on many trainees.1,2 Recognized stressors during these years of training include the effects of fatigue and sleep deprivation, heavy workloads, information overload, challenges encountered in the training environment, cultural and minority issues, and financial and interpersonal pressures.1,2 These pressures may be compounded by the need to adapt to new personal and professional expectations and to pursue ongoing career development.1,2 Collectively, such factors may impact postgraduate trainees’ health and well-being, including increasing their risk for developing new, or for experiencing worsening, mental health disorders.1,2
In recent years, attention to the issue of trainee (and physician) well-being has mounted considerably. This interest has been augmented by a spotlight on trainee mental health following the suicides of two postgraduate trainees in New York3,4—events reflecting the ongoing epidemic of physician suicide in the United States.4,5 Meanwhile, the scholarly literature has continued to document the prevalence and consequences of physician burnout, a condition for which trainees are at high risk.6
As with any other patient group, postgraduate trainees require ongoing primary, preventive, and occupational health care, particularly because their risk for certain conditions—including occupational exposures, trauma, burnout, and depression—may exceed that for many other patient populations. Yet, access to health care for many trainees is inconsistent and insecure,7,8 despite the availability of employer-sponsored health insurance and the fact that many trainees spend most of their time in health care institutions.
Taken together, these circumstances suggest that postgraduate trainees may benefit from the application of existing best practices in clinical care, including a focus on patient-centered care. Here, we offer our perspective—as postgraduate medical trainees—of the medical and mental health care needs facing this patient population, and we suggest a model for implementing systematic, trainee-centered improvements in health care delivery.
General Health Care Needs
Insufficient and informal access to care
The lack of timely, effective, consistent, and private health care among many postgraduate medical trainees is a concern. Recent estimates suggest that an average of at least 40% to 50% of trainees, ranging up to 80% to 90% in some instances, lack sufficient access to health care or receive at least some of their health care by informal means, such as informally consulting (“curbsiding”) with colleagues or self-prescribing.7,9–12 Another 37% to 49% of trainees have reported not having a primary care physician at all.8,10
The consistency of these findings across research reports, despite differences in study designs and study populations, indicates that trainees at many postgraduate programs likely share similar concerns. Thus, improving health care access among the postgraduate trainee population may be one step toward improving trainee health and wellness.
Several systematic factors may limit access to health care for trainees. Many trainees experience an abrupt discontinuation of their previous health care following their transition from the role of a medical student (in which they may have received care in an affiliated student health clinic or under a parent’s comprehensive insurance plan) to that of an employed, postgraduate trainee. Reestablishing care during training may be particularly challenging for new trainees because, frequently, they are unfamiliar with their new work environment, and their focus is directed to learning how to care for their own patients rather than where to seek care as patients themselves.
At the same time, some trainees report privacy concerns related to disclosing their personal health information within their current training institution or to other employees who could be their colleagues or supervisors.8,9 Further complicating postgraduate trainees’ access to care are profound constraints on their schedules. Trainees have little flexibility, scheduling consistency, or available time for personal health care during training.7,8,10 Such practical barriers to care must be considered—and effectively addressed—by any care model that aims to improve utilization of care among trainees.
Mental Health Care Needs
The topic of physician wellness has become inextricable from concerns about physician burnout, mental health, and suicide. Postgraduate medical trainees are known to be at high risk for burnout—a condition characterized by emotional exhaustion, depersonalization, and a diminished sense of personal efficacy or accomplishment.13 Although burnout rates vary by specialty, year of training, training environment, and other factors, most estimates indicate that an average of 40% to 60% of trainees experience significant occupational burnout6,14–19—and rates extend as high as 75% or more under some circumstances.6,17,18
Along with other forms of physician distress, burnout is thought to contribute to a number of adverse professional outcomes among physicians, trainees, and students, including reduced effectiveness, empathy, professionalism, and professional satisfaction.20–26 Burnout and other forms of distress are also associated with increased potential for medical errors, cynicism, and absenteeism.19,21,22,27
In almost any population health context, such a prevalent burden of need, paired with such serious potential manifestations and complications, would necessitate urgent, population-based intervention. We believe that any successful attempt to address the health care needs of trainees should appropriately acknowledge the high prevalence of burnout in this patient group. Additional evidence suggests that regular primary and preventive care may protect some practicing physicians from burnout and reduced quality of life.28
Depression and suicide
Many postgraduate medical trainees experience mental health conditions other than burnout, including depressive disorders. Some estimates indicate that as many as 22% to 50% of residents may suffer from depression,14,19,29–31 including major depressive disorder. Although some evidence indicates that some matriculating medical students may actually have a lower prevalence of depression than that of their age-similar college graduate peers,32 the rate of depression among interns may rise from as low as 4% to 25% during the first year of clinical training.30 Although the onset of depressive disorders among postgraduate trainees may involve a number of incident causes, we believe that the persistent occupational stressors of medical training and the high prevalence of burnout likely play a role in the prevalence and prognosis of mental health conditions within this population.
A related concern is the epidemic of physician suicide, manifested by significantly elevated rate ratios for suicide among both male (rate ratio = 1.41; 95% confidence interval [CI]: 1.21–1.65) and female (rate ratio = 2.27; 95% CI 1.90–2.73) physicians compared with the general population and resulting in an estimated 300 to 400 physician suicides per year in the United States.4,5 In particular, women physicians appear to have a higher suicide risk than women in the general population, with twofold to fourfold higher odds of suicide completion despite an estimated rate of suicide attempts (1.5%) that is at or below the population average.5,33
Estimated rates of suicidal ideation among medical faculty, trainees, and students generally range from 6% to 8%,34,35 although as many as one-third report having some history of suicidal ideation, and about 13% report having had thoughts about suicide as well as thoughts about specific methods by which to commit suicide within the preceding year.36
Not surprisingly, suicidality has also been linked to burnout,34 reflecting an intuitive—if incompletely understood—relationship between the dual epidemics of physician burnout and physician suicide. We believe that improved access to health care, including mental health care, may have an overlapping, positive impact on both epidemics.
Suicide patterns among physicians and trainees may be related, in part, to receiving suboptimal treatment or having suboptimal access to mental health care. For instance, some evidence suggests that providers experiencing suicidal thoughts may be less likely to seek mental health care because of concerns about their medical licensure.34 (The same providers are, however, more likely to self-prescribe antidepressants.34) Another study of physicians (including medical residents) and nonphysicians whose deaths resulted from suicide showed that known mental illness preceding death was marginally more likely among physicians (adjusted odds ratio [OR] = 1.34; 95% CI: 1.01–1.81).37 Interestingly, the authors of this study reported that postmortem toxicology screens demonstrated that antipsychotics (adjusted OR = 28.7; 95% CI: 7.94–103.9), benzodiazepines (adjusted OR = 21.0; 95% CI: 11.4–38.6), and barbiturates (adjusted OR = 39.5; 95% CI: 15.8–99.0), but not antidepressant agents (adjusted OR = 1.31; 95% CI: 0.82–2.10), were more likely to be present in physicians than in nonphysicians. (Given the nature of data collection for this study, determining whether informal care practices [e.g., self-prescription or curbsiding] played a role is not possible.)
Help for physicians and physicians-in-training who are experiencing poor mental health is possible. Evidence has shown that access to mental health care for physicians and trainees at high risk for depression or suicide may be improved by educational efforts and screening programs sponsored by institutions or departments and tailored to the specific concerns of this patient group.31,35
Certainly, the standards of medical and mental health care, particularly those regarding quality, safety, and privacy, should apply to all patients, including postgraduate medical trainees. Yet, as the literature consistently indicates, the health care needs of trainees frequently remain unmet altogether or are only partially met.
We believe that to effectively promote “clinical learning environments characterized by excellence in clinical care, safety, and professionalism”—a vision articulated by the Accreditation Council for Graduate Medical Education38—postgraduate training programs should strive to ensure that such excellence applies to trainees as both providers and recipients of care. We believe that one potential model for achieving this standard and addressing the unique health care needs of trainees is an adaptation of the patient-centered medical home (PCMH) model.
The PCMH Model
Effective health care for postgraduate trainees must center on trainees as patients, rather than as learners or employees of a program or institution. It must also address the specific needs of this unique patient group, including their schedule constraints, their specific occupational risks, and their employment- and training-related concerns about security and confidentiality. The PCMH—a model for organizing health care around the needs and values of patients and coordinating care through the patient’s primary care clinic (or “medical home”)39—provides a means of achieving both of these goals.
Table 1 lists the functions of the PCMH model, as defined by the Agency for Healthcare Research and Quality,39 and describes potential applications of these standards to the trainee patient population.
Currently, health care delivery practices vary across postgraduate training programs and institutions; some offer structured resources and opportunities to promote wellness resources. Examples of programs, centers, and initiatives have been previously described,2,31,40–44 yet a review of the available literature suggests that no program has formally reported applying the PCMH model to trainee health care.
One recent report described a model integrating medical and mental health care, plus other wellness resources, for U.S. Air Force drone pilots and analysts in response to concerns about their access to care as well as the prevalence of burnout among this group.45 Notably, their burnout rates were estimated to be lower (around 30%)46 on average than those typically identified among postgraduate medical trainees. We believe that trainees may benefit from a similarly coordinated approach. Below, we outline several practical elements to consider when designing or implementing a PCMH for postgraduate trainees. These elements may be addressed in a medical home dedicated specifically to postgraduate trainees or within an existing clinic system devoted to a larger patient population (e.g., students, employees, or the general population).
Key Practical Elements of a PCMH That Serves Trainees
Care coordination and referral support
As we described above, many trainees may be uncertain about where to seek care. This uncertainty may lead to inadequate or informal care practices, such as deferral of primary health care during the years of training or curbsiding.
Similarly, as we mentioned earlier, clinical training imposes significant scheduling constraints on trainees. Training schedules offer limited flexibility for arranging medical appointments during standard clinical hours. Moreover, trainees cannot often predict or control their schedules in a way that is conducive to setting (and keeping) health-related appointments. This barrier is especially problematic for planning clinical appointments that must be reserved well in advance.
A hallmark of the patient-centered model is the involvement of a care coordinator, such as a nurse trained in patient-centered care coordination. For trainees, this coordinator could serve as a consistent, central navigator who will keep the trainee’s health concerns confidential. This coordinator would be familiar with the needs of trainees as a patient population and would maintain a network of wellness resources specific to this group. These resources might include a list of clinical providers who are willing to offer flexible scheduling or to practice telemedicine. The coordinator should be readily available by phone, e-mail, or other secure electronic means of communicating. A care coordinator working with trainees may also handle any of the following specific tasks:
- Scheduling appointments at the patient’s medical home,
- Procuring referrals to other health and wellness resources, as indicated,
- Assisting with the scheduling of appointments at subspecialty clinics or for other health services,
- Providing referrals to off-site clinics for trainees who prefer to receive their medical and/or mental health care at another clinic, and
- Aiding trainees with changes in their work schedule or patient care duties if they are acutely ill, need urgent medical or mental health assistance, or require regular appointments for a medical or mental health need.
Importantly, for training programs where implementing a dedicated PCMH is not feasible, identifying a care coordinator devoted to trainee health care may still be a useful stand-alone intervention. Ideally, this coordinator should not hold any dual role in the oversight of trainees as employees or learners (such as in program administration).
Confidential care without perceived conflicts of interest
Medical staff providing first-line care to trainees should include faculty-level physicians as well as other providers, such as physician assistants or nurse practitioners, according to clinical staffing needs. To preserve privacy, institutions should restrict the rotation of postgraduate trainees or medical students through the trainee-focused clinic. To provide the best possible patient-centered care and to preserve the quality and safety of care, providers should be well versed in the potential implications of medical and mental health conditions on professional performance as well as the related legal and policy frameworks pertaining to licensure and certification.
The clinical environment should serve as an accessible, safe, and confidential site where trainees are not simply viewed as employees, providers, or learners, but where they are affirmed as patients and active participants in their own care. Ideally, medical staff employed in the PCMH should not serve in supervisory roles in any postgraduate training program on campus in order to preserve the privacy, security, and integrity of the patient–provider relationship and to avoid any actual or perceived conflicts of interest among patients or providers.
Integrated medical and mental health care
Co-location of medical and mental health services may reduce barriers to care by providing more convenient access to care at a single site, by integrating and coordinating care between providers at that site, and by normalizing the delivery of care across the spectrum of health care needs at a single clinic.47 For those affected by mental health conditions, the co-location model may promote privacy and confidentiality because such a setting may reduce the perceived disclosure of a mental health diagnosis upon presenting for care at the clinic. Ideally, the mental health services offered would include urgent consultations, treatment of chronic mental health conditions, and psychotherapy. The mental health service could also provide referrals to community practitioners for trainees who wish to pursue their care with outside providers.
Additional patient-centered considerations
To accommodate the unique needs of the trainee patient population, specific scheduling accommodations should be available through the PCMH. These may include extended after-hours assistance, shorter-term scheduling options, and telemedicine and telemental health care.48 Similarly, if financially feasible, co-pay waivers or co-pay assistance would help to defray the cost of care for the many postgraduate trainees who face significant financial constraints; these and other related financial considerations may reduce the financial barriers to care. Importantly, some trainees may prefer to receive some or all of their care at clinics outside the PCMH. Those who wish to decline the use of the medical home for some or all of their care should still have access to referrals to alternative clinics through the care coordinator.
Population-centered considerations: The medical neighborhood
Previous adaptations of the PCMH have recognized the related concept of the medical neighborhood,49 which might include subspecialty clinics and other health care resources to which patients are referred. For postgraduate medical trainees, the medical neighborhood might be extended to include institutional and programmatic influences on health and wellness. The medical home could serve as an institutional sponsor of interventions intended to enhance training environment safety, promote wellness, and foster a supportive work environment and culture. For example, the medical home could provide mental health resources to trainees and their program leaders, or it could organize wellness initiatives aimed at the prevention of burnout. In keeping with the principles of patient-centered care, trainee representatives should be closely involved in the functioning and decision making of the medical home and medical neighborhood.
Although attention to the health and wellness of postgraduate medical trainees has increased in recent years, the medical literature consistently indicates that the care afforded to this population often falls short of the current standards. Combined with the prevalence of burnout among trainees, inadequate health care for this patient group may result in negative outcomes for their health, safety, and performance.
An adaptation of the principles of the PCMH model may serve as an effective solution to more comprehensively address the unmet and partially met health care needs of postgraduate trainees. This model would focus on the unique needs of trainees as patients while also providing a coordinating center for campus- or institution-wide health and wellness efforts. The medical home approach may ultimately have applications to other trainee groups, other physician groups, or even those in other fields who have a high risk for burnout. In sum, this proposed model upholds the idea that one important step toward improving health and wellness is to apply the relevant, evidence-based, and patient-centered principles of the field to the care of those who train within it.
Acknowledgments: This trainee-specific patient-centered medical home model was developed as part of the University of Texas Southwestern Housestaff Health and Wellness Initiative. The authors would like to thank Dr. Adam Brenner for his thoughtful review of an earlier version of this article.
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