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Innovation Reports

Removing Barriers: A Confidential Opt-Out Mental Health Pilot Program for Internal Medicine Interns

Major, Ajay MD, MBA; Williams, John G. MD; McGuire, W. Cameron MD; Floyd, Eleanor MD; Chacko, Karen MD

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doi: 10.1097/ACM.0000000000003965
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In recent years, a substantial body of literature has been published in the realm of physician mental health. Much of this research has focused on identifying the prevalence of burnout and depression among resident physicians, and the resulting data suggest that the mental health of physicians at all levels of training is worse than that of the general population. 1–3 Although addressing resident mental health is intrinsically worthwhile, it is important to note that resident mental health also directly affects patient care, with research demonstrating that residents with poor mental health report more frequent medical errors than their colleagues. 4

There is no single universal intervention to improve the mental health of all resident physicians. As suggested by the Accreditation Council for Graduate Medical Education (ACGME) Council of Review Committee Residents, a multimodal approach is likely necessary to improve resident mental health. 5 One of the interventions suggested by the ACGME is improved availability of confidential mental health resources. 5 Developing mental health programs for residents can be challenging, as previous research has revealed that lack of time, concerns about confidentiality, concerns about stigma, and cost are significant barriers to residents seeking mental health care. 6–8 However, these studies also found that the majority of residents felt they would benefit from mental health services 7 and would be very likely to seek out services if they were available. 6

As part of a multimodal approach to improving the mental health of our residents, we sought to improve access to mental health resources by addressing these barriers through the development of a confidential opt-out mental health pilot program for our internal medicine and internal medicine-pediatrics interns and to assess the feasibility, acceptability, and resident satisfaction with the program.


We enrolled all internal medicine and internal medicine-pediatrics interns in the 2017–2018 residency class at the University of Colorado into our opt-out mental health program. We obtained permission from residency leadership to provide each intern with an additional half-day off from clinic during their continuity clinic week. We then scheduled mental health screening appointments at the campus health center with an in-network mental health provider during that half-day off. The cost of the appointment to the residency program was negotiated ahead of time and was set as a $20 co-pay for an attended appointment and a $40 fee for a no-show. Funding for the program was provided by a portion of the residency budget. Deidentified invoices were sent to the residency program periodically for collection.

Interns were subsequently informed of the logistics of the program. This included the scheduled appointment, the additional half-day off, and 3 ways to opt out of the appointment. They could cancel the appointment up to 48 hours in advance by calling the campus health center, emailing the mental health clinic coordinator, or contacting the chief resident. Opt-outs and no-shows were tracked by the mental health clinic and reported back to the study coordinators through deidentified invoices. Interns were also informed that any fees, whether a co-pay or a no-show fee, would be covered by the program. If they did not intend to attend the appointment, interns were strongly encouraged to cancel in advance. Interns who canceled the appointment were still provided with the additional half-day off as a way of blinding the residency program to individual participation and to avoid providing an undue incentive for the intern to attend the appointment. All interns were encouraged to use the additional time however they saw fit.

The mental health appointments were scheduled over a 3-month period from January to March 2018. Individual appointments were scheduled during nonoverlapping time slots to ensure that intern participation remained anonymous and that the mental health providers would have adequate time to continue seeing patients who were not part of the opt-out program. Records of what was discussed at attended appointments were kept confidential.

After all of the appointments were complete, an anonymous online follow-up survey was distributed to the entire intern class in April 2018 using Google Forms (Google, Mountain View, California). The survey included questions about whether interns attended the appointment and how they used the additional time off (respondents could select more than 1 reply for this question), free-text questions about the program, and Likert-style questions about how the program affected their wellness and if the program should continue in future years. Interviews were conducted with the participating mental health providers to discuss themes from the appointments. Fisher exact test with Freeman-Halton extension was used for statistical analysis (VassarStats, Vassar College, Poughkeepsie, New York).

The Colorado Multiple Institutional Review Board determined this project to be exempt from review.


All 80 internal medicine and internal medicine-pediatrics interns in the 2017–2018 University of Colorado residency class participated in the program. Of the 80 interns, 23 (29%) attended the scheduled mental health appointment (including 1 intern who elected to attend an appointment with their own previously established mental health provider), 12 (15%) were no-shows to their appointment, and 45 (56%) opted out in advance (Table 1). The cost of the program was $940 (Table 1) or $11.75 per intern.

Table 1:
Participation Categories and Cost by Category in a Confidential Opt-Out Mental Health Pilot Program for Internal Medicine and Internal Medicine-Pediatrics Interns, University of Colorado, 2017–2018

Forty-one (51%) interns responded to our anonymous postappointment follow-up survey. Of the 41 responding interns, 16 (39%) had attended the appointment, 23 (56%) had not attended the appointment, 1 (2%) had attended an appointment with their own previously established mental health provider, and 1 (2%) tried to attend but had the appointment canceled by the clinic.

Of the 41 respondents, 35 (85%) answered “yes” that the opt-out program should continue next year, while the remaining 6 (15%) interns answered “not sure.” Significantly more interns who did not attend the appointment answered “not sure” to this question (P = .03). Of the respondents, 30 (73%) interns felt the program should be continued during the January to March quarter in future years. The majority of responding interns felt the program positively affected their wellness regardless of whether they attended the appointment, with 14 (34%) stating they felt it very positively affected their wellness, 10 (24%) somewhat positively, 16 (39%) neutrally, 1 (2%) somewhat negatively, and none very negatively. There was no significant difference between attendees and nonattendees in terms of responding positively, neutrally, or negatively to the question, “How did this program impact your wellness?” (P = .20).

Appointment attendees

Of the 16 interns who both attended the appointment and completed the survey and who did not have their own mental health provider, 4 (25%) reported receiving additional mental health referrals or follow-up appointments after the mental health screening appointment. The majority of the 17 total attendees, including the 1 intern with their own mental health provider, felt that the appointment positively impacted their well-being, with 5 (29%) stating they felt it very positively impacted their well-being, 6 (35%) somewhat positively, 6 (35%) neutrally, and none somewhat negatively or very negatively. After going to the appointment, attendees used the remainder of their half-day off for time to themselves (12), sleep (8), errands (7), household chores (7), time with family or friends (4), movies (4), reading (4), television (4), exercise (4), clinical work (2), or another health care appointment (1).

Appointment nonattendees

The 23 interns who did not attend their appointments and completed the survey were asked retrospectively if they wished they had attended the appointment. Four (17%) interns either agreed or strongly agreed, 9 (39%) were neutral, and 10 (43%) disagreed or strongly disagreed.

The majority of nonattendees used their half-day off similarly to the attendees, reporting time to themselves (7), sleep (7), exercise (5), errands (4), household chores (4), time with family or friends (4), clinical work (4), movies (1), reading (1), television (1), or another health care appointment (1). In response to the free-text question “What were the reasons that you didn’t go to the appointment?,” nonattendees primarily responded that they felt obligated to use the time in another way (10) or that they were simply not interested (6). Four reported difficulties with scheduling appointments for various reasons.

Free responses and interviews

In the free-response feedback section of the survey, 2 interns who attended stated the appointment was worthwhile:

Thank you so much for setting this up; I personally had wanted to speak to somebody for a while but felt some sort of barrier, but having it set up for me opened up that wall for me, which has been very helpful. I hope this continues next year.

Three interns who opted out stated the program was important for the residency:

It may be a nice option for those who need it, particularly those who are isolated and need a better support system … there is also something to be said for having programs [like this] available, the mere existence of which show the [residency] program cares about its residents. That notion in and of itself is therapeutic, truly.

Several interns commented that there were scheduling difficulties, particularly for those who were off-site and had to travel to the main campus for their appointments: “Do not make appointments on post-call days. I came home at 7 a.m. and my appt was at 11 a.m., which was difficult.”

Interviews with participating mental health providers revealed that themes of isolation and harassment were the most notable among the attendees.

Next Steps

Mental health is an increasingly important issue among resident physicians, with a pressing need in graduate medical education to identify and address contributors to burnout and worsening mental health in trainees. The purpose of this article was to report on the development of a confidential opt-out mental health pilot program for our interns that mitigated time, confidentiality, and cost as barriers to accessing mental health care and to assess the feasibility, acceptability, and resident satisfaction with the program.

Of the 80 internal medicine and internal medicine-pediatrics interns who participated in the pilot program, 29% attended the mental health screening appointment and at least 4 interns received follow-up mental health referrals or appointments. Although we recognize that a 56% cancellation rate is high, we expected the acceptability and utilization of the program to be at its lowest during the pilot phase. However, our finding that removing previously identified barriers to mental health care for residents resulted in almost one-third of the interns attending a mental health screening appointment emphasizes the value of such a program.

The program was feasible, as it was relatively low cost at $11.75 per intern and was simple to implement as it required only 1 additional half-day off during the continuity clinic week. We believe that the successful implementation of our pilot in a large residency program and demonstration of a low per-intern cost are strengths of our program. The program has been continued for each subsequent intern class such that all current residents have participated in the opt-out program, demonstrating full scalability and sustainability. Other residency programs at our institution have also implemented parallel programs for their trainees with similar ease and feasibility.

With respect to resident satisfaction with the program, our postappointment follow-up survey revealed that interns felt the mental health program positively affected their wellness regardless of whether they attended the appointment. For the attendees, this benefit was at least partially due to the appointment itself. However, it is interesting that nonattendees also felt the program was beneficial to their well-being. We presume that a half-day off from clinic to allow interns to participate in their own wellness activities played an important role in this finding.

Interviews with the mental health providers who conducted the appointments revealed themes of isolation and harassment that were helpful at a residency program level to identify target areas for future interventions.

The limitations of our pilot program include a low response rate to the postappointment follow-up survey, lack of longitudinal data, and the absence of a formal tracking process to anonymously confirm the rate of referral for ongoing care. To address these limitations, we have modified our program in subsequent years. We have improved our survey response rate with more frequent reminders, and we have designated a wellness chief medical resident who checks in with the mental health clinic on a quarterly basis to obtain deidentified data on the number of residents who are receiving ongoing care. Finally, we have expanded our program to include opt-out primary care appointments for all interns, thereby providing another layer of support to our residents.

A similar opt-out program was executed at West Virginia University by Sofka and colleagues in 2018, which demonstrated logistical feasibility and possibly increased utilization of mental health services. 9 Our opt-out program adds to this literature because we have a larger program, demonstrate lower costs, provide data about participation in a more real-world scenario (as our residents were given the choice to opt out and still receive the additional time off), and provide rates of those who went on to receive additional mental health services. This last observation is critical, as it is possible that those interns in need of additional mental health services may not have received counseling without this program. Given the increasing rates of burnout and suicide among resident physicians, even initiatives that demonstrate small increases in providing necessary mental health services to trainees are noteworthy, and further study of interventions that remove barriers to accessing mental health care for residents is urgently needed.

In conclusion, our confidential opt-out mental health pilot program demonstrated feasibility and satisfaction in a large internal medicine residency program. The program has continued sustainably and has served as a model for other residency programs at our institution, which have adopted parallel programs for their trainees. The program design intentionally removed many of the traditional barriers to mental health care that adversely affect the general population but are especially pronounced among trainees. Finally, survey comments suggested that the mere presence of our mental health program positively influenced the well-being of residents by demonstrating that the residency program was “walking the walk” and not simply “talking the talk” with regard to wellness.


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