Article Text

Emergency medicine resident perspectives on well-being during COVID-19: a qualitative study
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  1. Anish Agarwal1,2,
  2. Hareena Sangha2,
  3. Amanda Deutsch2,
  4. Anthony Spadaro2,
  5. Rachel Gonzales1,2,
  6. Jacob Goldenring2,
  7. Mira Mamtani2,
  8. Lauren W Conlon2,
  9. Kevin Scott2
  1. 1Center for Digital Health, Penn Medicine, Philadelphia, Pennsylvania, USA
  2. 2Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Anish Agarwal, Emergency Medicine, University of Pennsylvania, Philadelphia 19104, Pennsylvania, USA; anish.agarwal{at}pennmedicine.upenn.edu

Abstract

Background Emergency medicine (EM) clinician well-being has been negatively impacted throughout the COVID-19 pandemic. Resident physicians are particularly vulnerable yet less is known about their perspectives.

Methods The objective of this study was to use qualitative methods to understand EM residents’ perspectives on well-being during COVID-19. EM residents at an urban, academic institution in the USA were recruited via email and participated in virtual, semi-structured interviews between November 2020 and February 2021. Interviews were conducted by a trained qualitative researcher, recorded, transcribed and de-identified by a third party vendor. All transcripts were double coded by two trained study team members using thematic analysis to identify the themes and interviews were stopped when no new themes emerged.

Results Seventeen semi-structured interviews were conducted until thematic saturation was reached with residents in their first 4 years of training: 6 postgraduate year (PGY)-1 (35%), 6 PGY-2 (35%), 2 PGY-3 (12%) and 3 PGY-4 (18%). Five themes were identified: (1) isolation from peers in training contrasting with a collective call to action, (2) desire for increased acknowledgement and structured leadership support, (3) concerns about personal needs and safety within the clinical environment, (4) fear of missed educational opportunities and lack of professional development and (5) need for enhanced mental and physical health resources.

Conclusions This qualitative study elucidated factors inside and outside of the clinical environment which impacted EM resident well-being. The findings suggest that programme and health system leadership can focus on supporting peer-to-peer and faculty connections, structured guidance and mentorship on resident career development and develop programmes which bolster resident on-shift support and acknowledgement. These lessons can be used by training programmes to better support residents, but the generalisability is limited due to the single-centre design and participation.

  • COVID-19
  • education
  • teaching
  • teaching

Data availability statement

Data are available on reasonable request.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Quantitative survey-based studies have highlighted the rising rates of burnout and pyschological distress in medicine, and the effects of COVID-19.

  • Few studies have focused on emergency medicine resident trainees who have been shown to have high risk for burnout and distress through qualitative methods to deeply explore their attitudes and perspectives.

WHAT THIS STUDY ADDS

  • Using semi-structured qualitative interviews, this paper identified five key themes that impacted residents’ well-being throughout the pandemic including the lack of connections within the residency, need for proactive support and positive acknowledgement from leadership, the negative impact on career and professional growth and negative impacts on personal health.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • These themes highlight the existing gaps in the support of residents, and how they were exacerbated during the COVID-19 pandemic.

  • The results signal priority areas in personal support, intergroup camaraderie, resident appreciation and career development for leaderships to focus broadly on resident training and particularly during a pandemic.

Introduction

COVID-19 has placed an immense psychological burden on the healthcare workforce, especially in emergency medicine (EM).1–6 A gap remains in understanding how the pandemic has affected EM resident physicians. Trainees are at high risk for burnout and psychological distress.7 8 Investigating the perspectives of residents training throughout the pandemic is important to support their education and mental health.9 10 There has not been a qualitative study which examines EM residents’ perceptions and beliefs on well-being during the pandemic.

Qualitative exploration may highlight priority areas for the years to come in supporting these individuals. An investigation into these factors can elucidate the concepts which promote and influence resident well-being during profound and historic events. The experiences of EM residents can inform strategies to support learners during the subsequent phases ahead. Beyond the pandemic, these insights will help identify key areas of opportunity across educational and clinical missions. The objective of this study was to use qualitative methods to explore the perspectives of EM residents within an urban, academic environment on well-being during the pandemic.

Methods

Study design

The study followed the Standards for Reporting Qualitative Research.11 In-depth, semi-structured interviews of EM resident physicians at a single large, urban, academic institution serving four downtown EDs were conducted using an interpretivist perspective. This interpretivist approach seeks to investigate behaviour and experiences of individuals within their environments and the meanings attached to their actions and reactions.12

Eligibility and recruitment

All EM residents were eligible and we recruited to include perspectives across this 4-year training programme. We used a voluntary snowballing sample approach and sent a series of three emails. Semi-structured interviews were conducted between November 2020 and February 2021 by a research team member with experience and training in qualitative interviewing (HS) who had no association with educational, clinical or programme leadership to avoid conflicts of interest and bias. All participants were compensated with a US$20 gift card. Interviews were audio-recorded (Microsoft Teams or Zoom), transcribed and de-identified by a third-party platform (Rev; www.Rev.com).

Data collection

A semi-structured, open-ended interview guide (online supplemental appendix 1) was created by the study team with experience in EM, resident training and qualitative methods (AA, AD) to explore attitudes, beliefs and experiences regarding well-being and the pandemic. The interview guide was developed using established constructs and the National Academy of Medicine conceptual framework on clinician well-being.13 The guide included open-ended questions and probes and was pilot tested and refined with other non-participant EM resident physicians and attending physicians with experience in education. Additional questions explored aspects related to the resident’s year of training.

Analysis

De-identified transcripts were analysed using thematic analysis14 (NVivo V.12.0, QSR International, Burlington, Massachusetts, USA). The coding process included (1) development of the codebook through an iterative review of the dataset by three team members (AS, JG, HS), (2) refinement of the codebook by coding three interviews at random and assessing inter-rater reliability (unweighted kappa of 0.72), (3) coding the entire dataset and (4) double coding (AS, JG) the entire dataset to assess inter-rater reliability (unweighted kappa of 0.70). The team revised the codebook and definitions until coding disagreements were resolved and agreement on the final codebook was reached. Data were unmasked to the training level after coding. To minimise bias, AD and AA only had access to de-identified transcripts. Emerging themes were identified using thematic analysis.15 16 Interviews were stopped when double-coding did not identify any new or emerging themes.

Results

Seventeen EM residents were interviewed, although a small group, it allowed for an in-depth investigation acceptable within qualitative research and when thematic saturation was reached.17 The sample consisted of males (n=7; 41%) and females (n=10; 59%); mean age (SD) was 27.9 (1.9) years. Six (35%) were postgraduate year (PGY)-1, six (35%) were PGY-2, two (12%) were PGY-3 and three (18%) were PGY-4. Five themes emerged through the analysis including (1) isolation from peers in training contrasting with a collective call to action, (2) desire for increased acknowledgement and structured leadership support, (3) concerns about personal needs and safety within the clinical environment, (4) fear of missed educational opportunities and lack of professional development and (5) need for enhanced mental and physical health resources. Representative quotes for each theme can be found in the online supplemental table 1. Taken in their entirety, these themes reflect clinical, educational and social areas which residents identify as either well-being strain or support (table 1).

Table 1

Qualitative themes, subthemes and potential approaches

Theme 1: isolation from peers in training contrasting with a collective call to action

Residents described specific COVID-19-related isolation from peers and found it difficult to decompress after clinical care or having stressful encounters. Isolation was common for junior residents and permeated other aspects of residency, such as workplace connections and mentorship. Senior residents, those in their third or fourth year, expressed a positive component within their clinical teams and embolded camraderie. This manifested as a ‘coming together’ phenomenon to face a public health crisis as a team or ‘family’. Junior residents noted a lack of social support during the initial pandemic surge and did not feel as connected to other staff (eg, faculty, nursing) and had looser ties to their peers.

Theme 2: desire for increased acknowledgement and structured leadership support

Residents desired acknowledgement for their role and contribution within the larger context of the health system. They commented on wanting their voices to be valued and clearer communication surrounding operational and clinical uncertainties. This was true within the landscape of shifting care guidelines and with personal safety (eg, protective equipment use and availability). Participants felt their role as physician trainees was unique as compared with nurses, faculty or students. The residents expressed a lack of understanding how their role was valued, frustration over staffing the clinical care areas and what the future held for them within the context of the pandemic. Changes in scheduling for residents was seen an example of particular uncertainty as their collegues were exposed to COVID-19 or contracted COVID-19. The residents desired a clearer staffing plan from leadership.

Theme 3: concerns about personal needs and safety within the clinical environment

Participants identified clinical environment factors that impacted their well-being including their own safety (eg, personal protective equipment), the difficulty of caring for themselves, transportation to the hospital and the beneficial impact of small acts of kindness (eg, food) from leadership that were efforts to relate and express gratitude.

Theme 4: fear of missed educational opportunities and lack of professional development

Residents worried about their career future and felt they had missed out on educational opportunities. They noted a profound shift to service without a counterbalanced increase in education. Residents felt the strain of the pandemic negatively impacted their clincial learning as acuity and volume overwhelmed the healthcare system. Professional development such as mentorship, planning for the future and research, felt stalled and not supported. For juniors this was reflected as loss of opportunities to develop or explore interests early in their training. Senior residents reflected on anxiety about job security and availability when transitioning beyond residency.

Theme 5: need for enhanced mental and physical health resources

Residents felt their mental and physical health was negatively impacted. Residents felt anxious and struggled to find adequate resources for mental health support. Physically, residents struggled to stay active. initially due to public health measures.

Discussion

This qualitative study within an urban academic institution identifies themes impacting EM residents’ well-being during the pandemic and provides insights into how programmes understand and support trainees. The qualitative interpretivist approach investigates behaviour and experiences of residents within their environments and the meanings attached to their actions and reactions, in this context related to EM resident well-being during COVID-19. The qualitative analysis used thematic saturation and revealed five themes of the impact on camaraderie and connection within trainees, need for leadership supporting and communication, increased barriers to clinical operations, missing opportunities for career development and addressing individual health.

The findings here build on the literature which reveals rising level of burnout and psychological distress in resident trainees.18 This study reaffirms that trainees are experiencing issues related to burnout and well-being during their training. The qualitative themes which emerged from interviews highlight five specific topic areas, three of which (themes 2, 4, 5) can broadly apply to EM training and the remaining (themes 1 and 3) being more specific to the pandemic. Residents discussed the importance of acknowledgement, professional development and prioritising self-care in the forms of physical and mental health support. These are core values to the US National Academy of Medicine conceptual framework on physician well-being and have been highlighted as key components of physician well-being from a recent US Surgeon General report.13 19 20 The findings from this study suggest the importance of these concepts begins in training and guide well-being efforts for educational leaders. Residency leaders may need to specifically provide support for trainees’ well-being early to overcome these stressors.4 Some programmes have attempted to provide residents with well-being and mindfulness training, but the evidence for these approaches is either limited or have yet to show broad effectiveness.21 These areas extend beyond the pandemic as EM faces critical challenges in capacity restraints impacting patient care, education and physician burnout.22

This study adds pandemic-specific areas impacting resident well-being including isolation and strains within the clinical environment. Residents expressed a desire to maintain connections with one another and faculty to decompress and provide support. Isolation was most pronounced for junior residents and missing events with faculty was a critical gap. Conversely, senior residents felt their connection to an EM ‘family’ strengthen as they came together to face COVID-19. This is a compelling finding as it speaks to shared sense of teamwork and camaraderie during extraordinary circumstances. Creating opportunities for residents to connect outside of clinical care, focus on efforts to encourage junior trainee attendance and facilitate these events to foster peer-to-peer and faculty-to-trainee mentorship may help support the well-being of EM residents.

The insights from this single-centre study are informative but generalisability may be limited due to the sample size and location of the study. There has been geographic variation in COVID-19 case load, morbidity and mortality. Thus, these themes may be more pronounced or muted given the local severity and strain on health systems. Nonetheless, these themes identify potential starting points for educational leaders to address well-being in trainees. The waves of the COVID-19 pandemic continue to have considerable impacts on EM residents. Future research is needed to understand these variations to develop adaptive models of trainee support.

There are limitations to this study. First, due to methods of recruitment and voluntary participation there may be selection bias in those who chose to decline to participate. Also, this is a study with a sample of EM residents at a single urban academic institution, where experiences may differ from those of residents at other EM residency locations and types of programmes. The local construct of this residency programme, including the case counts of COVID-19, local and regional public health response and the overall public reaction, influence EM practice greatly. This study explores resident attitudes and perceptions of well-being throughout the pandemic to date, but these likely vary by programme, health system and region.

Conclusion

EM residents identified key factors impacting their well-being as residents during the pandemic, including isolation, acknowledgement, on-shift factors, professional development and mental and physical health. These takeaways are an important contribution to the literature describing and highlighting pandemic-specific and broader aspects of importance of well-being from the perspective of EM residents.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study was approved by the University of Pennsylvania Institutional Review Board and participants provided verbal informed consent.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Handling editor Ellen J Weber

  • Twitter @agarwalEM, @TSpadaro91

  • Contributors The authors report no external funding source for this study. The authors declare they have no competing interests. The study/data/abstract have not been presented and this paper has not been published online or in print and is not under consideration elsewhere. AA conceived the study and designed the trial. AA supervised the conduct of the trial and data collection. HS, AS and KS provided advice on study design and analysed the data. AA drafted the manuscript, and all authors contributed substantially. AA takes responsibility for the paper as a whole and is the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.