Preparedness for Self-Care and Wellness Among Family Medicine Graduates: 1985-2005

Preparedness for Self-Care and Wellness Among Family Medicine Graduates: 1985-2005
Anil Rickhi Emergency Physician

(Example Description) As a board certified reproductive endocrinologist, specializing in the field of Assisted Reproductive Technology (ART), it has been my life’s work to help build families. Many of my patients come to me with little hope and often misdiagnosis’. I have been influential in the births of more than 6000... more

*Note this was a previous manuscript our team with myself being the lead author that was rejected for peer review publication. I still still this data is very useful.

Anil Rickhi, MD, B.Sc(Hons], MRCP, FCFP

Rodney A. Crutcher, MD, MMedEd, CCFP(EM), FCFP

Olga Szafran, MHSA

Wayne Woloschuk, PhD

John Fralick, MSc 

Author Bios:

Dr. Rickhi is a Physician, Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada. He is currently with MSF USA.

Dr. Crutcher is Professor, Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada.

Ms. Szafran is Associate Director (Research), Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada.

Dr. Woloschuk is Director of Program Evaluation, Undergraduate Medical Education, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.

Mr. Fralick is a medical student, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.

Corresponding Author: R RickhIDepartment of Family Medicine, University of Calgary

Disclosure of Funding: The surveys were jointly funded by The Alberta Rural Physician Action Plan (RPAP), Alberta International Medical Graduate (AIMG) Program, Capital Health (Edmonton), and Calgary Health Region. 

September 6  2013

Abstract

Purpose

While physician health and wellness is receiving increasing emphasis in medical education and practice, it is unknown whether family physicians’ preparedness for self-care/wellness has improved over time. The purpose of this study was to explore family medicine graduates’ self-reported preparedness for self-care/wellness over a 21-year period. 

Methods

Three retrospective, cross-sectional surveys were conducted in 1997, 2001 and 2006 of family medicine graduates of the University of Alberta and University of Calgary, Canada during 1985-95, 1996-2000, or 2001-2005. The data were combined for longitudinal analysis and four cohorts created. Data were analyzed using descriptive statistics and logistic regression. 

Results 

Of 1448 family medicine graduates, 966 (66.7%) responded to the surveys. The percentage of family medicine graduates who reported being prepared for self-care/wellness steadily increased with each cohort from 1985-90 (47.4%) to 2001-05 (78.2%).   Neither age nor gender were predictive or self-care/wellness preparedness.  

Conclusion 

Family medicine graduates’ preparedness for self-care/wellness has steadily increased over 21 years. 

Introduction 

Physician health has become a prominent theme in medical education and professional culture in recent decades. Currently, there is explicit recognition that physicians have a responsibility for maintaining their own health and wellness.  The Canadian Medical Association’s (CMA) policy on physician health and well-being states that “Physicians should strive to manage professional stress and maintain their own health and well-being and to maximize their ability to provide quality health care to their patients”.1 This is consistent with the CanMEDs framework for competencies in family medicine2 and the American Medical Association policy related to physician health.3 

Research shows that a physician’s health and well-being influences the amount and quality of care provided4,5 and overall performance.6 Physicians who lead healthy lifestyles are also more likely to provide healthy lifestyle counselling to their patients7 . Poor physician health may lead to reduced workload,8,9 medication errors,10,11  and ineffective communication with patients.12

To prepare physicians in training to address personal wellness, medical education programs throughout Canada and the USA have introduced initiatives to engage medical students and residents in efforts to reduce stress and promote wellness.  Some programs have incorporated topics on physician wellness into the medical curriculum.13 Many include sporadic and informal events aimed at enhancing well-being.  

Although increasing priority has been placed on physician health programming, it is not known whether family physicians’ preparedness for self-care/wellness has improved over time. The purpose of this study was to explore the trend in family medicine graduates’ self-reported preparedness for self-care/wellness over a 21-year period. 

Methods

Study Design, Sample & Procedures

In 1997, 2001 and 2006, we conducted cross-sectional, mailed surveys of family medicine graduates who completed the two-year residency program at the University of Alberta or University of Calgary during 1985-95, 1996-2000, or 2001-05, respectively. All graduates (n=1,448) for whom contact information was available through the Alberta Medical Directory or the Canadian Medical Directory were mailed survey packages containing an information letter, questionnaire, and return post-paid envelope. Non-respondents were mailed reminder notices and contacted up to five times by telephone, fax and/or email. We combined data from the three surveys for longitudinal analysis. Each  survey, as well as the combined longitudinal analyses, were approved by the Health Research Ethics Board (Health Panel) at the University of Alberta and the Conjoint Health Research Ethics Board at the University of Calgary.

Questionnaire

The overall purpose of the three surveys was to examine graduate’s educational experiences during residency training and practice patterns after graduation. The surveys included questions related to preparedness for various dimensions of practice. Questions were similar across the three surveys, enabling analysis of trends. The question on physician preparedness for self-care/wellness was as follows: ‘Please indicate the degree to which the Family Medicine Residency Program prepared you for dealing with physician self-care and wellness.‘ Preparedness for self-care/wellness was measured using a 4-point Likert scale (1=very unprepared, 2=somewhat unprepared, 3=somewhat prepared, 4=very prepared) in all surveys, except in the 1985-95 University of Calgary survey, where it was assessed as either ‘adequately prepared’ or ‘under prepared.’  Preparedness for self-care/wellness was not explicitly defined in the questionnaire. 

Data Analysis

We combined data from the three surveys for longitudinal analysis using SPSS 19 for Windows. For analytical purposes we grouped respondents into four cohorts according to year of residency program completion [Cohort 1 (1985-90), Cohort 2 (1991-95), Cohort 3 (1996-2000), Cohort 4 (2001-05)]. We recoded preparedness for self-care/wellness into binary outcomes, such that ‘very unprepared,’ ‘somewhat unprepared,’ and ‘under prepared’ were classified as ‘unprepared’ and ‘somewhat prepared,’ ‘very prepared,’ and ‘adequately prepared’  were defined as ‘prepared.’ Data were analyzed using descriptive statistics and logistic regression. 

Results

The overall response rate to the three surveys combined was 66.7% (966/1448), with individual survey response rates being 63%, 76.4%, and 64.2% for the 1985-95, 1996-2000, and 2001-05 surveys, respectively. Of the 966 respondents, we obtained complete cohort and preparedness for self-care/wellness data for 944. 

The majority (62.1%) of graduates were 30 years of age or older and 49.8% were female (Table 1). There was an even distribution of graduates across the cohorts, ranging from 22.6% in Cohort 1 to 29.2 % in Cohort 3 (Table 1). Of the 944 respondents, 630 (66.7%) indicated they were prepared for self-care/wellness.  

The percentage of graduates feeling prepared for self-care/wellness increased over time, from 47.4% in Cohort 1 to 78.2% in Cohort 4 (Figure 1). With each increment in cohort (1,2,3,4), the odds of being prepared for self-care increased 1.57 (95% CI = 1.38-1.78) times (p<0.0001).  Age and gender were not predictive of being prepared for self-care/wellness.

Discussion

Our study is the first in a family medicine setting to provide empirical evidence of 

family medicine graduates’ self-reported preparedness for self-care/wellness steadily increasing over a 21 year interval. This trend is encouraging.While we are tempted to believe that this finding  reflects the increasing attention of our two residency training programs in preparing residents for all aspects of practice, including those related to professional and personal lifestyle, we cannot confirm this.  Contextually, we note that  accreditation requirements have evolved to stipulate that physician wellness be included in Canadian undergraduate postgraduate medical education.  Furthermore, initiatives to keep Canadian physicians healthy have included the establishment of physician support programs in every province.14 

We suspect the observed trend of  increasing graduate preparedness for self-care/wellness is fundamentally part of a societal shift. While precise description is elusive, we believe it to be related to cultural change in and beyond medicine  -  from a culture implicitly or explicitly valuing professional workaholism to a nuanced and contemporary culture valuing work-life balance, wellness and taking personal responsibility for one’s own health. This may have had the effect of more recent graduates (later cohorts) feeling more empowered to place self-care/wellness as a priority in their own lives. 

We found no evidence of older residents being better prepared  for self-care/wellness compared to their younger colleagues. Perhaps older does not equal wiser in this context. We imagine that in the current teacher-learner dynamic there is sometimes a generational role reversal between teacher and learner, with older and likely more work-focused physicians’ being shown by their younger colleagues the benefits of work-life balance. 

Our study has limitations. The retrospective, cross-sectional nature of the surveys provided a measure of preparedness for self-care/wellness at a point in time and did not provide prospective measurement at discriminate intervals. Individual perceptions of preparedness may change over time. The generalizability of the findings to family medicine graduates or   graduates from other residency programs is unknown. The time between graduating residency and completion of each survey varied, therefore, recall bias may have influenced perceptions of preparedness for self-care/wellness. Our study neither defined nor objectively assessed preparedness for self-care/wellness, but rather examined self-reported preparedness; therefore, respondents may have interpreted preparedness differently. Graduates may have had a tendency to provide the socially desirable response for preparedness for self-care/wellness, not wanting to convey that they are not capable of taking care of their own health. Our study was also not able to examine the degree to which preparedness for self-care wellness is influenced by educational experiences within the training program versus factors external to the program, such as individual health status, life experience, coping skills, and personal resilience.  

Conclusion

Family medicine graduates’ preparedness for self-care/wellness has steadily increased over 21 years.  We encourage both reflection on our findings and the design of robust studies and evidence – informed programs to optimally promote physician wellness.

Acknowledgements: The authors thank Jody Boffa for her thoughtful analytical contributions in the early phase of developing this paper. 

Funding/Support: The surveys were jointly funded by The Alberta Rural Physician Action Plan (RPAP), Alberta International Medical Graduate (AIMG) Program, Capital Health (Edmonton), and Calgary Health Region.

Competing Interests: None 

Disclaimer: None

Ethical Approval: Each of the surveys and the combined longitudinal analyses were approved by both the Health Research Ethics Board (Health Panel), University of Alberta and the Conjoint Health Research Ethics Board, University of Calgary.

Previous Presentations:  Earlier version of this work were presented as:  a free-standing paper at the North American Primary Care Research Group (NAPCRG) Meeting in New Orleans, LA on December 2, 2012;  a free-standing paper at the Pre-Conference Research Day of Family Medicine Forum (FMF), College of Family Physicians of Canada in Toronto, ON on November 14, 2012 and at  FMF on October 13, 2010 in Vancouver, BC; and a poster at the Association of Medical Education in Europe (AMEE) Conference in Glasgow, UK held September4-8, 2010.

References 

  1. Canadian Medical Association. CMA Policy. Physician Health and Well-Being. Ottawa, Ontario: Canadian Medical Association; 1998. 
  2. http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD98-04.pdf. Accessed March 17, 2013.
  3. The College of Family Physicians of Canada. CanMEDS – Family Medicine. Mississauga, Ontario: Working Group on Curriculum Review, College of Family Physicians of Canada; October 2009. http://www.cfpc.ca/uploadedFiles/Education/CanMeds%20FM%20Eng.pdf. Accessed March 17, 2013.
  4. American Medical Association. American Medical Association Policies Related to Physician Health. Chicago, Illinois: Department of Physical Health and Health Care Disparities, American Medical Association; February 2011. 
  5. http://www.ama-assn.org/resources/doc/physician-health/policies-physicain-health.pdf. Accessed March 17, 2013.  
  6. Firth-Cozens J, Greenhalgh J. Doctors' perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997;44(7):1017-1022.
  7. Wallace JE, Lemaire J. Physician well being and quality of patient care: An exploratory study of the missing link. Psychol Health Med. 2009;14(5):545-552.
  8. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: A missing quality indicator. Lancet. 2009;374(9702):1714-1721. 
  9. Frank E, Rothenberg R, Lewis C, Belodoff BF. Correlates of physicians' prevention-related practices.  Arch Fam Med. 2000;9(4):359-367.
  10. Edwards S. Resident Wellness and Work/Life Balance in Postgraduate Medical Education.  Members of the FMEC PG consortium; 2011. http://www.afmc.ca/pdf/fmec/23_Edwards_Resident%20Wellness.pdf. Accessed September 6, 2013. 
  11. Bergman B, Ahmad F, Stewart DE. Physician health, stress and gender at a university hospital. J Psychom Res. 2003;54(2):171-178. 
  12. West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, Shanafelt TD. Association of perceived medical errors with resident distress and empathy. A prospective longitudinal study. JAMA. 2006;296(9):1071-1078.
  13. Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress satisfaction, and burnout with physician-reported error and suboptimal patient care: Results from the MEMO study. Health Care Manage Rev. 2007;32(3):203-212.
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Table 1:   Characteristics of 944 Alberta Family Medicine Graduates Who Completed Residency Training During 1985-2005

Characteristic

Number n=944 (%)

Gender

   Male

463 (49.0)

   Female

470 (49.8)

   Not Recorded

11  ( 1.2)

Age Group

   < 30 years

334 (35.4)

   ≥ 30 years

586 (62.1)

   Not Recorded

24  ( 2.5)

Cohort 

  Cohort 1 (1985-1990)

213 (22.6)

  Cohort 2 (1991-1995)

217 (23.0)

  Cohort 3 (1996-2000)

276 (29.2)

  Cohort 4 (2001-2005)

238 (25.2)