Residents attended 85% of the support groups (10.19/12 each year), and reported a mean satisfaction score of 6.56 (7 = very satisfied). Support group had a strong positive impact on well-being (mean = 6.34; 7 = strong positive impact, 1 = strong negative impact). Building supportive relationships with peers was frequently noted as the most important strength, while the short duration (1 hour) and low frequency of meetings (once per month) were seen as the greatest weaknesses.
The 729 extractions were coded using 6 broad themes and further subdivided into 23 subcategories (see ). A total of 791 thematic codes and categories were assigned. When an emotion was clearly articulated (“e.g. I feel so angry right now”), it was also coded into one of 12 possible emotion categories – guilt, anger, sadness, numbness/affective blunting, anxiety/fear, hopelessness, overwhelmed/stressed out, bored/apathetic, lonely, upset (generall feeling bad but not specified), any positive emotion (happy, excited, inspired, confident, proud), other emotion (shocked, disappointed). A total of 270 clearly articulated emotions were coded.
Support Group Themes and Categories
The frequencies of themes, categories, and emotions were noted over time by year of training. Not surprisingly, the theme most commonly present was the theme of Professional Development. The one exception occurred in the final third of PGY3 with Coping and Other Stressor Responses becoming the most frequent theme (See with the X-axis reflecting year of training starting with internship and proceeding through the end of the third year). Within the Professional Development theme, the most common categories were Professional Confidence (2.2) and MD/Resident Role and Responsibility (2.4). As trainees become more comfortable in their roles over time, MD/Resident Role and Responsibility drops to its lowest point in PGY3. The second-most frequent theme across all years was Coping and Other Stressor Responses. The most common categories within this theme were Cognitive Responses to Stress and Behavioral Responses to Stress.
Support Group Themes by Training Year
The most commonly expressed emotions over all training years were anxiety/fear, guilt, positive emotion, and anger (See ). Anxiety peaked at the beginning of the PGY2 (e.g. fear over running a team) and PGY3 years (e.g. job anxiety) but remained fairly consistent throughout the intern year. Guilt was highest in the middle of the intern year and at the end of PGY3 when residents were terminating their relationship with patients. Positive emotions (hope, pride, gratitude, happiness, feeling inspired) were concurrently present throughout all years but rose dramatically in PGY2 and PGY3. Anger steadily increased during the last third of the intern year and peaked during the transition from intern to PGY2 and did not notably drop until the last third of PGY2.
Emotion Frequencies by Trimester of Each Training Year
Qualitative Findings for PGY1
For interns, the most common subcategories were MD/Resident Role and Responsibility (Category 2.4; 9.2% of extractions), Cognitive Responses to Stress (Category 4.2; 8.8%), Professional Confidence (Category 2.2; 8.4%), and Behavioral Responses to Stress (Category 4.3; 7.6%). End-of-life issues and insufficient time with family and friends were frequent issues in the first trimester. Forming and navigating relationships with peers emerged as a more dominant theme in the second trimester. Attitudes and Values (category 3.4) was increasingly present over the course of the year, as interns reported struggling with their reasons for going into medicine and feeling disillusioned.
Stressors included the death of patients, feeling isolated from family and friends, challenges to self-esteem and confidence, and the erosion of an idealized view of medicine. Common cognitive responses to stress included remembering the “power and prestige of being a physician,” reframing (e.g. internship as an investment), normalization, suppression, changing expectations (e.g. “I don’t have to be perfect”), looking to the future, complaining, and escape fantasies (e.g. “It would be so incredible to work in a coffee shop all day.) Interns found little time or energy for common behavioral responses to stress such as exercise or time with family or friends. Behavioral responses included marking completed days off a calendar, sleeping through days off, and displacing anger onto nursing staff, family, or strangers.
The most frequently expressed emotions over the course of the entire year were guilt (17.2%), anxiety/fear (16.2%), feeling generally “upset” (14.1%), anger (14.1%), and positive emotions (12.1%). As the year progressed, anger became more prominent while guilt and positive emotions peaked in the middle trimester and dropped to their lowest points in the final third of the year. Guilt was triggered by not performing competently, losing compassion, or from placing work over time with family and friends. The lack of time and/or capacity to process intense emotions provoked by clinical situations often left the intern feeling overwhelmed and upset. Anger was most frequently directed at the program, program directors, or the general health care system. Positive emotions included hope (e.g. “Seeing people get better and leave the hospital gives me hope”), confidence (“I’ve really learned a lot here…I’m feeling a lot more confident”), and happiness.
Qualitative Findings for PGY2
For the PGY2 year overall, the most common categories were Local Program Issues and Complaints (Category 5.2; 13.9% of extractions), Cognitive Responses to Stress (Category 4.2; 10.2%), MD/Resident Role and Responsibility (Category 2.4; 9.0%), and Behavioral Responses to Stress (Category 4.3; 7.8%). Professional Confidence (Category 2.2) was an issue in the first trimester as new R2’s began leading a team. Residents continued to struggle with defining their professional roles and expectations, but unlike the intern year, end-of-life issues and medical mistakes were discussed less. Coping strategies included seeking professional counseling, seeking social support, taking SSRI’s, reading more journal articles or clinical guidelines, taking more time for self care (e.g. dental appointments, taking a sick day), and scheduling more social activities.
The most frequently expressed emotions over the course of the R2 year were anxiety/fear (23.0%), anger (17.6%), positive emotion (16.2%), and guilt (13.5%). Anxiety dropped dramatically over the course of the year as did anger. Guilt showed modest increases from first to last trimester. While positive emotions were entirely absent in the first trimester, they represented nearly 1/3 of all articulated emotions in the final trimester. Common triggers for anxiety were leading an inpatient team, feeling solely responsible for decisions regarding patient care, and worry about future career directions. First trimester anger still focused on the program, directors, and the health care system. The rising frequency of positive emotions was due to asserting themselves, getting fellowships or more clarity on career directions, increasing the number of peer-peer social contacts, and a growing sense of professional competence as evidenced by patient outcomes and feedback.
Qualitative Findings for PGY3
For PGY3’s, the most common categories were Cognitive Responses to Stress (Category 4.2; 13.2%), Local Program Issues and Complaints (Category 5.2; 10.5%), Career Path (Category 2.7; 9.5%), and Professional Confidence (Category 2.2; 8.8%). High levels of program complaints are seen initially, but decrease over the course of the year as career goals are pursued (and achieved) and more perspective is developed (e.g. “I’m not feeling so angry anymore. I’ve grown a lot. In a way I think I was mad at a loss of innocence.”). Both professional confidence and career issues peak in the middle trimester when most residents began finding jobs or settled further training plans. While R3’s may feel more competent and confident, there was still substantial worry about becoming autonomous practitioners with no clear “plan.”
Although cognitive and behavioral responses to stress are common categories across all years, their frequencies surge in the final trimester. As residents began to feel more secure and to reflect more on their training experiences, these coping strategies often mitigated their more negative emotions and supported important insights – e.g. “Did we make residency harder than it has to be? I mean, is part of our suffering because we were so neurotic and so perfectionistic? Was our anger part of the drama that was unnecessary?” The categories of Self-Awareness (3.3) and Attitudes and Values (3.4) were higher than in any other point in training as PGY3’s recognize how training has impacted them and their practice of medicine (e.g. “When I was an intern I could have told you hundreds of patient stories – the stories were the most salient. I couldn’t remember labs or algorithms to save my life. Now I remember the labs and all the patients just blur together. What happened?”).
The most frequently expressed emotions were anxiety/fear (24.2%), guilt (18.9%), positive emotion (16.8%), and anger (11.6%). While guilt and positive emotions increased over the course of the year, anxiety and anger decreased. The most common trigger for guilt was graduating and “abandoning” a panel of outpatients. Positive emotions were triggered by a realization of how much they had learned and grown, the increased appreciation of peer relationships, and being able to see the “finish line.”
On average, burnout scores were higher for PGY1’s than any other group (see burnout averages chronologically arranged in ). All 4 PGY1 cohorts (two PGY1 groups per year) had bimodal peaks of burnout near January and again in April/May. By January, most interns spent 5 of the past 6 months on the wards with frequent call nights resulting in cumulative fatigue. In late spring, the pressure and anxiety of leading an R2 ward team worsened burnout. Burnout scores for PGY2’s were lower than PGY1’s in the first two months but rise to similar levels in months 3–6. PGY2’s show lower burnout for the second half of the training year. Although PGY3’s generally have less burnout in the first half of the year, they are at similar levels to PGY2’s in the second half of the year.