Increasing Resident Physician Well-Being through a Motivational Fitness Curriculum: A Pilot Study.

INTRODUCTION: Healthcare professionals who participate in regular exercise better manage job related stressors, utilize fewer sick days, and discuss fitness with patients at increased rates. Although resident physicians are aware of the health benefits of exercise their rates of exercise are much lower than among medical trainees and practicing physicians. Resident physicians have reported lack of time for traditional structured workouts as one of the greatest barriers to fitness. This study sought to increase resident physician well-being by providing brief workouts through a motivational fitness curriculum.
METHODS: This pilot study utilized a nonexperimental design; a pre-/post-intervention consisted of a 10-month motivational fitness curriculum. Thirteen family medicine residents at a training program in the midwestern United States participated in this study. The Depression Anxiety Stress Scale-21 (DASS-21) and the Abbreviated Maslach Burnout Inventory (MBI-9) were used to measure the participants' well-being, pre- and post-curriculum. Standard descriptive statistics and paired samples t-test were used to analyze the data.
RESULTS: Twenty-eight percent (13/36) of eligible first-year and second-year family medicine resident physicians participated in the study. On the DASS-21, study participants displayed an improvement in depression, anxiety, and stress scores post-curriculum. On the MBI-9, the participants reported decreased score in emotional exhaustion, but there were no changes in depersonalization and personal accomplishment scores over time.
CONCLUSION: A motivational fitness curriculum may be a convenient way to support well-being among resident physicians. These findings were salient, as graduate medical education programs can implement similar initiatives to support resident physicians' psychological and physical well-being.

INTRODUCTION

Excessive workload, clerical burden, decreased control over workload, struggles with work-life integration, and dissolution of meaning in work are factors that are associated with burnout.1,2 Over 50% of University of Kansas School of Medicine-Wichita (KUSMW) resident physicians experienced at least one manifestation of burnout in 2017.2 Throughout the U.S., declining psychological health related to learner depression and burnout has led graduate medical educators to instill trainees with interpersonal skills and personal well-being habits.3 These interventions have targeted increasing learner confidence, satisfaction, self-validation, tolerance, and compassion.3,4 Although somewhat effective, these efforts fall short in accounting for the value of exercise on resident well-being. 4–6 Healthcare professionals who participate in regular physical activity manage job related stressors better, utilize fewer sick days, and discuss fitness activities with patients at increased rates.4–6

In addition, resident physicians experiencing positive mental and behavioral health are more satisfied with their jobs, make fewer errors, and display increased levels of empathy. Experiencing positive mental and physical health leads to better patient care; patient compliance increases and positive health related outcomes are experienced.4,7–10 Although resident physicians are aware of the health benefits of physical activity, resident physicians exercise less than medical students and practicing physicians.4–6,11 Resident physicians have reported lack of time for traditional structured workouts as being the greatest barrier to fitness.4 Given these findings, the current study sought to provide a motivational fitness curriculum targeted at providing workouts adaptable to the time constraints of residency to promote resident well-being.

METHODS

Study Design

This pilot study involved 13 first- and second-year family medicine residents at a training program in the midwestern United States. The KUSM-W Institutional Review Board approved the study. A sample size of 13 was calculated as necessary for adequate power (> 0.75) to detect significant group differences among the variables with 0.8 effect size and p < 0.05.12 A motivational fitness curriculum was created by one of the authors (JTG), who had experience with fitness programming. This curriculum was provided to the participants (see Appendix A) as an intervention.

This curriculum consisted of three, 30-minute, high-intensity workouts (see Appendix B) per week for ten months (from September 2018 and June 2019). The workouts could be done independently or with others and required minimal equipment that could be purchased or made available with a gym membership. Workout activities were provided in a GroupMe chat where participants could post their times and repetitions. In addition, articles, books, and podcasts on physical, psychological, spiritual, and financial wellness were provided to the participants. Depression Anxiety Stress Scale-21 (DASS-21)13–15 and the Abbreviated Maslach Burnout Inventory (MBI-9)1, 16–18 were used to measure participants’ well-being, pre-/post-curriculum.

Study Instruments

Each survey consisted of the two validated measures: the DASS-21 and MBI-9. The baseline survey also included demographic questions such as age, gender, and post graduate year. Participants were asked to provide general comments and feedback regarding the curriculum during the post-intervention data collection.

Depression, Anxiety, Stress

The DASS-21 consists of 21 questions in three scales designed to measure negative emotional states of depression, anxiety, and stress.13–15 These scales have been found to have high internal consistency and can be used in a variety of settings to measure current state or changes over time.19 Participants recorded how much a statement applied to them over the past week on a 4-point Likert scale (0 = Never, 3 = Almost Always). Scores for the seven questions specific to each of the three scales were summed with a possible score ranging from zero to 21. Higher scores indicate greater levels of the emotional state.

Burnout

The MBI-9, a validated 9-item questionnaire, is considered a criterion tool to measure manifestations of burnout among health care professionals, including physicians, medical trainees, and nonclinical professionals.2,15–18 The inventory assesses professional burnout across three dimensions: emotional exhaustion, depersonalization, and perception of personal accomplishment. Participants recorded their feelings for each item on a 7-point rating scale (0 = Never, 6 = Every day). Scores for the three questions specific to each of the dimensions were summed with a possible score ranging from zero to 18. We conceptualized burnout as a continuous variable along a spectrum ranging from low to high experienced feelings. For the emotional exhaustion and depersonalization dimensions, higher scores are indicative of greater emotional exhaustion and depersonalization, and greater burnout. For the personal accomplishment dimension, higher scores indicate a greater sense of personal accomplishment, and less burnout.

Statistical Analysis

Standard descriptive statistics and paired samples t-test were performed to analyze the quantitative data. All analyses were 2-sided with alpha of 0.05. The IBM SPSS (Statistical Package for the Social Sciences), version 26 was used for these analyses.

Qualitative Analysis

Two of the authors (RN and SO-D) used a phenomenological approach to analyze the open-ended responses. This approach focused on the commonality of a lived experience within a group to develop a description of the nature of the phenomenon.20 The researchers were intentional to convey the overall essence of participants’ experiences by incorporating description and context.

RESULTS

Twenty-eight percent (13/36) of eligible first-year and second-year family medicine residents participated in this study. The average age of the participants was 29.5 years (SD = 2.4); 54% (7/13) were males and 46% (6/13) were females; 62% (8/13) were first-year resident physicians and 38% (5/13) were second-year resident physicians. On the DASS-21, study participants displayed an improvement in depression, anxiety, and stress scores post-curriculum (Table 1). On the MBI-9, the participants had a decrease in emotional exhaustion score but there were no changes in depersonalization and personal accomplishment scores over time (Table 1).

Table 1

Outcome scores of surveys before and after the curriculum.

	Time pointa
Subscale (possible range)	Precurriculum (N = 13)	Postcurriculum (N = 13)	t	p value	Mean difference (95% CI)
MBI-9 Emotional Exhaustion (0–18)	11.0 (4.4)	10.1 (5.2)	−0.71	0.048	−0.9 (−3.4 to 1.7)
MBI-9 Depersonalization (0–18)	6.4 (3.8)	6.8 (4.3)	0.45	0.704	0.4 (−1.9 to 2.9)
MBI-9 Personal Accomplishment (0–18)	13.6 (2.6)	13.7 (2.5)	−0.08	0.935	0.1 (2.3 to 2.1)
DASS-21 Depression (0–21)	8.4 (10.8)	6.7 (6.9)	−0.54	0.048	−1.6 (−8.4 to 5.1)
DASS-21 Anxiety (0–21)	6.5 (5.6)	3.8 (4.7)	−1.68	0.046	−2.6 (−5.4 to 0.7)
DASS-21 Stress (0–21)	12.2 (8.8)	8.0 (6.1)	−2.05	0.042	−5.2 (−8.6 to 0.3)

MBI-9 = Abbreviated Maslach Burnout Inventory. DASS-21 = Depression Anxiety Stress Scales-21.

Notes: On MBI-9, higher scores on the Emotional Exhaustion and Depersonalization subscales, and lower scores on the Personal Accomplishment subscale indicate greater burnout. On the DASS-21 subscales, higher scores indicate greater levels of that emotional state.

Values shown are mean score (SD).

Narrative Feedback

Analysis of the open-ended responses showed that the participants had a positive feedback regarding the wellness intervention. Three major themes emerged: unique and convenient workouts, motivational environment, and time constraints as a continued barrier (Table 2). Resident physicians identified the workouts as convenient and engaging as there were three unique workouts provided each week. Motivation and a sense of community were fostered through participants posting their workout times and scores, as well as pictures of their workouts on the GroupMe application. Conversely, some participants felt a sense of guilt during the weeks their participation was lower due to residency related time restrictions.

Table 2

Participants’ open-ended comments.

Themes	Significant Statements
Theme 1: Unique and Convenient Workouts.The motivational fitness curriculum provided residents with three physically and mentally rewarding workouts per week. Participants identified that the workouts were feasible and alleviated the need to spend time deciding on workouts to complete.	1. “Good, quick workouts that helped me get a workout in when I had a small amount of time.”2. “It was great to have new workouts throughout the week.”3. “I enjoyed receiving three workouts per week, so I didn’t have to think about what I was going to do at the gym.”
Theme 2: Motivational Environment.With utilization of the GroupMe application, community and motivation were fostered through participants posting their workout pictures and times/scores.Whether or not residents were able to engage in all three workouts each week, they continued to feel encouraged by participants’ posts.	1. “It was great motivation knowing others were doing great workouts as part of a community.”2. “I was encouraged to see the results of other participants”.3. “It was great to see others do well. That was motivation for me.”
Theme 3: Time Constraints as a Continued Barrier.Time constraints created a barrier to completion of all three weekly workouts. With decreased completion rates, a sense of guilt could be experienced.	1. “I sometimes chose easier workouts for time and learning ease.”2. “I participated some weeks more than others.”3. “I felt guilt when there wasn’t time to get a workout in.”

DISCUSSION

The findings suggested that a motivational fitness curriculum consisting of brief, high-intensity workouts may improve emotional exhaustion, symptoms of depression and anxiety, and stress among resident physicians. Resident physicians who participated in the motivational fitness curriculum experienced decreased symptoms of depression, anxiety, and overall stress, and emotional exhaustion decreased. This was crucial because although prior studies have shown that residents were aware of the benefits of physical activities, the rates they have been exercising were lower compared to medical students and practicing physicians.4–6

Though several academic studies have shown the benefits of physical activity among physicians,4–6 this study demonstrated potential benefits of a motivational fitness curriculum that consisted of brief, high-intensity workouts to improve the well-being of resident physicians, while simultaneously providing a sense of community through a mobile application. The findings are of pertinence as graduate medical education programs nationally have increased well-being initiatives for resident physicians. To assist graduate medical education programs in implementing similar well-being initiatives, a detailed description of the exercise curriculum and sample workouts are provided in the appendices. Exercise programs will likely be most successful when championed by a resident or a fellow physician, due to increased buy-in from peers. In addition, it is paramount that this champion is well educated in fitness regimens to develop engaging workouts that are physically safe and effective for all participants.

This study was limited by having been conducted in a single residency program. The small sample size and nonprobability-based nature of the convenience sample limit generalizability of the findings. Also, there was a potential for sample bias in residents who participated in this study. The residents with the least amount of time, greatest burnout, and most emotional distress may not have participated in the study. In addition, social desirability bias may limit the findings of the study as respondents’ responses to the survey questions might not be reflective of their true thoughts or feelings. The lack of control group makes it difficult to infer causation and reduces generalizability as there was no way to know if the improvements were linked directly to the motivational fitness curriculum. Additional research is warranted. A prudent next step would include implementing a motivational fitness curriculum in multiple residency programs (both family medicine and other residency programs) to see how the effects of the curriculum compared across different specialties. Given the exploratory nature of the study, the statistical findings should be viewed cautiously.

CONCLUSIONS

In conclusion, the findings suggested that a motivational fitness curriculum consisting of brief, high-intensity workouts provided a convenient way to reduce depression, anxiety, stress, and emotional exhaustion among resident physicians. The improvement in resident physicians’ mental and behavioral health potentially could translate to better patient care as a result. These findings are salient, as graduate medical education programs can implement similar initiatives to support resident physicians’ psychological and physical well-being.