Sarah Sofka, MD, FACP, noticed a pattern. As program director for the internal medicine (IM) residency at West Virginia University (WVU), in Morgantown, she was informed when residents were sent to counseling because they were affected by burnout, depression, or anxiety. When trainees returned from these visits, many told her the same thing: They wished they had sought help sooner.
IM residents and their families had access to free counseling at WVU, but few used the resource, says Sofka. “So, we thought, let’s just schedule all of our residents for a therapy visit so they can go and see what it’s like,” she said. “This will hopefully decrease the stigma for seeking mental health care. If everybody’s going, it’s not a big deal.”
In July 2015, Sofka and her colleagues launched a universal well-being assessment program for the IM residents at WVU. The program leaders automatically scheduled first- and second-year residents for a visit to the faculty staff assistance program counselors. The visits were not mandatory, and residents could choose not to go; but if they did go, they received the entire day of their visit off from work.
Five and a half years after launching their program, Sofka and her colleagues conducted one of the first studies of the efficacy of an opt-out approach for resident mental wellness. They found that the program led to more counseling visits that were resident-initiated and fewer that were mandated, suggesting that residents were seeking help proactively after having to at least consider it.
Opt-out counseling is a recent concept in residency programs ― one that’s attracting interest from training programs across the country. Brown University, the University of Colorado, Penn Medicine, and the University of California, San Francisco, have at least one residency program that uses the approach.
Lisa Meeks, PhD, an assistant professor of family medicine at Michigan Medicine, in Ann Arbor, and other experts also believe opt-out counseling could decrease stigma and help normalize seeking care for mental health problems in the medical community while lowering the barriers for trainees who need help.
No Time, No Access, Plenty of Stigma
Burnout and mental health are known to be major concerns for healthcare workers, especially trainees. College graduates starting medical education have lower rates of burnout and depression compared to demographically matched peers; however, once they’ve started training, medical students, residents, and fellows are more likely to be burned out and exhibit symptoms of depression. The ongoing COVID-19 pandemic is further fraying the well-being of overworked and traumatized healthcare professionals, and experts predict a mental health crisis will follow the viral crisis.
The Accreditation Council for Graduate Medical Education recently mandated that programs offer wellness services to trainees. Yet this doesn’t mean they are always used; well-known barriers stand between residents, medical students, and physicians and their receiving effective mental health treatment.
Many state medical licensing boards still require physicians to disclose mental health treatment, dissuading many trainees and providers from seeking proactive care…
Two of the most obvious are access and time, given the grueling and often inflexible schedules of most trainees, says Jessica Gold, MD, a psychiatrist at Washington University in St. Louis, Missouri, who specializes in treating medical professionals. Gold also points out that to be done correctly, these programs require institutional support and investment ― resources that aren’t always adequate.
“A lack of transparency and clear messaging around what is available, who provides the services, and how to access these services can be a major barrier,” says Erene Stergiopoulos, MD, a second-year psychiatry resident at the University of Toronto, in Canada. In addition, there can be considerable lag between when a resident realizes they need help and when they manage to find a provider and schedule an appointment, says Meeks.
Even when these logistical barriers are overcome, trainees and physicians have to contend with the persistent stigma associated with mental health treatment in the culture of medicine, says Gold. A recent survey by the American College of Emergency Physicians found that 73% of surveyed physicians feel there is stigma in their workplace about seeking mental health treatment. Many state medical licensing boards still require physicians to disclose mental health treatment, which discourages many trainees and providers from seeking proactive care, says Mary Moffit, PhD, associate professor of psychiatry and director of the resident and faculty wellness program at Oregon Health and Science University.
How the Opt-Out Approach Works
“The idea is by making it opt-out, you really normalize it,” says Maneesh Batra, MD, MPH, associate director of the University of Washington/Seattle Children’s Hospital residency program. Similar approaches have proven effective at shaping human behavior in other healthcare settings, including boosting testing rates for HIV and increasing immunization rates for childhood vaccines, Batra says.
In general, opt-out programs acknowledge that people are busy and won’t take that extra step or click that extra button if they don’t have to, says Oana Tomescu, MD, PhD, associate professor of clinical medicine and pediatrics at the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia.
In 2018, Sofka and her colleagues at WVU conducted a survey that showed that a majority of residents thought favorably of their opt-out program and said they would return to counseling for follow-up care. In their most recent study, published in the Journal of Graduate Medical Education in 2021, Sofka and her colleagues found that residents did just that ― only 8 of 239 opted out of universally scheduled visits. Resident-initiated visits increased significantly from zero during the 2014–2015 academic year to 23 in 2018–2019. Between those periods, program-mandated visits decreased significantly from 12 to three.
The initiative has succeeded in creating a culture of openness and caring at WVU, says second-year internal medicine resident Nistha Modi, MD. “It sets the tone for the program — we talk about mental health openly,” says Modi.
Crucially, the counselors work out of a different building than the hospital where Modi and her fellow residents work and use a separate electronic medical record system to protect resident privacy. This is hugely important for medical trainees, note Tomescu, Gold, and many other experts. The therapists understand residency and medical education, and there is no limit to the number of visits a resident or fellow can make with the program counselors, says Modi.
Opt-out programs offer a counterbalance to many negative tendencies in residency, says Meeks. “We’ve normalized so many things that are not healthy and productive…. We need to counter balance that with normalizing help seeking. And it’s really difficult to normalize something that’s not part of a system.”
Costs, Concerns, and Systematic Support
Providing unlimited, free counseling for trainees can be very beneficial, but it requires adequate funding and personnel resources. Offering unlimited access means that an institution has to follow through in making this degree of care available while also ensuring that the system doesn’t get overwhelmed or is unable to accommodate very sick individuals, says Gold.
Another concern that experts like Batra, Moffit, and Gold share is that residents who go to their scheduled appointments may not completely buy into the experience because it wasn’t their idea in the first place. Participation alone doesn’t necessarily indicate full acceptance. Program personnel don’t intend for these appointments to be thought of as mandatory, yet residents may still experience them that way. Several leading resident well-being programs instead emphasize outreach to trainees, institutional support, and accessible mental health resources that are — and feel — entirely voluntary.
“If I tell someone that they have to do something, it’s very different than if they arrive at that conclusion for themselves,” says Batra. “That’s how life works.”
When it comes to cost, a recent study published in Academic Medicine provides encouraging data. At the University of Colorado, an opt-out pilot program for IM and pediatrics interns during the 2017–2018 academic year cost just $940 total, equal to $11.75 per intern. As in West Virginia, the program in Colorado covered the cost of the visit, interns were provided a half day off (whether they attended their appointment or not), and the visits and surveys were entirely optional and confidential. During the 1-year pilot program, 29% of 80 interns attended the scheduled appointment, 56% opted out in advance, and 15% didn’t show up. The majority of interns who were surveyed (85%), however, thought the program should continue and that it had a positive affect on their wellness even if they didn’t attend their appointment.
In West Virginia, program costs are higher. The program has $20,000 in annual funding to cover the opt-out program and unlimited counseling visits for residents and fellows. With that funding, Sofka and her colleagues were also able to expand the program slightly last year to schedule all the critical care faculty for counseling visits. Cost is a barrier to expanding these services to the entire institution, which Sofka says she hopes to do one day.
Research in this area is still preliminary. The WVU and Colorado studies provide some of the first evidence in support of an opt-out approach. Eventually, it would be beneficial for multicenter studies and longitudinal research to track the effects of such programs over time, say Sofka and Major.
Whether a program goes with an opt-out approach or not, the systematic supports — protecting resident privacy, providing flexible scheduling, and more — are crucial.
As Tomescu notes, wellness shouldn’t be just something trainees have to do. “The key with really working on burnout at a huge level is for all programs and schools to recognize that it’s a shared responsibility.”
“I felt very fortunate that I was able to get some help throughout residency,” says Modi. “About how to be a better daughter. How to be content with things I have in life. How to be happy, and grateful. With the kind of job we have, I think we sometimes forget to be grateful.”