Feeling inadequate: Residents’ stress and learning at primary care clinics in the United States

Abstract

Background: Educators hope that residents’ experiences in primary care continuity clinics will influence more trainees to enter primary care careers. Unfortunately, evidence shows that outpatient primary care training in the United States is stressful and fails to promote primary care careers. We conducted qualitative interviews with residents to understand the source of stress and to explain this failure.

Methods: In-person individual interviews were conducted with 37 primary care residents training at outpatient clinics in the US. Analysis used the constant comparative method and included open and focused coding, allowing themes to emerge inductively from the data.

Results: 73% of residents interviewed reported negative emotions about clinic. Beyond stress, residents reported feeling inadequate as primary care physicians at clinic. Four factors contributed: mental distractions, unfamiliarity with primary care medicine, management of outpatients, and relationships with patients. Residents’ comparisons of hospital-based and outpatient experiences favored the former in relation to the four factors.

Conclusions: Residents feel unprepared for primary care and inadequate as primary care physicians, and these feelings discourage them from practicing primary care. This phenomenon must be studied within the entire context of residency, as residents’ attitudes about their outpatient experiences were shaped in relation to their inpatient experiences.

Acknowledgements

We wish to thank the resident respondents who shared their experiences with us, as well as the Residency Program Directors who helped coordinate access to residents.

Approval for this study was granted from Harvard T.H. Chan School of Public Health Institutional Review Board, approval number 22560.

Disclosure statement

The authors report no declarations of interest.

Glossary

Primary care specialties in the US: Comprises general internal medicine, general pediatrics (plus a combination: med-peds), and family medicine.

Primary care residency training in the US: Follows 4 years of undergraduate medical education. It comprises an internship year and 2 additional years of training in both hospitals and ambulatory care sites. (acgme: accessed November 3, 2017) www.acgme.org/portals/0/pfassets/programrequirements/2017_07_01). One may decide to sub-specialize – i.e. to pursue a fellowship after residency – at any time during primary care training. (Connelly et al. 2003)

Notes on contributors

Joanna Veazey Brooks, MBE, PhD, is a medical sociologist who studies medical education, primary care, and socialization. She is currently an Assistant Professor at the University of Kansas School of Medicine in the Department of Health Policy & Management.

Sara J. Singer, MBA, PhD, is a Professor of Medicine at the Stanford University School of Medicine and Professor by courtesy at the Graduate School of Business. Her research focuses on how organizational leadership and culture impact implementation of health delivery innovations, integrated patient care, and safety of health care organizations.

Meredith Rosenthal, PhD, is a Professor of Health Economics and Policy and Senior Associate Dean for Academic Affairs at the Harvard T.H. Chan School of Public Health. Her research focuses on policies to slow growth in healthcare spending, including changes in payment incentives, benefit design, and behavioral “nudges” to patients and providers.

Alyna T. Chien, MD, MS, is an Assistant Professor at Boston Children’s Hospital and Harvard Medical School. She’s an expert in the use and impact of incentives on health care delivery and a primary care physician.

Antoinette S. Peters, PhD, is a retired educational psychologist, currently corresponding faculty member in the Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School. Her research includes studies of primary care education, feedback, and innovations in medical education.

Additional information

Funding

This research was supported by a grant from the Harvard Medical School Center for Primary Care. JVB was also supported by the Robert Wood Johnson Foundation Scholars in Health Policy Research Program.