1. Identify clinic factors external to the resident that differentiate residents who enjoy their residency clinic experience from those who do not 2. Identify internal affective factors that differentiate residents who enjoy their residency clinic experience from those who do not 3. Identify factors related to resident beliefs about interpersonal aspects of clinic experience that differentiate residents who enjoy their residency clinic experience from those who do not 4. Encourage faculty to monitor, teach and actively foster the development and expression of those factors over which residents have some control in order to enhance their clinic experience

 15+ years of noting there have always been some residents who aren’t happy about clinic › 11% of 775 Pediatric residents dissatisfied with clinic 1  Resident initiated QI studies done on: › Work load unfairness--More Pts for residents whose last names were at front of alphabet (neg. findings) › Tracking flow (flow consistent with FM residencies)  Complaints RE: unhelpful M.A.s, late Pts, too many “difficult Pts” in 15 min appt slots, inconsistent preceptors (outside their control)  “An inability to care for patients is significantly associated with career dissatisfaction” 2

 “The degree to which employees like their job is influenced by a combination of characteristics of the environment, the job, and personality variables.” 3  1996 survey 4 of 119 primary care residents identified 6 job characteristics and 1 personal characteristic as significantly correlated with satisfaction: › 6 th Strongest correlation--Work group loyalty (R=.215) › 5 th --Work that encourages professional growth (R=.224) › Tied for 3 rd --Autonomy & Collegiality (R=.241) › 2 nd --Role conflict (R= -.310) (#1 was?—next slide)

 PA is defined as: “…the extent to which a person feels enthusiastic, active, & alert.” 5  “…a state of  energy full concentration, (flow?) and pleasurable engagement” 5 (  PA)  ↓ PA is associated with dullness/lethargy  “Negative Affect” (NA) is a general dispositional dimension marked by: › Distress and lethargy › Negative mood states such as anger, contempt, disgust, guilt, fear and nervousness 5 (  levels) › Calm, placid, relaxed and serene (If NA is ↓)

 Population n=28 (minus researcher) = 27 › Initial Sample n=23 (- 1 incomplete record) = 22  “How satisfied are you with your outpatient ambulatory clinic experience? › Note: 1= completely unsatisfied, 10 = could not be more satisfied  Negative Skew › X = ,  =  Excluded 5’s & 6’s  Unsatisfied n=7 ( 30% )  Satisfied n=10 ( 43% )  Phase Two n=14 › 6/7 plus 8/10

 Second section was the PANAS-X 6 (1994) › A 60 adjective expansion of the original (1988) “ P ositive A nd N egative A ffect S cale” (PANAS) 5  PANAS made up of the 2 10-item (+\- affect ) scales  PANAS-X 6 added 11 additional affect subscales  Additional adjectives to serve primarily as camouflage  However, we thought we might find additional relationships Instructions: This scale consists of a number of words and phrases that describe different feelings and emotions. Read each item and then mark the appropriate answer in the space next to that word. Indicate to what extent you have felt this way during the past few weeks. Use the following scale to record your answers:

very slightly* a little moderately quite a bit extremely __ cheerful __ sad __ active __ angry at self __ disgusted __ calm __ guilty __ enthusiastic __ attentive __ afraid __ joyful __ downhearted __ bashful __ tired __ nervous __ sheepish __ sluggish __ amazed __ lonely __ distressed __ daring __ shaky __ sleepy __ blameworthy __ surprised __ happy __ excited __ determined __ strong __ timid __ hostile __ frightened __ scornful __ alone __ proud __ astonished __ relaxed __ alert __ jittery __ interested __ irritable __ upset __ lively __ loathing __ delighted __ angry __ ashamed __ confident __ inspired __ bold __ at ease __ energetic __ fearless __ blue __ scared __ concentrating __ disgusted __ shy __ drowsy __ dissatisfied with self with self

 Continuity of Care  Autonomy  Work that encourages professional growth  Collegiality w/ res./fac. › Professional interaction  Work group loyalty › Among residents  Role Conflict  Lasting Relationships with pts was one of my primary reasons for selecting F.M. as a specialty  Building a working relationship involves learning more about one’s Pts than their presenting sxs and medical concerns

 Challenging Relationships (degree to which actively fostering a working relationship with “hard to like” Pts is an essential part of the “art of medicine”)  Supporting staff cohesion (degree to which a positive working relationship currently exists between myself and clinic nurses, M.A.s and front office staff)  Patient adherence (degree to which to the best of their ability, patients generally follow their physician’s treatment recommendations and comply with the recommended treatment plan)

 Correlation of phase 2 questionnaire items with the satisfaction with clinic score  Surprisingly, none of the 6 clinic characteristics that were significant in the 1996 study 4 were significantly associated with our resident satisfaction  Only 1 of the 5 “personal beliefs” was significantly related to satisfaction  Supporting staff Cohesion.801 (p-value=.001) › degree to which a positive working relationship currently exists between myself and clinic nurses, M.A.s and front office staff

Note: Some dots represent >1 data point

 Both NA and the “Hostility” subscale of the PANAS-X were significantly negatively correlated with belief concerning staff cohesion › The lower the resident NA (p-value=.028), and “Hostility” (p-value =.019) the stronger the belief that there is good staff cohesion  “Joviality” was positively correlated with: 1) clinic satisfaction.553 (p-value=.021) Pearson correlation, 2) belief regarding staff cohesion.538 (p-value=.047), 3) desire for lasting relationships.538 (p-value=.047), & 4) belief that Pts do their best to “comply” with their doctor’s tx recommendations.741 (p-value=.002)

 Either residents whose outlook is high in NA/hostility don’t enjoy clinic, or clinic creates NA in certain residents (for reasons unaddressed by this study)  First conclusion fits with emerging research showing happy mood/optimistic outlook precedes success 7 › Physician/researcher who “controlled” for affect in 1997 study has changed his views that disposition CAN change › Resiliency, reflection, self-care, for residents who c / o clinic?  Aspects of clinic & resident beliefs about the nature of family medicine were not big factors (how clinic is run is outside of their control anyway)  Clinic staff cohesion is related to enjoyment  Correlation does not prove causation  Small n (w e hope to replicate with additional residencies)

1. Serwint J, Feigelman S, Dumont-Driscoll M, Collins R, Chan M, Kittredge D. Factors associated with resident satisfaction with their continuity experience. Ambulatory Pediatrics. 2004;4: Devoe J, Fryer G, Hargraves L, Phillips R, Green L. Does career dissatisfaction affect the ability of family physicians to deliver high-quality patient care? Journal of Family Practice. 2002;51(3): Agho A, Mueller C, Price J. Determinants of employee job satisfaction--An empirical test of a causal model. Human Relations. 1993;46(8): Randall C, Bergus G, Schlechte J, McGuinness G, Mueller C. Factors associated with primary care residents’ satisfaction with their training. Family Medicine. 1997;29(10): Watson D, Clark L, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS Scales. Jn of Personality and Social Psychology. 1988;54(6): Watson D, Clark L. The PANAS-X Accessed September 3, Achor, S. The Happiness Advantage: the seen principles of Positive Psychology that fuel success and performance at work. New York: The Crown Publishing Group; 2010.