Education in the Health Professions

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 5  |  Issue : 3  |  Page : 85--95

Supporting resident wellness through reflection on professional identity: A novel curriculum


Diana Toubassi, Milena Forte, Lindsay Herzog, Michael Roberts, Carly Schenker, Ian Waters, Erin Bearss 
 Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada

Correspondence Address:
Dr. Diana Toubassi
Department of Family & Community Medicine, University of Toronto, 440 Bathurst Street, Suite 300, Toronto, ON M5T 2S6
Canada

Abstract

Background: Interventions to address distress among medical trainees often include reflective practice, as well as peer support. Few, however, have emphasized the role of professional identity formation, increasingly recognized as critical to wellness. The structural aspects of curricular interventions have also received little attention. A novel curriculum was therefore designed and evaluated with the goal of understanding how best to support resident wellness through reflection on professional identity. Materials and Methods: The curriculum consisted of 8 2-hour sessions, each focusing on a theme commensurate with residents’ professional identity at the time of its delivery. Two Family Medicine sites at the University of Toronto participated, with residents divided into small groups by residency year. Qualitative data were collected through feedback forms, and resident and faculty focus groups, transcripts of which were subjected to pragmatic thematic analysis. Results: Four major themes were developed relating to 1) the curriculum’s ability to support resident wellness, 2) the importance of protecting reflection, 3) the impact of participants’ professional developmental stage, and 4) the critical role of facilitators. Conclusions: A curriculum encouraging reflection on professional identity appears to support resident wellness. To optimize impact, structural factors such as robust curricular integration, confidentiality and group member continuity, require care.



How to cite this article:
Toubassi D, Forte M, Herzog L, Roberts M, Schenker C, Waters I, Bearss E. Supporting resident wellness through reflection on professional identity: A novel curriculum.Educ Health Prof 2022;5:85-95


How to cite this URL:
Toubassi D, Forte M, Herzog L, Roberts M, Schenker C, Waters I, Bearss E. Supporting resident wellness through reflection on professional identity: A novel curriculum. Educ Health Prof [serial online] 2022 [cited 2023 Mar 31 ];5:85-95
Available from: https://www.ehpjournal.com/text.asp?2022/5/3/85/357121


Full Text



 Background



In an effort to address the concerning prevalence of distress among medical trainees,[1],[2],[3],[4] educational programs have attempted numerous interventions. Those demonstrating the most promise encourage some form of reflection[5],[6],[7],[8] and/or peer support.[9],[10],[11],[12],[13] To date however, there has been little exploration of the ways in which these elements interact, or of the impacts of other, more logistical aspects of an intervention.

The role of professional identity in supporting wellness has also received comparatively little attention. Professional identity is an individual’s self-representation as it relates to their work,[14],[15],[16] and its formation underpins the evolution from “doing the work of a physician” to “being a physician”.[15] Professional identity develops incrementally, in stages over time, leading gradually to a sense of self that integrates “the characteristics, values, and norms of a profession”.[17] When undertaken in a purposeful, adaptive manner, professional identity formation (PIF) provides a unique opportunity to ground trainees in the meaningfulness of their work,[18],[19],[20],[21] supporting both resilience and wellness.[18],[22],[23],[24],[25],[26],[27],[28],[29]

We consequently sought to develop and evaluate a resident wellness curriculum that combined the triad of reflection, peer support and PIF in a novel way. While there have been other attempts to promote PIF in medical curricula (e.g., reflective writing programs, seminar series, etc.),[30],[31],[32] our effort is unique in its simultaneous focus on the postgraduate environment (where trainees are more differentiated and curricular content can therefore be more specific), and explicit interest in wellness. As the integration of the medical humanities into educational curricula has been shown to effectively support PIF,[32],[33],[34],[35],[36] we leveraged their potential contribution in our design.

Our aims were to (1) develop and implement a curriculum that was maximally supportive of resident wellness, and (2) to examine feedback about the curriculum’s structure and content.

 Materials and Methods



Curriculum design

The reflective curriculum was developed by a group of medical educators at our institution, and included two resident representatives. Eight 2-hour sessions were scheduled approximately 3 months apart during the 2-year Family Medicine residency. Given that PIF theory views PGY-1 and -2 as distinct developmental stages, groups were divided by PGY level. Drawing on published literature, extensive educational experience among study authors, and resident representation on the research team, session content was tailored to this developmental trajectory. For example, the first session in PGY-1 revolves around the theme of “responding to a new title,” acknowledging the inherent tensions of transitioning from the role of student to resident physician. Similarly, the final session of PGY-2 focuses on “future authoring,” asking residents to deliberately craft their ideal futures as they prepare to embark on independent practice (Appendix 1).

Each session had a similar overall structure (Appendix 2). This structure was adapted from a highly successful undergraduate program at our institution,[37] with two significant logistical adjustments: (1) we limited all activity to the sessions themselves; unlike medical students, residents were not required to do any pre-reading or post-writing, and (2) there was no formal evaluation of resident performance. These modifications were made in alignment with our focus on wellness (not a primary goal of the undergraduate curriculum), and our attendant attempt to convey to residents that the program existed primarily for their personal benefit.

The small group format was chosen to encourage the incorporation of multiple perspectives,[38] as well as to support engagement with the problematic aspects of “the hidden curriculum,” including failures to effectively communicate with patients, collaborate with colleagues, engage in evidence-based decision-making and ensure patient safety.[39],[40],[41] To encourage the development of local “communities of practice[42] – crucial to the development of PIF[43] – group members (including facilitators) were held constant throughout the curriculum’s duration.

Each session began with a reminder from facilitators of the basic fundamentals such as confidentiality. Then a resident would be asked to volunteer to read a provided companion piece, a short story or poem relevant to the session theme, and a brief discussion would ensue. This functioned as an “ice-breaker” of sorts, and stimulated the beginning of reflection on the relevant ideas. Residents would then be invited to engage in reflective writing in response to one of several prompts, also related to the main theme. After a period of 10–15 minutes, volunteers were asked to share their pieces with the group, and further discussion would occur. If the session time had lapsed, or if the facilitator felt the theme had been exhausted, the session would close with reflection on “meaningful take-aways,” realizations the group had gained from their exchange.

Facilitators attended an orientation prior to the first session. The goals of the curriculum, tips for supporting deep and critical reflection, and practical resources to manage serious concerns were reviewed.

Setting and participants

All Family Medicine residents (50) at two University of Toronto teaching units participated in the curriculum as part of their mandatory academic time (2018–2019). They were divided into 4 small groups in total, each assigned a faculty facilitator from the alternate site.

Study design

We adopted a largely constructivist theoretical approach to evaluate our curriculum.[44],[45],[46] This approach recognizes that “multiple realities exist…that are dependent on the individual,” and that “we construct knowledge through our lived experiences;”[44] it therefore emphasizes methods such as in situ observations and interviews for data generation. We therefore collected brief narrative feedback forms immediately after each reflective session, and scheduled three semi-structured, facilitated focus groups at the end of the academic year, one for each site’s residents, and one for facilitators (Appendix 3). Residents and facilitators were invited to contribute to either the feedback forms, focus groups, or both.

Post-session feedback forms and focus group interview guides were developed from a pragmatic perspective (i.e., seeking to understand which parts of the curriculum worked well and which needed improvement, how effective the curriculum was at supporting wellness, etc.)[47]

REB approval was sought from both affiliated hospitals; one provided approval (Mount Sinai Hospital, REB 18-0227-E) and the other (University Health Network) provided a waiver.

Data collection and analysis

Post-session feedback forms were shared with the study team within a week of each session’s completion. These took the form of short, point-form comments and were used primarily to inform “real time” changes to the curriculum. For example, some early comments voiced a need for a closing sentiment or gesture so that attendees could leave each session with a well-crystallized representation of what had been discussed. In response to this, facilitators were asked to implement the “meaningful take-aways” portion of the session. Similarly, some feedback expressed a concern that some of the companion pieces were overly dark and could be interpreted as negative, and in response, some of the later companion pieces were adjusted to provide a lighter and more optimistic counterbalance.

Focus groups were conducted by two interviewers; neither participated in the curriculum’s conception or delivery. Recordings were transcribed verbatim by an independent transcriptionist, and ranged from 21 to 51 minutes.

Thematic analysis was undertaken using an analytical framework,[48] a flexible tool that adapts well to various epistemological positions and qualitative approaches. Two investigators concurrently and independently analyzed each transcript (DT and each of CS, LH and IW). Interpretive description was used to permit the identification of patterns in the transcripts, particularly with the goal of applying the findings to future curricular plans and interventions.[49] Each pair of authors held iterative discussions to reconcile codes and then populate the code list. In keeping with our pragmatic approach, we strove for sufficiency (rather than saturation);[45],[50] this was felt to be achieved when no new codes could reasonably be identified that contributed further value or meaning. A subset of the study authors (DT, CS, LH, and IW) then grouped similar codes into categories, and developed themes using well-established protocols.[48],[51] Codes, categories and themes were then shared with the larger study team.

Several strategies were employed to maintain rigor throughout. Our theoretical stance recognizes that researchers are shaped by their lived experiences, and that these experiences will necessarily impact the knowledge they generate.[44] To account for this, coders engaged in reflexivity,[52] considering the influence of their own training histories, career trajectories, personal challenges with wellness, etc. These reflections were recorded in writing during the coding process, and discussed verbally during team meetings.

As mentioned, we also strove for intercoder agreement within the initial author pairs, and then through iterative discussion, within the small author subset group. Codes, categories and themes were then crystallized[53] through further engagement with the impressions of the larger project team, the post-session feedback form data, as well as the analysis of an independent research associate. This allowed us to strive for consensus repeatedly, and to ensure that no meaning units had been overlooked. To this end, we actively searched for quotes that contravened or challenged our interpretations.

 Results



Post-session feedback form data were brief, but useful in guiding swift curricular change. For example, early comments voiced a need for a closing sentiment to summarize and synthesize small-group learnings. In response, facilitators implemented the “meaningful take-aways” session conclusion. Similarly, some expressed concern that companion pieces were overly negative; some of the later companion pieces were subsequently adjusted to provide a more optimistic counterbalance.

With respect to the three focus groups, eleven (45.8% of total) residents from one teaching site, three (13.6% of total) from the other, and five (100%) facilitators participated, respectively. As there were no meaningful differences between the data extracted from each of the resident focus groups, their codes and categories were combined in the final thematic analysis [see [Table 1] and [Table 2]]. Four major themes were recognized, as outlined below.{Table 1} {Table 2}

Theme 1. Supporting wellness

Both residents and facilitators believed the curriculum supported well-being. The experience was perceived to be enjoyable and comfortable, and the opportunity for residents to debrief with their peers in a supportive environment, reflect as a group, and share common experiences was considered useful. One resident remarked, “I thought that it was a very space safe space and we were able to share stories that otherwise we wouldn’t have the space to share.”

With respect to the curriculum’s content, residents and faculty facilitators felt that most chosen themes, companion pieces and reflective prompts resonated well. Some commented that some of the material may be emotionally triggering, and that it was beneficial that the sessions had varying degrees of emotional valence (i.e., affirming vs. challenging).

With respect to curricular structure, the small-group format was considered helpful. Many commented that it helped promote peer connection, and that the communal sharing of experiences enhanced coping. One resident commented, “I think that it normalized a lot of experiences and worries that we have through residency… seeing that we weren’t the only ones.”

Interestingly, facilitators themselves experienced the opportunity for reflection as therapeutic and evocative. One faculty member stated, “reflecting with the residents was also very enriching for myself. That’s maybe a bit of a selfish comment, but that was a benefit of doing it, because I think that the topics that were covered were relevant even at my stage. So, we really were able, I think, to do the exercises together, which was a neat experience.”

Theme 2. Promoting and protecting reflection

The curriculum was generally reported to support reflection quite well. The number of sessions per year, the amount of time between sessions, and the length of the sessions were all felt to encourage comfort within the reflective groups:“With anything like this you are going to have people being more shy to participate in the beginning and then as the group sort of gets to know each other deeper, a little bit over the course of the year then people are going to be more open to sharing.”

Residents commented that there was a tension between providing too few sessions (which would not allow a reasonable level of familiarity to develop) and providing too many (which would reduce time for other academic work in a relatively short residency program).

Both residents and facilitators appreciated the structure provided, but also remarked on the benefits of flexibly deviating from this structure when indicated. One resident state, “I feel like it was nice to debrief and have somewhat of a structure to talk about. And some of the more meaningful conversations that we had were also going off script.” Similarly, one facilitator commented, “I think it is hard because you can’t really set one approach. I think it really depends a lot on the day and on the participants and I think it helps if you can be a bit flexible about having some stuff to go with if you need to.”

Facilitator continuity was considered critical, as was the confidentiality of the discussions, and the need for sharing within the groups to remain voluntary: “You shouldn’t push people to volunteer and speak if they don’t feel comfortable speaking, especially when you are talking about personal experiences.”

Both residents and facilitators stressed the need to protect the reflective experience in a number of ways. For example, it was considered quite important that the sessions be scheduled during mandatory academic half-day time, as this telegraphed the curriculum’s value relative to other academic responsibilities. Further, doing so meant that participation did not encroach upon their personal time (which would itself have compromised wellness). Residents also considered it important that facilitators not be based at their home training site. One resident remarked, “I felt that was helpful, in having somebody who is not evaluative, so that you know people could feel more open to sharing things.”

Theme 3. Impact of professional identity formation

Facilitators were more attuned than residents to the correlation of session themes to residents’ stages of training. For example, one facilitator spontaneously noted that “the prompts were superbly chosen for the various stages of the year, that was one of the general impressions, was that they really were thoughtfully chosen to elicit the kind of response that I think that they were hoping to elicit.”

In contrast, residents’ references to PIF were mostly implicit, alluding to the later stage of their facilitators and the process of progressing to that stage: “[facilitators] would reflect on their time as a resident versus their time as a staff and how things changed. And I think having that perspective for us having a staff versus… it is nice sharing with residents and knowing that everyone is in the page but also hearing that the staff have been there too. And that it gets better, and this is what you can do in the future.”

While residents entertained the idea of combining PGY-1/2 reflective groups, facilitators felt this would be suboptimal due to the different PIF stages of the two cohorts.

Finally, it is worth noting that facilitators spontaneously noted the importance of explicitly addressing PIF in a wellness curriculum: “They spend so much time learning medicine topics, let’s say like management and diagnosing people. But I think the more that you do the more you realize that medicine is much more than medical topics right? And there are all of these issues and boundaries and relationships and dealing with difficult times. And medical schools are definitely trying to start thinking about these types of issues. And it definitely makes more sense to continue this, because it is just as an important part of the jobs that we do and the careers that we have as the medical topics.”

Theme 4. Facilitator role

Residents and facilitators all felt that the facilitators played a significant role in the success of the curriculum. Residents noted that facilitators deftly alternated between guiding the sessions, bearing witness to residents’ stories, and offering their own experiences. The latter seemed to be particularly appreciated: “Our facilitator would participate, share their own stories, like get really involved and was really supportive of our point of view. And would reflect on their time as a resident versus their time as a staff and how things changed…I found from our point of view that that was a very good use of the role.”

Facilitators themselves perceived their purpose to be multi-faced, including the encouragement of resident connections, the provision of permission to share experiences, the positioning of residents to move onto the next stage of training or practise, and the offering of mentorship and guidance.

 Discussion



Using a pragmatic constructivist approach, our study demonstrates that a small-group reflective curriculum focused on PIF successfully supports resident wellness. To our knowledge, this is the first demonstration of such an effect in the literature, particularly at the post-graduate level, and therefore offers great promise to programs who are struggling to identify evidence-guided approaches to support resident wellness.[54]

Our study also demonstrates that the logistical aspects of the curriculum require extreme care. For example, the number of sessions per year must be intentionally chosen to optimize group bonding without compromising the remainder of the training program. Continuity of group membership must be maintained to foster peer-peer as well as peer-facilitator relationships. Inclusion in the mandatory academic program was also found to be key. These observations are in keeping with the literature on reflection and reflective portfolios in medical education, which confirms the importance of genuine, trusting interactions, mentorship and guidance, as well as robust curricular integration.[55],[56]

Related, both the structure and content of the curriculum is critical. While a reflective framework is necessary, this is ideally viewed more as a guide than a rigid template.[57],[58] The content of the sessions must also strike reasonable and varying emotional notes (with a balance between more positive and challenging material across the curriculum), and include a meaningful closing gesture or summary at the end of each session to consolidate any achieved insights. Also of importance, multiple measures must be instituted to protect deep reflection.[59],[60] It was quite clear in our data that residents require the reassurance of confidentiality and the non-evaluative relationships with their facilitators to disclose potentially sensitive experiences. In the same vein, all participation in discussion should remain strictly voluntary.

Facilitators’ contributions also cannot be overstated. They help secure an appropriate reflective environment, deciding when to share or listen, and must exercise skill in deciding when to share and when to listen, how best to guide reflections, how to grapple with uncertainty and complexity, and how to manage residents’ more emotional responses.[60] To this end, robust facilitator orientation prior to the onset of the curriculum is critical.[59]

Finally, it is interesting to note that perceptions of the curriculum varied somewhat with professional developmental stage. For example, later stage facilitators viewed PIF as a major function of the curriculum, while residents focused more on proximal benefits, such as the opportunity to share with peers. Similarly, while residents mused about combined PGY-1/2 reflective groups, facilitators recognized this would compromise the sequential nature of the stage-relevant themes. We do note that more generally, the concept of PIF was not observed frequently or spontaneously in focus group discussions (particularly the resident ones). This dovetails with suggestions that PIF is a relatively opaque process to most trainees, and that explicit efforts must be made to address it in pedagogical activities.[42] We have therefore renewed our emphasis on PIF in more recent iterations of the curriculum, making it a more clearly defined learning objective and coaching our facilitators on the importance of highlighting its role during sessions.

Our study has several limitations. Although the entire resident cohort of two teaching units participated in the curriculum, only a portion provided feedback in this study. Our results may therefore have excluded the potentially divergent viewpoints of those who declined participation. Another potential methodological concern is that the focus group format may have been biased against more introverted participants, who may have preferred to provide their feedback in other ways, such as one-on-one interviews. In addition, as our curriculum was piloted in the Department of Family and Community Medicine, it could be argued that other residency programs may have varying needs or reactions to such a curriculum. However, we invested substantial effort in crafting a program that was both transferable and scalable. In fact, we have already collaborated with other residency programs at our institution, and are supporting efforts to pilot the curriculum in these programs with only minimal adjustments to Family Medicine-specific content.

 Conclusions



Our study demonstrates that a curriculum encouraging reflection on professional identity enhances resident wellness. This is likely because the process of PIF, when rendered explicit, becomes an opportunity for trainees to participate fully and deliberately in the “making” of their own professional selves. Such involvement and agency cannot help but improve the odds that the identities developed will better integrate the core values of the profession, as well as support both short- and long-term wellness. It therefore behooves us as educators to further explore this phenomenon, and to implement effective programmatic initiatives to support it.

Acknowledgements

The authors would like to thank the faculty and residents who participated in this study, as well as Soumia Meiyappan and Shelly-Anne Li for their assistance with recruitment and data analysis.

Financial support and sponsorship

The authors are grateful for the support of the University of Toronto Department of Family and Community Medicine “Art of the Possible” grant, and for a stipend from the Thomas Geleff Fund.

Conflicts of interest

There are no conflicts of interest.

Appendix 1. Curriculum Session Content

PGY1, Session 1: Responding to a New Title

Companion piece, “First Night Call”1

The transition from medical school to residency is a highly challenging time for many trainees, involving a significant number of personal and professional changes, as well as increased responsibility and independence.

Reflecting on the last few months, write about one of the following:

- a time when your idealism was challenged

- what it feels like to be addressed as “Doctor”

- something that has surprised you about your new role

- what has worried you most about your new role

PGY1, Session 2: Preventing/Managing Burnout

Companion piece, “Who would want to do this?”2

The life of a physician, especially an apprentice physician, is a demanding one. It is emotionally, cognitively and physically taxing, and requires significant personal investment and sacrifice.

Write about one of the following:

- a time when you ignored your own physical or emotional signals at work

- the last time you perceived yourself as healthy

- a letter to yourself

- a time when you derived meaning from your work

- something significant you are sacrificing for your training

PGY1, Session 3: Patient-Physician Boundaries

Companion piece, “The Birthday Party” 3

Boundaries create an appropriate therapeutic distance between patients and their physicians, allowing for safe, objective care. Boundaries may sometimes be difficult to negotiate however, and can occasionally be blurred or crossed.

Reflecting on your experiences as a resident to this point, write about one of the following:

- a time when you got too close to a patient

- a time when it felt challenging to maintain distance

- a patient you could not stop thinking about

- a time when you accepted a gift from a patient

PGY1, Session 4: A New Social Identity

Companion piece, “Sister First, Doctor Second” 4

Being a physician can have various social implications, many advantageous, some not.

Write about one of the following:

- a time you received a medical request from someone you know socially

- a time when you struggled as physician due to your age, gender, race, etc.

- a time when being a physician conflicted with another one of your roles

- a time when you benefited socially from being a physician

PGY2, Session 5: Unresolved Cases

Companion piece, “An Intern’s Guilt” 5

As you move into your second year of residency, you are accumulating clinical experience and maturing into your role as a physician. This often includes a variety of lingering feelings about the cases you have encountered.

Write about one of the following:

- a clinical incident that is emotionally unresolved

- a case which provokes feelings of guilt or regret

- a patient or family that you continue to think about

PGY2, Session 6: Becoming a Family Physician

Companion piece, “Playing a hunch” 6

You are training not only to become a physician, but a family physician. This has varying implications, depending on your perception of the unique identity of family physicians.

Write about one of the following:

- a time when I felt I was really acting as a family physician

- the hardest thing about being a family physician

- what brings me a sense of purpose as a family physician

- a time when I felt I was following the core values of Family Medicine

PGY2, Session 7: Reflecting Back

Companion piece, “Miles Together”7

Your education and apprenticeship have been a long and demanding, and have provided you not only with knowledge and skills, but with a novel professional identity. You now prepare to conclude your residency in the coming months. As you reflect back, write about one of the following:

- if you could start over, what would you do differently?

- the ways you have changed as a result of your training

- something you wish you had known when you started

- the rewards and costs of the path you have walked

PGY2, Session 8: Future Authoring

Companion piece, “What does it mean to be a personal physician?” 8

You are near the completion of your formal training, and stand on the precipice of independent practice. As you prepare to embark on a new chapter in your career, think carefully and deliberately about what would constitute your ideal future.

Write one of the following:

- a detailed description of your ideal day 5 years from now

- your thoughts about a physician you deeply respect

- your retirement speech

- advice you would give to a junior mentee

References

“First Night Call.” Pulse: Voices from the Heart of Medicine, 9 Jan 2009, http://pulsevoices.org/index.php/pulse-stories/46-first-night-call.

Beard, Kristin. “Who would want to do this?” Pulse: Voices from the Heart of Medicine. 07 July, 2017. http://pulsevoices.org/index.php/pulse-stories/ 1110-who-would-want-to-do-this.

Scholtens, M. The birthday party. Can Fam Physician 2017; 63(1): 54-55.

Sediqzadah S. Sister First, Doctor Second. N Engl J Med. 2019 Jul 11;381(2):108-109.

Kaltsas, Anna. “An Intern’s Guilt.” Pulse: Voices from the Heart of Medicine, 11 Dec 2009, http://pulsevoices.org/index.php/pulse-stories/96-an-intern-s-guilt.

Crawford- Faucher, Amy. “Playing a hunch.” Pulse: Voices from the Heart of Medicine. 8 Dec, 2017. http://pulsevoices.org/index.php/pulse-stories/1216- playing-a-hunch.

Denniston CR. A piece of my mind. Miles together. JAMA. 2011 May 11;305(18):1840-1.

M.D. Robinson & L.A. Robinson. What does it mean to be a personal physician? A father’s advice to his son. J of Am Brd of Fam Med 2013; 26 (1): 96-97.

Appendix 2. Curriculum Session Structure

Each session adheres to the same basic structure:

Facilitators remind residents of the basic fundamentals (e.g., confidentiality, putting away electronic devices, etc.).

A resident is asked to read a provided companion piece, a short story or poem relevant to the session theme, and a brief discussion ensues. This is intended to function as an “ice-breaker” of sorts, and to stimulate the beginning of reflection on the relevant ideas.

Residents are then be invited to engage in reflective writing in response to one of several prompts, also related to the main theme.

After a period of 10–15 minutes, volunteers are requested to share their pieces of writing with the group, and further discussion occurs.

When the session time lapses (or if the facilitator feels the theme has been exhausted and further discussion is unlikely), the group closes with reflection on “meaningful take-aways,” realizations each participant has made from their exchanges.

Appendix 3. Data collection

A.Post-session feedback form

Please reflect on your session today and provide brief responses to the following:

What did you think of today’s session elements (theme, reflective prompts, discussion, etc.)?

What did you like about the session?

What would you recommend changing about the session?

B.Resident focus group questions

1. Tell me about your experience with the Portfolio curriculum.

Prompts:

- What did you think of the themes for each session? Did they resonate with them?

- What did you think of the reflective prompts? Were they too general? Too specific? Did they make you think?

- What did you think of the companion pieces that came with each session? Were they relevant?

2. What was your understanding of your role as a resident member of the group?

3. What was your understanding of the role of the faculty facilitator?

4. Was it helpful to have a facilitator who you did not work with clinically?

5. Do you have any other thoughts about how your group functioned?

Prompts:

- Did everyone have a voice?

- Did people feel comfortable sharing personal experiences?

- Was it a supportive environment?

6. Do you have any general comments on the logistics of the sessions (e.g., size, location, duration, timing)?

Prompts:

- size of the small groups?

- locations? Appropriate to foster safety and openness?

- duration of the sessions? Was 2 hours too long or too short?

- timing of the sessions during the academic year? Spaced out appropriately? More or fewer meetings?

7. What was your perception of the role of the Portfolio curriculum in your residency?

8. What do you think you took away from the curriculum?

Prompts:

- Did it help foster reflection?

- Did it support your wellness?

- Did it foster connections between you as residents? Between you and your facilitator?

9. Do you think the curriculum should continue to be offered going forward?

10. What changes, if any, would you recommend?

C.Faculty facilitator focus group questions

1. Tell me about your experience with the Portfolio curriculum.

Prompts:

- What did you think of the themes for each session? Did they resonate with residents?

- What did you think of the reflective prompts? Were they too general? Too specific? Did they make residents think?

- What did you think of the companion pieces that came with each session? Were they relevant?

2. What was your understanding of your role as the faculty facilitator?

3. What was your understanding of the role of the residents?

4. Was it helpful to facilitate residents who you did not have work with clinically?

5. What was the most challenging part of being a facilitator?

Prompts:

- Was it difficult to encourage everyone to contribute?

- Did you ever worry about a resident’s wellness or safety? How did you manage that?

6. Do you have any other thoughts about how your group functioned?

Prompts:

- Did the residents feel comfortable sharing personal experiences?

- Did you feel comfortable sharing your own experiences?

7. Do you have any general comments on the logistics of the sessions (e.g., size, location, duration, timing)?

Prompts:

- size of the small groups?

- locations? Appropriate to foster safety and openness?

- duration of the sessions? Was 2 hours too long or too short?

- timing of the sessions during the academic year? Spaced out appropriately? More or fewer meetings?

8. What was your perception of the role of the Portfolio curriculum in residency?

9. What do you think residents took away from the curriculum?

Prompts:

- Did it help foster reflection?

- Did it support resident wellness?

- Did it foster connections between residents? Between you and your residents?

10. Do you think the curriculum should continue to be offered going forward?

11. What changes, if any, would you recommend?

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