Assessing Resident Well-Being: Ethical Considerations for Researchers When Conducting Qualitative Wellness Research With Resident Populations.

BACKGROUND Resident-related research is pervasive throughout medical literature. Frequent areas of investigation include physical stress, burnout, and mental health. These critical studies aid in the improvement of curriculums, augmentation of resources, and over-all advancement of training programs. As a go-to convenience sample, residents are routinely approached to participate in a variety of studies during their training. These studies are frequently resident and faculty led, from within their current institution or those of potential future fellowship training or professional positions. Residents’ high-levels of education and in-depth knowledge of scientific practices belies the vulnerability of this captive group. The complexity of resident status within the hierarchy of graduate medical education structures and the factors motivating them to participate in scientific inquiry need to be investigated. Ethical considerations regarding residents’ diminished states of health during these intense years of training and the collection of health-related data should also be examined. In the current literature, issues related to coercion, collection of sensitive data, and participant risk are underdeveloped for resident participants in scientific study. We illuminate this through examples of research into rising rates of burnout, depression, and suicide during residency.1 Identifying mitigating factors for improving resident wellness is a priority among training programs, ours included.1 When designing a research study focused on resident wellness, we sought to explore the impact of rigorous training on those closest to the residents—their loved ones. The reciprocal and intimate relationship of residency stressors on residents and loved ones, potentially amplifying or dampening burnout and related issues, had not been previously described. To address these knowledge gaps, we previously designed an exploratory qualitative study that sought to collect the perspectives and experiences of those closest to surgical residents.2,3 This group included spouses, parents, and others identified by trainees as primary supporters. A semistructured interview protocol was developed to elicit information regarding participants’ own wellness, perceptions of their residents’ wellness, experiences with the resident during training, and perceptions of residency. The goal of this study was to establish foundational knowledge about the implications of surgical residency on loved ones and their perceptions of their resident’s well-being. Planning this study required attention to important ethical concepts, such as who would interview the participants and what to do with sensitive responses. As more resident well-being studies are conducted, similar issues must continue to be carefully considered. Here, we present our experience to help inform future researchers on ethical practices conducting qualitative studies with resident participants. ETHICAL DILEMMAS IN QUALITATIVE RESEARCH WITH RESIDENTS Qualitative research is used to explain, clarify, and elaborate on different aspects of the human experience. Common ethical dilemmas in qualitative research ranging from those that affect the wellbeing of the participant (personal distress, identification, and exploitation) to the integrity of the project (misrepresentation, bias, and intervention) have been previously described4; however, due to the dynamic nature of qualitative work, even after theoretical dilemmas are addressed, ethical ambiguity can persist in practice. Our team, therefore, considered strategies to mitigate the frequency and manage the occurrence of such dilemmas. CONFIDENTIALITY AND CONSENT In studies evaluating resident wellness, the issue of confidentiality can quickly become complex and has been previously noted as a sensitive area. Some studies involving medical trainees are exempt from Institutional Review Board oversight under the premise of education-based research.5 To proactively address this issue, it is important that qualitative investigators formulate plans to minimize potential harm to participants. The bioethical principles of nonmaleficence and respect for autonomy mandate that participants be educated on all aspects of the study to promote informed decision-making. Through this framework, individuals become willing participants rather than merely means to the research end. This shift involves discussing, in clear and simple language, the nature of the study, the participants’ role, the identity of the researcher and the financing body, the objective of the research, how data will be collected and analyzed, and how the results will be published and used.6 Caution is necessary when asking trainees to participate in research being conducted by a peer or faculty member with whom they train. Altruism and desire to contribute to scientific discovery should not be assumed. The training experience involves seeking approvals and endorsements needed to move to the next step of the educational process. There is an inherent desire for approval, to be seen as collaborative, and to be well-liked. It is easy to underestimate these informal demands of a microprofessional culture. Importantly, consent must be viewed as a process rather than a single event. Participants must be made aware that they may revoke consent at any time during the research process and assured that any information they shared will be removed from analysis. In our study, engaging residents and supporters in the consent process was crucial. Residents were first solicited for participation by a nonclinical faculty member and asked to identify a primary supporter. Residents then forwarded supporter contact information to the study team. Resident choice to participate and self-designate supporters was at the core of the methodological design. Member checking—a method of respondent validation in which data are returned to participants to check for accuracy and resonance with their experiences—not only provides a useful method of data validation but also extends the consent process to allow for reflection on the data they have contributed, how it was analyzed, and interpreted.7 Residents also were included in our member-checking process. Participants were asked to review data with their resident and both consents were required for inclusion in the final articles. PARTICIPANT PROTECTIONS AND ANONYMITY The inherent purpose of information gathered in research is study and dissemination. A researcher, therefore, has 3 key obligations to research participants: (1) to protect them from potentially harmful consequences that may result from participation; (2) to preserve participant autonomy; and (3) to ensure reliability of scientific inquiry.4 Dictated by these obligations, identifying information must be vehemently protected across all circumstances. Our study was a resident-led project. The study team included both a resident clinician and nonclinician behavioral researchers. The collection of wellness narratives added further complexity to confidentiality because of the collection of and access to sensitive personal and health-related data about colleagues. Stigma is still attached to struggles with mental health in residency; this is coupled with the social desirability to be presented in a favorable manner.8 Ethically gathering data from peers is possible, but requires further caution and care.9 In our study, to mitigate possible breaches of confidentiality, the resident researcher recused themselves from conducting interviews with supporters of residents from their specific residency program as well as individuals they had interacted with personally or professionally. These data were collected by the behavioral researcher who had no such connections to the participants. When designing our study interview guide and data collection protocols, thought was given to the possible disclosure of worrisome mental health information or indication of impending physical harm. When suicidal ideation is present, a healthcare provider assessing a patient has a duty to act. Researchers have different obligations. Ethicists have argued that the primary role of the researcher is solely to “produce knowledge, not [judge] the activities of research participants.”10 When sensitive situations arise, “the moral obligation of researchers is to refer participants to counseling or ensure that they have regained control of the situation by talking. In some cases, a follow-up phone call or visit may be appropriate.”6 Of note, a nonclinician researcher acting in accordance with research ethics is not exempt from feeling moral angst when holding difficult information. Anticipating this need, we created a mental health access guide to distribute to participants. Some conversations in our study were highly sensitive in nature and elicited heavy emotional responses from some participants. Intense levels of worry, frustration, fear, and anger were communicated, including descriptions of the vulnerability of study participants and the residents they supported. In these instances, we ended the interview with a debriefing on institutional, local, and national mental health resources the participant and their resident could access; the mental health resource guide was shared electronically. Lastly, anonymization of participant data must be thorough. Qualitative interviews contain intimate narratives with numerous identifiers. Personal and health-related information should not be recognizable by peer researchers during the data structuring and analysis process as it may have important negative ramifications. Guarantees of anonymity are foundational to the mutual trust that permits qualitative research to take place.6 As such, the rich data obtained from participants can create opportunities for insights and inform future strategies for improving trainee wellness. Medical training communities can be small. For example, our general surgery residency welcomes seven trainees each year. Camaraderie and close relationships develop, both within, across, and beyond residency programs. For this study, anonymity was protected by having a behavioral researcher initially manage data derived from participants associated with the resident researcher. Once these transcripts were anonymized and related data coded, the resident researcher was given access. This protocol enabled the resident researcher to engage with the data once identifiable elements were removed. STRATEGIES TO MITIGATE OCCURRENCE OF ETHICAL DILEMMAS Consideration of ethical dilemmas should begin at a project’s inception. Investigators should refrain from soliciting information that is not closely related to the research question. Consent is an ongoing process that lasts from study initiation to publication and must be continuously reinforced through open dialogue, goal transparency, and member checking. Researchers must clearly identify and define their role—to themselves, the team, and the study participants. This should be discussed in depth during the informed consent process. When possible and if resources exist, we recommend partnering with nonclinician researchers to assist with collection of qualitative data. Finally, despite best efforts, some ethical uncertainty is almost inevitable. Therefore, when ethical dilemmas arise, we encourage researchers to consider consultation with their institutional research ethics committee. CONCLUSIONS In qualitative research that includes residents as participants, potential ethical issues can arise regarding motivations for participation, participant protections, and anonymity. These issues require careful consideration by investigators, especially when exploring wellness with peers as part of the research team. An open and continuous informed consent process decreases ethical ambiguity through participant buy-in, accurate representation, and clear expectations. The methodological design should consider how the study team may influence motivations for participation. To avoid participant identification, a thoughtful methodological design is key. Each study requires a specially tailored approach. Proactive efforts may mitigate risk of harm to participants while maintaining the quality of scientific inquiry.