Opt-Out Therapy and Why We Should Consider It

Authors: Evelyn Huang, MD (Emergency Medicine Resident, Northwestern University, Chicago, Illinois, @EvelynHuangMD) and Jennifer Robertson, MD, MSEd (Assistant Professor, Emory University School of Medicine) // Reviewed by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Physician burnout is, unfortunately, very common. In the most recent 2020 Medscape Survey, an overall 42% of physicians reported being burned out (1). A meta-analysis of more than 17,500 residents found that 21-43% of trainees screened positive for depression or depressive symptoms during residency and this has increased each year (2).  Burnout and depression are serious problems, because both can lead to poor outcomes for patients and physicians (2, 3).  Burnout can negatively affect a physician’s professionalism, prescribing habits, and increase the likelihood of medical errors (4). Depression also overlaps with burnout and given the high rates of suicidal thoughts in physicians, this is also a concerning issue (1, 5). Thus, both mental health and burnout are issues that should be addressed with concrete solutions. However, unlike diabetes or hypertension, physician burnout and mental health have a social stigma. How can we help those that are tasked with helping others?

As a medical student, I received email surveys several times a year to assess whether I was burned out. However, many do not complete, let alone open or look at, surveys (6). Thus, rather than administering surveys that are often deleted or simply not completed, there may be a better way to help our physicians. Luckily the first step, awareness of the problem, is now widespread. The next step is finding out the best way to fix it, which may be through therapy and mental health care. However, residents and physicians may not automatically seek care due to social stigma. Opt-out strategies, where physicians are automatically scheduled for an appointment with a therapist and given the option to cancel, may be a solution to this problem. Opt-out therapy has been shown beneficial in medicine and thus, may be useful for resident and physician burnout and mental health (7, 8).

Therapy for residents is not a new concept, especially in the field of psychiatry. Studies from the 1950s and 1980s showed that two-thirds of residents sought therapy (9). A look at psychiatry residency training directors in 2010 found that 89% thought that personal therapy was useful for residents but estimated that less than 30% of residents sought therapy (9). While the reasons for the decline may be complex, this presents an opportunity to initiate therapy through the residency leadership. One way to do this is through an Employee Assistance Program (EAP) which provides free and short-term mental health services and referrals (10). One program noticed that residents were not using these services on a voluntary basis, so they scheduled group meetings with EAP counselors for all PGY-1 residents within their first 6 months of training. This introduction to EAP familiarized the residents to the services provided and destigmatized the process. They increased the number of sessions due to the popularity of the program and also found a 250% increase in EAP individual counseling sessions after the introduction of this program (10). By scheduling these sessions that were built into the resident schedules, they were able to increase the number of residents who sought care.

Several barriers to therapy include time, lack of motivation/energy, cost, and stigma (11). Simply advertising well-being services may not be enough to fight these barriers. Opt-out strategies are an attempt to overcome these barriers. A study by Sofka et al. tested an opt-out program where their PGY-1 and PGY-2 internal medicine residents were scheduled for appointments with therapists and given the entire day off, with the option to opt-out and be scheduled for a work day instead. 93% of their residents attended the appointments. The majority of residents responding to their survey stated that they were more likely to use the services in the future when compared to residents who did not attend (12). While this was a relatively small and single-center study, it is exciting that this program may promote the use of counseling in the future.

With more programs adopting this approach, multi-center research is needed to measure its effectiveness. One argument is the cost. The study done by Sofka et al. noted that their program cost approximately $488 per resident (12). However, this cost must be weighed against the cost of the resident who does not seek care and the potential repercussions for themselves and their patients. Another argument against opt-out therapy includes trivializing therapy and implying that everyone is suffering (13). However, one counterargument is that the worst thing that happens is that the resident “wastes” their time. Another counterargument is that residents may learn helpful tips in their sessions to help themselves or even their patients.  Of note, therapy is most helpful if introduced to residents early in their training so that they are familiar and comfortable if they are struggling in the future. One should remember that this is not a forced strategy, but rather, an opportunity to allow residents to be introduced to an optional, yet potentially useful program. Residents can always opt-out.

Opt-out strategies have already been shown to be successful in both medicine and research. For example, sending a survey to a participant (opt-out group) yielded more responses than simply inviting participants to request a survey (opt-in group) (14). This strategy has also been used for behavioral interventions for poorly controlled diabetic patients, with patients who received a letter stating that they were already enrolled in a research study (opt-out) were more likely to participate than patients who were simply invited to join (opt-in) (7). Opt-out options also increase the likelihood of flu vaccinations, with more people getting vaccinated when appointments were already scheduled for them than people who were asked to schedule it themselves (8). In the realm of organ donation, research has shown that default organ donation (opt-out) increases the number of people who choose to be organ donors across several countries (15). A hypothesis suggests that default options imply a recommended action, and that making a decision takes more effort than accepting the recommended default (15).

The opt-out approach may help to introduce residents to services that they may need in a time of crisis (11). In general, opt-out programs work. It is time to take actionable steps to help our residents and physicians. With many residents citing time, cost, and stigma as significant barriers to seeking therapy, opt-out programs may offer an exciting way to counter those hurdles in order to get our physicians the help they need.


References/Further Reading:

  1. Kane, Leslie. “Medscape National Physician Burnout & Suicide Report 2020: The Generational Divide.” Medscape, 15 Jan. 2020, medscape.com/slideshow/2020-lifestyle-burnout-6012460.
  2. Mata, Douglas A et al. “Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis.” JAMA vol. 314,22 (2015): 2373-83.
  3. McClafferty, Hilary, Oscar W. Brown, and Committee on Practice And Ambulatory Medicine. “Physician health and wellness.” Pediatrics 4 (2014): 830-835.
  4. Shanafelt, Tait D. “Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care.” JAMA 12 (2009): 1338-1340.
  5. Wurm, Walter, et al. “Depression-burnout overlap in physicians.” PloS one 11.3 (2016): e0149913.
  6. Baruch, Yehuda, and Brooks C. Holtom. “Survey response rate levels and trends in organizational research.” Human relations 8 (2008): 1139-1160.
  7. Aysola, Jaya et al. “A Randomized Controlled Trial of Opt-In Versus Opt-Out Enrollment Into a Diabetes Behavioral Intervention.” American journal of health promotion: AJHP 32,3 (2018): 745-752.
  8. Chapman, Gretchen B., et al. “Opting in vs opting out of influenza vaccination.” JAMA 304.1 (2010): 43-44.
  9. Habl, Samar, David L. Mintz, and Adrian Bailey. “The role of personal therapy in psychiatric residency training: a survey of psychiatry training directors.” Academic Psychiatry 34.1 (2010): 21-26.
  10. Graessle, William et al. “Utilizing Employee Assistance Programs for Resident Wellness.” Journal of graduate medical education vol. 10,3 (2018): 350-351.
  11. Batra, Maneesh et al. “Improving Resident Use of Mental Health Resources: It’s Time for an Opt-Out Strategy to Address Physician Burnout and Depression (Commentary).” Journal of graduate medical education 10,1 (2018): 67-69.
  12. Sofka, Sarah, et al. “Implementing a universal well-being assessment to mitigate barriers to resident utilization of mental health resources.” Journal of Graduate Medical Education1 (2018): 63-66.
  13. Myers, Michael, and Carol Bernstein. “Should Psychotherapy Be Mandatory for Medical Students/Residents?” Healio, 24 Oct. 2019, healio.com/news/hematology-oncology/20191016/should-psychotherapy-be-mandatory-for-medical-studentsresidents.
  14. Hunt, Katherine J et al. “Participant recruitment in sensitive surveys: a comparative trial of ‘opt in’ versus ‘opt out’ approaches.” BMC medical research methodology 13 3. 11 Jan. 2013.
  15. Johnson, Eric J., and Daniel Goldstein. “Do defaults save lives?.” Science (2003): 1338-1339.

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