Open Access Research article

Using focus groups to understand causes for morale decline after introducing change in an IM residency program

Lloyd Rucker1, Johanna Shapiro2*, Cliff Fornwalt3, Keenu Hundal4, Swapna Reddy5, Zarema Singson6 and Khanh Trieu7

Author Affiliations

1 Department of Medicine, University of California, Irvine School of Medicine, Irvine, CA, USA

2 Department of Family Medicine, University of California, Irvine School of Medicine, 101 The City Drive South, Rte 81, Bldg 200, Ste 835, Orange, CA 92868, USA

3 Department of Medicine, University of California, Irvine School of Medicine; VA Long Beach Healthcare System, Long Beach, CA, USA

4 Providence Health and Services, Portland, Oregon, USA

5 The Oregon Clinic, Portland, Oregon, USA

6 Gastroenterology Consultants of San Antonio, San Antonio, Texas, USA

7 Southern California Kaiser Permanente Medical Group, Irvine, CA, USA

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BMC Medical Education 2014, 14:132  doi:10.1186/1472-6920-14-132

Published: 3 July 2014



Although program evaluation is a core requirement of Internal Medicine residencies, little is reported in the literature regarding resident satisfaction with training. Most program evaluation consists of numerical rating scales from which it is often difficult to pinpoint exact sources of dissatisfaction.


Our goal in this work is to evaluate the utility of focus group methodology to uncover in detail the reasons for residents’ deteriorating morale in an IM residency program, as well as to solicit suggestions for correction. This study employed focus groups (FG) in a qualitative research design, in which descriptive statistics from a resident program evaluation survey served to guide an intensive focus group process. Participants were 40 of 45 2nd and 3rd year internal medicine residents enrolled in the IM residency training program. Five chief residents were trained to conduct 5 focus groups with 8 residents in each group. The focus groups examined possible issues contributing to the deterioration of morale noted in the quantitative survey.


Many unexpected themes were uncovered by the FGs. Residents identified the following factors as the major contributors to deteriorating morale: 1) Pace of change 2) Process of change 3) The role of chief residents in change 4) Fear of intimidation and retaliation. Groups also suggested practical recommendations for improving the culture of the residency.


Introducing change in residency training is a challenging process. Respectful attention to resident frustrations and solution-focused discussions are necessary to understand and improve morale. Focus groups proved to be a useful tool in revealing the precise source of pervasive resident concerns as well as providing potential solutions. In addition, FGs methodology can be adapted in a practical manner to residency evaluation.

Education medical graduate; Residency program evaluation; Focus groups; Qualitative research; Morale; Burnout