Default Enrollment, Improved Access: The Implementation and Impact of a GME-Wide Opt-Out Mental Health Appointment Program

Abstract

Background: Medical training significantly impacts mental health, with high rates of depression among trainees. This has significant implications for both trainee wellbeing and their patients. Opt-out mental health appointment programs are emerging as an effective strategy, though gaps remain regarding the impact among fellows. Objectives: The objectives of this study were to: (1) assess intern and fellow utilization of mental health resources before and after implementation of an opt-out mental health appointment program at Boston Children’s Hospital, (2) Describe fellow perspectives about the program, and (3) understand the time required by program administrators to coordinate appointments. Methods: An opt-out mental health program was implemented for pediatric interns at Boston Children's Hospital in 2023–2024 and expanded to first-year fellows in 2024–2025, with both programs continuing in subsequent years. The program was offered through the hospital's mental health clinic, the Office of Clinician Support (OCS). Assessment used a mixed methods approach, combining a pre- and post-intervention design with cross-sectional survey data. Results: Engagement with the opt-out program was high among interns (n=56, 90%; n=58, 94%) and first-year fellows (n=91, 71%; n=126, 77%) across two academic years, though interns had significantly higher engagement in each year (Chi-Square = 8.82, p=0.0030; Chi-Square = 8.31, p = 0.0039). The number of trainees with at least one OCS appointment, beyond initial opt-out appointments, increased among both interns and first-year fellows post-implementation, though differences were not statistically significant (Chi-Square = 2.05, p=0.15; Chi-Square = 1.25, p=0.26). Fellow referrals for therapy and medication initiation were significantly higher after program implementation (Chi-Square = 16.54, p.001; Fisher’s Exact p=0.015). Free-text survey responses highlighting what fellows enjoyed about the program revealed three themes: structural accessibility, personalized care, and culture of support. Program coordinators spent approximately 18 minutes coordinating each trainee’s appointment. Conclusions: Engagement with an opt-out mental health program was high across a GME population, with interns engaging at higher rates than fellows. Multiple metrics of mental health access improved following the program, though not all significantly. Fellow perspectives were overall positive, and program coordinator time commitments were manageable. Given high engagement, positive reception, and feasibility, this intervention can be considered in other programs to support trainee wellbeing.