Residents Vote! A Framework and Toolkit to Improve Resident Voting Rates Open Access

Elections have a substantial impact on health care, affecting our patients, communities, and educational environments.¹  However, physician voting rates are 6 to 14 percentage points lower than the general population and further lag other professionals.^2-5  This low turnout rate may impact the ability of medical professionals to influence health policy, especially as recent court decisions constrain regulatory experts’ authority.⁶ 

Graduate medical education (GME) training is an important time for physicians’ professional identity formation.⁷  Involving residents and fellows in the electoral process and emphasizing the role of their advocacy may facilitate lifelong involvement, and this may impact governmental policy and patient care. Prior investigations have found that trainees are highly motivated to vote, yet they experience unique barriers to voting, such as scheduling conflicts beyond their control and being unregistered after having recently moved to a new voting jurisdiction for training.^8-12  We found only one study on reducing these barriers, which used peers to encourage resident voter registration in a single program.¹³ 

To remove barriers and emphasize voting as part of a physician’s professional identity, we examined the feasibility and acceptability of a centralized, institution-wide approach to improve GME trainee awareness, registration, and participation in the electoral process.

Our framework was developed and implemented at Henry Ford Health (HFH), an integrated health system in southeastern Michigan. All trainees (843 residents and 198 fellows in accredited GME programs) were invited to participate. HFH Government Affairs (GA) provided expert speakers for informational sessions (described below) and ensured that all content was nonpartisan. Individual framework components (Figure 1) were developed based on authors’ expertise in GME administration, advocacy, and GA. We follow the DoCTRINE guidelines to report this innovation (online supplementary data).¹⁴ 

During June 2023 GME orientation, all new HFH trainees (N=240) were instructed on how to register to vote in their current jurisdiction and how to join the permanent absentee ballot list. On National Voter Registration Day (September 19, 2023), an email was sent to all trainees with deadlines to register to vote and request mail-in ballots. The emails also included links to nonpartisan information on candidates and issues and encouraged residents to use mail-in and early voting. Another similar email was sent 6 weeks prior to the Michigan presidential primary election (February 27, 2024).

We created 2.25-inch campaign-style wearable buttons with a QR code from Vot-ER (Figure 2).^15,16  Scanning the QR code led to a website where users could check their voter registration, register to vote, request a mail-in ballot, and learn about voting.¹⁷  Considering trainees’ busy schedules and the amount of information they must absorb, we felt that persistent contact could serve as “cues to action” that would aid in changing behavior.¹⁸  The buttons were distributed to all trainees who attended an informational session prior to the primary election. Each of these sessions featured expert speakers from GA who covered political and legislative processes, the role of GA in advocating for the health system, opportunities for physician participation in advocacy, and important topics for the upcoming election. Careful emphasis was on encouraging all eligible residents to vote, not telling them how to vote. The sessions were scheduled at each GME primary site for the institution, replacing regularly scheduled didactics for the largest program. All residents at the site were invited to attend, and lunch was provided.

The primary outcome was whether trainees voted, which was assessed using the existing GME weekly text message feedback system. This system sent a weekly question via text message to all trainees at HFH, to a phone number of their choice, except to those who opt out; responses are anonymized. On election day, we used this system to ask trainees whether they voted (Table).

To help other institutions replicate this project, we created the Residents Vote! GME Toolkit.¹⁹  Feedback from a nationwide group of GME leaders at the Association of American Medical Colleges (AAMC) GME Leadership Development Certificate Program was incorporated into the final toolkit.

This project was determined to be nonhuman subjects research by the Henry Ford Health Institutional Review Board.

We conducted 4 informational sessions between January 18, 2024, and February 7, 2024. One hundred fifteen of 1041 (11%) trainees attended the sessions, which required a total of 5 hours of time from 1 faculty and from 2 GA personnel. Each session had food provided by GA and a $50 gift card drawing. As of May 17, 2024, the button QR code had been scanned 22 times (cost for 1000 buttons: $450, paid by GME office).²⁰  The text message question was sent to 826 trainees (cost: $20), and 123 responded (15%). Responses to the text message question are shown in the Table. Excluding trainees who were ineligible to vote (n=42) and counting those who affirmed that they already voted or would vote by the times polls closed (n=14 + 21), text survey respondents reported a 43% (35 of 81) voting rate for the 2024 Michigan presidential primary election. This compares favorably to the statewide rate of 23%.^21,22 

The Residents Vote! GME Toolkit¹⁹  is an online open-access resource that was created by the authors and took approximately 10 hours to develop. It provides references to published data, advocacy resources, and tips for GME leaders to engage with institutional GA and legal offices. It includes an email template generator to introduce the initiative to senior institutional leadership, and language to send to all trainees prior to elections. The toolkit allows institutions to use their own Vote-ER code to track their impact.

We received informal positive feedback from multiple trainees at the informational sessions and from GME leaders at the AAMC program.

This multistep intervention, including orientation materials, informational sessions, materials to facilitate registration, and voting reminders, was implemented institution-wide with low resources and costs, and appeared acceptable to trainees.

The multistep approach was designed to deliver information over time and, given trainees’ busy schedules, to reach trainees at different points during the year, from new trainee orientation through election day. Wearable buttons and text messages could act to remind those who may have deprioritized voting among other daily activities. Although many trainees view voting as an important civic duty and are intrinsically motivated to participate, in this intervention few attended the informational sessions and few responded to the text message queries.^8-11  As residents and fellows are accustomed to receiving frequent emails and other information, voting reminders may become part of information overload, or “noise.” It is not known if the residents who reported voting in our project would have voted in the absence of this program, although we suspect far fewer would have voted. Repetition of this approach, over each year of training and starting in medical school, may be needed to substantially change resident and fellow voting behaviors. The benefit of introducing voting as professionalism during training may be that behaviors learned during residency often persist decades into the future.⁷ 

Our program was developed around the 2024 presidential primary election and continued in the run-up to the 2024 general election. In June 2024, all new residents received voter registration forms and wearable buttons. The GME toolkit¹⁹  was used to create an email sent to all trainees on National Voter Registration Day in September 2024. Program coordinators also had wearable buttons to give to trainees. A systemwide voter information push was launched by GA with educational sessions open to all employees as well as GME trainees. We plan for voter and election awareness to be an ongoing effort.

This intervention was developed for a large institution with active GA leadership (GA is our advocacy arm, sometimes referred to as “government relations” at other hospitals and universities) and thus may be less feasible in other settings. Participation in the informational sessions, QR scanning, and text message outcome assessment was voluntary; thus, the generally positive feedback from trainees may not be generalizable to the entire GME population. Without prior years’ information regarding trainee voting or data on actual voting by trainees in this election, the effect of this intervention on voting is unknown. In addition, this study was conducted around the 2024 presidential primary election, and support of leadership and trainee participation may vary in other elections.

We will continue this initiative for future elections and will work on improved data collection to better characterize the effectiveness of each intervention. Accurate measurement of trainee voting rates is a key metric that we continue to explore, and we would welcome ideas from the GME community. For example, it may be possible to get public records on individual trainee voting histories, though it would require additional resources and may be perceived as intrusive. We also hope to distribute the toolkit¹⁹  widely to allow others to implement this framework, and we welcome any suggestions for additional content.

We implemented an institution-wide, multistep framework, including new trainee orientation materials, informational sessions, texts, and other reminders, to improve our residents’ and fellows’ voter registration and participation in local and national elections. The interventions were low resource, appeared acceptable to trainees, and are sustained. From this work, an online open-source toolkit was developed to allow other institutions to replicate this effort.

The authors would like to thank Dr Emily Irvin, Dr Katherine Joyce, and Elizabeth Kutter who helped with the collection and dissemination of preliminary data that formed the basis for this study. The project would not have been possible without the support of Marc Corriveau, Taylor Neumann, and Barry Blackwell from Government Affairs, and Dr Kimberly Baker-Genaw and Dr Karla Passalacqua from Graduate Medical Education. They also want to thank Dr Kathryn Andolsek who encouraged the publication of this work and provided helpful feedback.

The online supplementary data contains the DoCTRINE guidelines used in this study.

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

This work was previously presented as a poster presentation at the Association of American Medical Colleges Council of Faculty and Academic Societies, Group on Resident Affairs, and Organization of Resident Representatives 2024 Joint Spring Conference, April 2-4, 2024, Arlington, Virginia, USA.