Evaluating Wellness Interventions for Resident Physicians: A Systematic Review

BACKGROUND

Wellness initiatives implemented by graduate medical education programs can help mitigate burnout in resident physicians.

OBJECTIVE

This systematic review seeks to identify factors that impact the effectiveness of resident wellness interventions and to provide a conceptual framework to guide future interventions.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 6 electronic databases were searched in November 2019 using variations of the keywords "resident physicians," "wellness," and "intervention." Peer-reviewed full-text English-language articles on controlled studies were considered for inclusion. The quality of the studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines.

RESULTS

The initial search disclosed 1196 articles, of which 18 studies enrolling 666 resident physicians met inclusion criteria for qualitative review. Interventions using peer support and individual meditation enhanced well-being. Effective wellness interventions also used educational theory to guide program development, surveyed participants to guide intervention design, incorporated programming into existing didactic curricula, and recruited voluntary participants. The quality of most of the included studies was poor (13 of 18, 72%) and could be improved by using standardized wellness assessments supported by validity evidence.

CONCLUSIONS

This systematic review suggests that future resident wellness initiatives should focus on grounding interventions in educational theory, forging consensus on wellness instruments with validity evidence, and examining the impact of initiatives on patient outcomes. A logic model can provide a framework for designing and implementing effective wellness interventions.

Intervention for Physician Burnout: A Systematic Review

Burnout is an important problem for physicians, with a strong impact on their quality of life and a corresponding decrease in the quality of care with an evident economical burden for the healthcare system. However, the range of interventions used to decrease this problem could be very fragmented and with the aim to shed some light on this issue, this study reviews and summarizes the currently available studies. We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify studies about intervention on physician burnout. Two authors independently searched into scientific databases to analyze and review the full papers that met the inclusion criteria. As a result, from an initial search of 11029 articles, 13 studies met full criteria and were included in this review. Of the 13 studies presented, only 4 utilized randomized controlled trials, therefore the results should be interpreted with caution. Future interventions should focus on a more holistic approach using a wider range of techniques. According to the studies selected in this review, it appears that a successful intervention for burnout should take into account the broad range of causes incorporating a variety of therapeutic tools.

Experiences of Public Doctors on Managing Work Difficulties and Maintaining Professional Enthusiasm in Acute General Hospitals: A Qualitative Study

Background

Overseas studies suggest that 10–20% of doctors are depressed, 30–45% have burnout, and many report dissatisfaction with work-life balance. A local study on public doctors showed that 31.4% of the respondents satisfied the criteria for high burnout. Young, but moderately experienced doctors who need to work shifts appeared most vulnerable. This study aims to explore the experiences of those public doctors who have managed their work difficulties and maintained professional enthusiasm for references in medical education and continuing professional training.

Method

Ten public doctors with reputation were invited respectively from three acute general hospitals for an in-depth interview. Interviews were audio recorded and transcribed. Content analysis was carried out to identify major themes in relation to the research questions.

Results

Three themes emerging from difficulties encountered were (1) managing people, mostly are patients, followed by colleagues and then patients’ relatives; (2) constraints at work, include time and resources; and (3) managing self with decision-making within a short time. Three themes generating from managing work difficulties included (1) self-adjustment with practicing problem solving and learning good communication appeared more frequently, followed by maintaining a professional attitude and accumulating clinical experiences; (2) seeking help from others; and (3) organizational support is also a theme though it is the least mentioned. Four themes emerging from maintaining work enthusiasm were (1) personal conviction and discipline: believing that they are helping the needy, having the sense of vocation and support from religion; disciplining oneself by continuing education, maintaining harmonious family relationship and volunteer work. (2) Challenging work: different challenging natures of their job. (3) Positive feedback from patients: positive encounters with patients keep a connectedness with their clients. (4) Organization support: working with good colleagues and opportunity for continuous training.

Conclusion

Some implications for medical education include, developing good communication skill for medical students and junior doctors, preparing senior doctors to be mentors, and exploring the motivating force of spirituality/religion.

Evaluation of self-care skills training and solution-focused counselling for health professionals in psychiatric medicine: a pilot study

OBJECTIVE

The purpose of this pilot study was to implement and to evaluate a self-care skills training with solution-focused counselling to support psychiatrists in handling their daily work challenges.

METHODS

A total of 72 psychiatrists working in a psychiatric clinic were randomised in a single-blind trial to either an intervention group or a control group. Outcomes were measured at baseline and at the end of the training (follow-up 1: after 3 months; follow-up 2: after 6 months). A validated questionnaire including the Perceived Stress Questionnaire, the Copenhagen Psychosocial Questionnaire, Brief Resilient Coping Scale, Self-Efficacy Scale and the Quality of Relationship Inventory was used.

RESULTS

Psychiatrists in the intervention group reached a significant reduction in perceived job stress (p = 0.01, d = 0.05), improvements in job satisfaction (p = 0.02, d = 0.04), resilience (p = 0.02, d = 0.04) and self-efficacy (p = 0.04, d = 0.02) from baseline to all follow-ups with no comparable results seen in the control group. Psychiatrists stated an improved quality of physician-patient relationship (e.g. support, conflict management; p < 0.05).

CONCLUSIONS

A self-care skills training, including solution-focused counselling, for psychiatrists was associated with significant improvements in perceived stress, job satisfaction, individual protective skills and quality of relationship to patients. This training is suitable to implement as a group training program for psychiatrists.

Burnout in medical residents: a study based on the job demands-resources model

Purpose. Burnout is a prolonged response to chronic emotional and interpersonal stressors on the job. The purpose of our cross-sectional study was to estimate the burnout rates among medical residents in the largest Greek hospital in 2012 and identify factors associated with it, based on the job demands-resources model (JD-R). Method. Job demands were examined via a 17-item questionnaire assessing 4 characteristics (emotional demands, intellectual demands, workload, and home-work demands' interface) and job resources were measured via a 14-item questionnaire assessing 4 characteristics (autonomy, opportunities for professional development, support from colleagues, and supervisor's support). The Maslach Burnout Inventory (MBI) was used to measure burnout. Results. Of the 290 eligible residents, 90.7% responded. In total 14.4% of the residents were found to experience burnout. Multiple logistic regression analysis revealed that each increased point in the JD-R questionnaire score regarding home-work interface was associated with an increase in the odds of burnout by 25.5%. Conversely, each increased point for autonomy, opportunities in professional development, and each extra resident per specialist were associated with a decrease in the odds of burnout by 37.1%, 39.4%, and 59.0%, respectively. Conclusions. Burnout among medical residents is associated with home-work interface, autonomy, professional development, and resident to specialist ratio.

The effect of resident physician stress, burnout, and empathy on patient-centered communication during the long-call shift

During the long-call shift medical residents experience a number of stressors that could compromise the quality of care they provide to their patients. The aim of this study was to investigate how perceived stress and burnout affect changes in empathy over the long-call shift and how those changes in empathy are associated with patient-centered communication practices. Residents (n=93) completed self-report measures of stress, burnout, and empathy at the start of their long-call shift and then completed measures of empathy and patient-centered communication at the end of the same shift. There was a significant decline in physician empathy from the beginning to the end of the long-call shift. Perceived stress was significantly associated with higher burnout, which was, in turn, significantly associated with declines in empathy from pre- to posttest. Declines in empathy predicted lower self-reported patient-centered communication during the latter half of the shift. This study suggests that residents who perceive high levels of stress are at risk for burnout and deterioration in empathy toward their patients, both of which may compromise the quality of their interactions with patients.

Crying: experiences and attitudes of third-year medical students and interns

BACKGROUND

The medical socialization process is emotionally stressful for trainees; anecdotally, crying is a frequent response.

PURPOSES

To understand the experiences and attitudes related to crying among 3rd-year medical students and interns.

METHODS

Web-based survey distributed to all 3rd-year medical students and interns at two medical schools and affiliated internal medicine residency programs.

RESULTS

Participation rates were 208/307 (68%) students and 93/126 (74%) interns. Sixty-nine percent of students and 74% of interns self-reported crying for reasons related to medicine. For both, the most common cause was "burnout." Although there were no significant differences in crying between students and interns (p =.38), twice as many women cried as men (93% vs. 44%, p <.001). Seventy-three percent of students and 68% of interns thought discussion of physicians' crying was inadequate.

CONCLUSIONS

Crying is common among medical students and interns, especially women. Many consider it unprofessional to cry in front of patients and colleagues. Trainees want more discussions of crying.

Burnout and patient care in junior doctors in Mexico City

BACKGROUND

Burnout is known to occur in public service workers leading to a reduction in effectiveness at work.

AIM

To estimate the prevalence of burnout in junior doctors and its impact on patient care.

METHODS

A cross-sectional study of junior doctors at three hospitals in Mexico City was conducted. Measures used included the Maslach Burnout Inventory (MBI), measuring depersonalization (DP), emotional exhaustion (EE) and personal achievement (PA), a questionnaire about patient care practices and attitudes and one on sociodemographic characteristics. Logistic regression analysis was used to assess the association between burnout and suspected risk factors.

RESULTS

A total of 312 junior doctors participated (response rate 65%). In total, 57% were male and the average age was 28. Average scores in MBI subscales were EE: 18.2, DP: 6.9 and PA: 37.6. Burnout prevalence was 40% (126). Junior doctors with burnout were more likely to report suboptimal patient care practices occurring monthly (OR 5.5; 95% CI 2.7-11.2) and weekly (OR 5.2; 95% CI 1.6-16.3). The logistic regression model for burnout included shifts lasting >12 h, current depression, former major depression, first- or second-year junior doctors, male gender and single status.

CONCLUSIONS

Burnout was most strongly associated with shifts >12 h and with both current and previous depression. Reported suboptimal patient care was also associated with working shifts of >or=12 h. Burnout may be adversely affecting junior doctors' health and their patients' care.

Burnout in chairs of academic departments of ophthalmology

PURPOSE

To evaluate the incidence of burnout in chairs of academic departments of ophthalmology, identify stressors, and propose methods for reducing and preventing burnout in our academic leaders.

DESIGN

Cross-sectional study.

PARTICIPANTS

One-hundred thirty-one chairs of academic departments of ophthalmology in the United States and Canada.

METHODS

Confidential surveys mailed to ophthalmology chairs.

MAIN OUTCOME MEASURES

Questionnaires assessed demographics, potential stressors, satisfaction with personal life, self-efficacy, burnout as measured by the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), and quality of life.

RESULTS

Questionnaires were returned from 101 chairs, a response rate of 77%. Each chair had served an average of 9.4 years. They worked an average of 62 hours each week, spending 41% on patient care, 36% on administrative duties, 13% on teaching, and 9% on research. There was no difference in hours worked each week in chairs who had served >10 years from those who had been chair <5 years. The most frequently identified stressors were faculty retention, Residency Review Committee/Accreditation Council for Graduate Medical Education issues, department or hospital budgets, and compliance issues. Seventy percent of chairs reported they are currently satisfied with their positions compared with 79% who reported feeling that way 5 years ago. Nine chairs (9%) were considered to have burnout based on their MBI-HSS surveys, and 9 (9%) chair's scores showed no characteristics of burnout. Fifty-six percent had scores consistent with low personal achievement, the highest risk factor for burnout. Overall, the MBI-HSS revealed moderate subscale scores for emotional exhaustion, low for depersonalization, and low for personal accomplishment.

CONCLUSIONS

The overall prevalence of burnout in chairs of academic departments of ophthalmology is similar to burnout rates seen in chairs of other academic departments. The MBI-HSS scores for ophthalmology chairs showed high levels of emotional exhaustion, moderate levels of depersonalization, and moderate levels of personal accomplishment. Because the cost of burnout can be high, both in terms of a chair's psychological well-being and the actual cost associated with replacing a chair, it is important that strategies are put in place to reduce burnout in our academic leaders.

'Memorable patient deaths': reactions of hospital doctors and their need for support

OBJECTIVES

To investigate the reactions experienced by hospital doctors following a recent memorable patient death, defined as a patient death that had occurred in the previous few months that the doctor recollected for any particular reason, the coping strategies employed to deal with these reactions, the impact of training, and the need for support in future situations.

METHODS

We carried out a descriptive survey in 2 teaching hospitals and 1 district general hospital in West Yorkshire, UK. Subjects comprised 188 hospital doctors of all grades (from pre-registration house officer to consultant) who were attending 12 educational lunchtime meetings. Main outcome measures included the associations between the intensity of emotional and physical reactions measured using a categorical rating scale, and exposure to previous training, gender, seniority and medical specialty.

RESULTS

Reactions of moderate to severe intensity to a patient death were experienced by 5.0-17.5% of doctors, regardless of gender, seniority or medical specialty. Perceived need for both training and increased support from team members was significantly associated with more intense reactions. Common coping strategies included talking, spending time alone and exercise. There was no relationship between respondents' exposure to previous training and the intensity of emotional or physical responses.

CONCLUSIONS

Many doctors perceive that they deal with death well. In a minority of doctors, more supportive approaches are necessary that may include both proactive and reactive measures. Examples include raising awareness of support services and establishing formal training programmes, and increasing awareness among senior clinicians of the need to support some team members after a patient's death, which may include ensuring that timely access to a counsellor is provided.

Burnout in medical residents: a review

OBJECTIVES

This study aimed to review current knowledge on burnout in medical residents, including reported prevalence rates, and to establish which risk and resistance factors contribute to or prevent burnout in medical residents.

METHODS

We conducted a comprehensive search of the literature published between 1975 and 2005, using the Medline, EMBASE (from 1989) and PsychINFO databases.

RESULTS

A total of 19 studies met our inclusion criteria. Only 5 studies appeared to meet more than 2 of the Cochrane quality criteria. The different studies report widely varying burnout rates among medical residents, ranging from 18% to 82%. Predictors of burnout can be characterised as either occupational or individual. Inconsistent results were reported with regard to the effects of some of these factors on burnout. Four of the 16 occupational risk factors appeared to be strongly related to burnout. The 11 individual risk factors examined were only weakly or moderately related to burnout.

CONCLUSIONS

Research on burnout among medical residents is scarce. The weak quality of the studies, the wide variety and limited predictive power of the predictor variables included and the inconsistent findings illustrate the need for a more systematic design with regard to future research among medical residents. A future research model should take account of the individual, occupational and training demands experienced by medical residents.

The effects of examination stress on the performance of emergency medicine residents

CONTEXT

Despite the finding that residents are exposed to significant stressors during their training, little is known about the impact of these stressors on performance. The objectives of this project were to measure the subjective anxiety felt by emergency medicine (EM) residents during in-training examinations, and to determine the effect of this anxiety on their ability to diagnose visual stimuli such as X-rays, photographs and electrocardiographs.

METHODS

Two examinations, matched for difficulty and length, were constructed based on the performance of 23 residents in 2 Royal College of Physicians and Surgeons of Canada (RCPSC) EM residency programmes. These examinations were then administered at 2-week intervals to another 24 residents in 2 additional RCPSC EM programmes. One examination was administered under high-stress conditions (in-training examination) and the other under low-stress (control) conditions. Perceived anxiety was measured using the state scale of the State-Trait Anxiety Inventory before and after each iteration of the examination.

RESULTS

Residents reported higher levels of anxiety in the high-stress condition (41.5 versus 35.9, P < 0.05). Examination scores were higher in the high-stress condition (70.4 versus 64.4, P < 0.01). The scores of junior residents improved in the high-stress condition, whereas those of intermediate and senior residents did not change.

CONCLUSIONS

Emergency medicine residents report higher anxiety during in-training examinations compared with control conditions. Residents at all levels exhibited similar perceptions of anxiety. Junior residents performed better under stress, achieving higher scores during the in-training examination than during the control condition. The performance of more experienced residents was not affected by the stress condition.

Paramedic performance in calculating drug dosages following stressful scenarios in a human patient simulator

BACKGROUND

Paramedics face many stressors in their work environment. Studies have shown that stress can have a negative effect on the psychological well-being of health professionals. However, there is little published research regarding the effects of stress on the cognitive skills necessary for optimal patient care.

OBJECTIVES

The primary purpose of this study was to investigate the effects of acute stress on the emotional response and performance of paramedics. Furthermore, the authors explored whether a paramedic's level of training or years of experience would mediate the effects of stress on performance.

METHODS

Paramedic performances in calculating drug dosages were compared in two stress conditions. In the low-stress condition, 30 paramedics calculated the drug dosages in a quiet classroom free of any stressor. In the high-stress condition, the same paramedics calculated comparable drug dosages immediately after working through a challenging scenario with a human patient simulator.

RESULTS

The paramedics obtained lower accuracy scores in the high-stress condition than in the low-stress condition [43% (95% confidence interval [CI]: 36.9-49.2) vs. 58% (95% CI: 48.6-67.1), p < 0.01 based on univariate analysis]. Neither work experience nor level of training predicted the individual differences in the stress-induced performance decrements.

CONCLUSION

These results suggest that the types of stressors encountered in clinical situations can increase medical errors, even in highly experienced individuals. These findings underline the need for more research to determine the mechanisms by which stress influences clinical performance, with the ultimate goal of targeting education or technologic interventions to those tasks, situations, and individuals most likely to benefit from such interventions.