Resident Wellness Matters: Optimizing Resident Education and Wellness Through the Learning Environment

Making housestaff feel at home: impact of workspace interventions on anatomic pathology trainee wellness

To improve trainee well-being in a healthcare setting, we implemented changes shown to significantly improve employee well-being in corporate settings in an anatomic pathology (AP) trainee workspace at one large academic program and measured changes in trainee stress and well-being. An IRB-approved survey was distributed to trainees before and after implementation of workspace modifications, which included deep cleaning of the physical space, making storage space for personal items, improving access to perishable and nonperishable foods, arranging equipment to facilitate ergonomic use, and providing real and artificial visuals of nature. The survey incorporated evidence-based scales including the Ambient Belonging Scale (ABS), the five-item WHO-5 Well-Being Index, the five-item modified Spielberger State and Trait Anxiety Scales, and the Growth Mindset Scale. Pre-intervention (n = 21) and post-intervention (n = 18) participants had scores consistent with a growth mindset, no significant anxiety state or trait, and above average sense of well-being. Compared with pre-intervention survey results, post-intervention AP residents who actively worked in the space had a significantly increased sense of belonging. Free-text feedback indicated that our efforts to improve the environment and to increase access to food positively impacted their well-being as AP trainees. We show that workspace interventions implemented at our institution significantly increased a sense of belonging for our trainees independent of their growth mindset, anxiety state or trait, and sense of well-being, which was high pre- and post-intervention. These simple and cost-effective workspace interventions can be implemented broadly to create a more supportive, inclusive environment for pathology trainees.

Evaluation of a pathology resident wellness initiative: Initial establishment and subsequent expansion through a time of high stress, the COVID-19 pandemic

OBJECTIVES

Recent studies have shown that the pathology workforce is at risk of decreased workplace well-being, which may lead to decreased job satisfaction, increased attrition, burnout, depression, anxiety, and suicidality, but there has been relatively little research on well-being initiatives designed for pathologists, pathology trainees, and laboratory professionals. Some studies have suggested that well-being initiatives may decrease burnout and increase workplace satisfaction and engagement.

METHODS

Here we describe the creation of a Pathology Wellness Committee in a large residency program. Interventions included emotional, social, and physical well-being interventions as well as system-based improvements. Additional initiatives were introduced in response to the increased stress, isolation, and social distancing guidelines during the height of the COVID-19 pandemic. The program's impact was measured by an annual House Staff Council Resident Wellness Survey over 4 years.

RESULTS

The annual surveys showed improvements in workplace and residency program satisfaction and emotional well-being following system-based improvements and well-being initiatives. Physical and social well-being showed slight but not statistically significant decreases over the 4-year period. Results from the annual Accreditation Council for Graduate Medical Education Survey were also evaluated.

CONCLUSIONS

We found that dedicated well-being initiatives in conjunction with system-based interventions may help improve overall well-being in pathology residents.

Characterizing Wellness Initiatives in Academic Radiation Oncology Departments

Purpose

Burnout is prevalent in radiation oncology (RO), and an increased focus on promoting physician wellness and formalizing wellness-directed efforts has transpired in recent years. We aimed to characterize current wellness leadership positions and efforts within academic RO departments.

Methods and Materials

Academic RO department chairs were contacted to inquire whether they had a departmental wellness leader with a request for leader contact information, if applicable. Wellness leaders were invited to complete an anonymous survey in January and February 2023 using Qualtrics. Questions assessed leader demographic characteristics, role structure and resources, current initiatives, and impacts to date. Descriptive statistics and summaries of free-text responses are reported.

Results

A total of 120 chairs were contacted. In total, 71 (59%) responded, with 43 (61%) having departmental wellness leaders, of which 17 (39.5%) responded, to the survey. A total of 70.6% were female, and 76.5% were physician faculty. Most respondents were early-career. The most common previously implemented initiatives included offering programming and education (33.3%) and improved access to mental health services (25%). The most common active initiatives include conducting studies to address root causes of burnout (41.7%), developing specific wellness goals (25%), performing a review of policies that encourage prolonged work hours (25%), and offering programming and education (25%). Challenges included limited bandwidth (66.7%), lack of funding (41.7%), and lack of departmental interest in organizing or attending events (33.3%). Leaders highlight the importance of a dedicated individual to tangibly implement changes and the unique opportunity of someone within RO to understand the specific challenges faced by those in our field.

Conclusions

Wellness leadership roles exist in many RO departments. As evidenced by a limited number of fully implemented initiatives, these roles are new and evolving. A focus on wellness has the potential to bring positive change to departments; however, the impact of newly established wellness roles on culture and balance requires longitudinal followup.

A survey on mental health among resident physicians: psychological resilience as a mediator

BACKGROUND

Sleep disturbances (SD) among resident physicians have been shown to negatively impact their mental health, potentially leading to suicidal ideation (SI) and reduced life satisfaction (LS). Psychological resilience (PR) is thought to buffer the negative effects of stressors, including SD, and may play a mediating role in this relationship. However, the specific mechanisms linking SD, PR, SI, and LS remain underexplored. This study aimed to examine the mediating role of PR in the relationship between SD, SI, and LS among resident physicians in China, building upon existing theories of resilience and stress in medical professionals.

METHODS

An anonymous four-part survey was conducted with 453 resident physicians training in tertiary hospital in China. Descriptive statistics and correlation analyses were performed using the Statistical Package for the Social Sciences software (version 27.0). The study employed structural equation modeling(SEM) to examine the interplay of variables and conducted a multiple-group analysis using Analysis of Moment Structure (version 23.0).

RESULTS

Based on a hypothetical model, SEM revealed that PR played a partial mediating role in the relationship between SD and SI (52.10% of the total effect of SD on SI was direct, and 47.90% of the total effect was mediated by PR). Moreover, in the relationship between SD and LS, PR also acted as a partial mediator, accounting for 79.00% of the direct effect of SD on LS and 21.00% of the effect mediated by PR. The multiple-group analysis further revealed that individuals over 25 years exercise more PR to enhance LS (t = 2.703, p < 0.01), and those with normal weight were less affected by SD in terms of LS (t = - 2.322, p = 0.02).

CONCLUSIONS

PR serves as a significant mediator in the relationship between SD and both SI and LS. These findings highlight the importance of fostering PR in resident physicians to mitigate the adverse effects of SD on their mental health and well-being. Policymakers and medical institutions should prioritize interventions aimed at improving sleep quality and supporting mental health to enhance the overall well-being of resident physicians.

How faculty with critical care specialties learn in a university hospital: a qualitative phenomenological study

OBJECTIVES

The study aims to explore the workplace learning experiences of medical faculty in critical care specialties at a university hospital, focusing on how they develop their professional identity and construct the meaning of their work.

DESIGN

Qualitative, phenomenological study.

SETTING

The current study was conducted at a university hospital in South Korea between November 2022 and October 2023.

PARTICIPANTS

Five faculty members (two males and three females) from critical care specialties (eg, emergency medicine) with over 15 years of experience, each having served as faculty at a university hospital for more than 5 years.

RESULTS

Six key themes emerged: cultivating 'doctor-ishness' in the realm of critical care, beacon of inner drive: guiding professional growth, nexus for leveraging expertise and fostering professional growth, the challenging reality of becoming an 'ideal' faculty, the shifting tides of the medical profession's role and weaving workplace learning into a unique rhythm of practice. These themes collectively highlight that faculty members' workplace learning involves a transition from functional professionals to reflective practitioners.

CONCLUSIONS

Workplace learning of faculty members with critical care specialties is understood as an ongoing, context-dependent and individualised process in which emotions play a crucial role in determining the depth and significance of learning and shaping professional identities. This study highlights their capacity for agency and potential, offering a perspective beyond previous research that has primarily focused on their hardships. By shedding light on their workplace learning from an insider's view and underscoring the need to support professional development in these high-stakes fields, our findings suggest theoretical and practical interventions to foster the mutual growth of faculty and hospital organisations.

Perceptions and barriers to the use and training of point-of-care ultrasound among Finnish emergency physicians - a nationwide survey

BACKGROUND

Point-of-Care Ultrasound (POCUS) has become integral to emergency medicine (EM) as a critical diagnostic support tool. In Finland, where EM was formally recognised as a specialty as recently as in 2013, a historical lack of systematic training for POCUS has existed. Such training has largely depended on individual initiative rather than a standardised program while many other areas of EM training have already seen the introduction of structured education. The aim of this study is to identify key factors and barriers influencing POCUS training, with the goal of improving its quality and delivery.

METHODS

A nationwide survey was conducted among emergency physicians, trainees, and specialists across Finnish emergency departments from late 2020 to early 2021. The survey included detailed questions on POCUS training, perceived barriers to training, experiences of the successful initiation of more structured approaches, as well as attitudes towards the integration of POCUS into clinical practice. Statistical methods for quantitative data and thematic analysis for qualitative data were used.

RESULTS

A total of 134 emergency physicians completed the survey, revealing a strong consensus among participants for several training needs. Key barriers identified include inadequate training, limited supervision, device availability, and time allocation. Notably, out of all open-ended questions, 96.5% of respondents called for the initiation of structured training programs that accommodate both foundational and advanced practitioner needs. Furthermore, hands-on training and senior support were highly valued.

CONCLUSIONS

The results highlight a need for reform in POCUS training in Finland, demonstrating a need for structured, competency-based educational frameworks that align with international standards. Improvements on training infrastructure, including enhanced mentorship and increased access to ultrasound equipment, are essential enablers of such a reform.

CLINICAL TRIAL REGISTRATION

Not applicable.

Perceptions of Justice in Clinical Learning Environments: Development and Validation of an Organizational Justice Measure for Medical Trainees

PURPOSE

This study aimed to develop an instrument to measure medical trainees' perceptions of justice in clinical learning environments.

METHOD

Between 2019 and 2023, the authors conducted a multiyear, multi-institutional, multiphase study to develop a 16-item justice measure with 4 dimensions: interpersonal, informational, procedural, and distributive. The authors gathered validity evidence based on test content, internal structure, and relationships with other variables across 3 phases. Phase 1 involved drafting items and gathering evidence that items measured intended dimensions. Phase 2 involved analyzing relevance of items for target groups, examining interitem correlations and factor loadings in a preliminary analysis, and obtaining reliability estimates. Phase 3 involved a confirmatory factor analysis and collecting convergent and discriminant validity evidence.

RESULTS

In phase 1, 63 of 91 draft items were retained following a content validation exercise gauging how well items measured targeted dimensions (mean [SD] item ratings within dimensions, 4.16 [0.36] to 4.39 [0.34]) on a 5-point Likert scale (with 1 indicating not at all well and 5 indicating extremely well). In phase 2, 30 items were removed due to low factor loadings (i.e., < 0.40), and 4 items per dimension were selected (factor loadings, 0.42-0.89). In phase 3, a confirmatory factor analysis supported the 4-dimensional model ( χ2 = 610.14, P < .001; comparative fit index = 0.90, Tucker-Lewis Index = 0.87, root mean squared error of approximation = 0.11, standardized root mean squared residual = 0.06), with convergent and discriminant validity evidence showing hypothesized positive correlations with a justice measure ( r = 0.93, P < .001), trait positive affect ( r = 0.46, P < .001), and emotional stability ( r = 0.33, P < .001) and negative correlations with trait negative affect ( r = -0.39, P < .001).

CONCLUSIONS

Results indicate the measure's potential utility in understanding justice perceptions and designing targeted interventions.

Why is it so hard to improve physicians' health? A qualitative interview study with senior physicians on mechanisms inherent in professional identity

Objectives

Current research increasingly describes physicians' health as endangered. Interventions to improve physicians' health show inconsistent results. In order to investigate possible causes for weak long-term effects, we examined senior physicians' perceptions about the relevance of their own health and analyzed whether and how these might affect the difficulty to improve physicians' health.

Method

The authors conducted 19 semi-structured interviews with senior physicians from different medical disciplines, analyzed the data and developed theory using the grounded theory method.

Results

Based on the interviews, we developed a conceptual model which identifies reinforcing factors for physicians' hesitancy in self-care as well as barriers to change. Participants regarded their own health needs as low and equated health with performance. These perceptions were described as being part of their professional identity and mirrored by the hospital culture they work in. Mechanisms as part of the collective professional identity (CPI) of physicians help to stabilize the status quo through early socialization and pride in exceptional performance. In addition, the tabooing of weakness and illness among colleagues, and dissociation from patients as well as sick doctors were identified as stabilizing mechanisms.

Conclusion

Findings support the assumption that one cause of physicians' health problems might lie in a CPI that includes tendencies to rate one's health as secondary or irrelevant. Identified mechanisms against change are, according to Social Identity Theory, typical group strategies which ensure the stability of CPI and make existing attitudes and beliefs difficult to change. However, barriers against change could possibly be overcome by addressing these underlying mechanisms and by a change process that is supported by experienced and competent members of the in-group for the benefit of both physicians and patients.

Developing a Postpandemic Model for Hybrid Clinical Ethics Rotations in Postgraduate Medical Education

Bioethics education in residency helps trainees achieve many of the Accreditation Council for Graduate Medical Education milestones and gives them resources to respond to bioethical dilemmas. For this purpose, The Providence Center for Health Care Ethics has offered a robust clinical ethics rotation since 2000. The importance of bioethics for residents was highlighted as the COVID-19 pandemic raised significant bioethical concerns and moral distress for residents. This, combined with significant COVID-19-related practical stressors on residents led us to develop a virtual ethics rotation. A virtual rotation allowed residents flexibility as they were called to help respond to the unprecedented demands of a pandemic without compromising high quality education. This virtual rotation prioritized flexibility to support resident wellbeing and ethical analysis of resident experiences. This article describes how this rotation was able to serve residents without overstraining limited bandwidth, and address the loci of resident pandemic distress. As pandemic pressures lessened, The Providence Center for Health Care Ethics transitioned to a hybrid rotation which continues to prioritize resident wellbeing and analysis of ongoing stressors while incorporating in-person elements where they can improve learning. This article provides a description of the rotation in its final form and resident feedback on its effectiveness.

Natural Semantic Networks: The Concept of Mistreatment and Good Treatment in Students of Health Careers

Natural semantic networks (NSNs) provide an approach to understanding concepts in terms of their density and strength. The objective of this study was to conceptualize mistreatment and good treatment among health science students in Chile, according to gender and training cycle. Methods: A mixed-methods study with a relational scope was conducted, involving 994 health science students. The present study is exploratory and combines both qualitative and quantitative analysis. We utilized the NSN technique, applying a questionnaire via SurveyMonkey after obtaining informed consent. Results: A total of 4386 defining words for mistreatment were identified, with the most relevant being 'aggression', 'abuse', and 'violence'. In the case of good treatment, a total of 4146 defining words were obtained, with 'respect', 'empathy', and 'kindness' standing out. For good treatment, a statistically significant relationship was observed between the defining words and the variables of gender (χ2 = 41.158; p < 0.05) and training cycle (χ2 = 28.698; p < 0.05). For mistreatment, a statistically significant relationship was found only with training cycle (χ2 = 35.858; p < 0.05). Conclusions: Exploring the meanings associated with mistreatment and good treatment has a theoretical implication in the way in which two highly polysemic aspects of the educational environment can be understood.

Burnout and Well-Being in Trainees: Findings From a National Survey of US Obstetrics and Gynecology Residents

Background Despite national attention on resident well-being, challenges persist. Effective solutions require greater understanding of personal and program factors. Objective To explore burnout, resilience, self-reported mental health, and perceptions of the learning environment in a national sample of obstetrics and gynecology (OB/GYN) residents. Methods An observational cross-sectional survey of OB/GYN residents taking the January 2022 national in-training examination included an abbreviated 2-item Maslach Burnout Inventory, a short version of the Connor-Davidson Resilience Scale, and subjective experience of other factors. Kruskal-Wallis and chi-square tests explored differences in outcomes and associations between variables. Results Among 5761 residents taking the examination, 3741 (64.9%) participated, with 2425 of 3741 (64.8%) reporting burnout, 2138 (57.2%) depression, 2651 (70.9%) anxiety, and 147 (3.9%) suicidal ideation. Women fared worse than men in terms of burnout (2105 of 3147, 66.9% vs 281 of 496, 56.7%, P<.001), depression (1843 of 3147, 58.6% vs 256 of 496, 51.6%, P=.004), anxiety (2318 of 3147, 73.7% vs 294 of 496, 59.3%, P<.001), and resilience (5.9±2.1 vs 6.2±2.1, P=.006). More nonbinary residents considered leaving residency (17 of 49, 34.7% vs 676 of 3147, 21.5% [women] and 108 of 496, 21.8% [men], P=.008). Race-based differences were seen in depression, suicidal ideation, and thoughts of leaving residency. Increased binge drinking was reported with increasing postgraduate year. Among 614 residents reporting that well-being was not a priority in their program, 539 of 614 (87.8%) reported burnout, 469 of 614 (76.4%) depression, and 508 of 614 (82.7%) anxiety. Conclusions Residents report high rates of mental health concerns, and these are worse among women, gender nonconforming individuals, Black residents, and those who perceive well-being is not a priority in their training program.

Improving staff wellness via an after-hours healthy sustainable meals program: A general surgery residency pilot

Healthcare worker wellness is foundational to delivering quality care. Yet, healthcare facilities often lack access to healthy and sustainable food overnight and on weekends. Healthy, low-carbon meals were provided free of charge after hours to on-call General Surgery residents at the University of British Columbia and the impact on resident well-being assessed using pre- and post-intervention surveys. Financial and time stress reduced significantly with the provision of meals (P's < .01), while emotional and physical stress levels did not change. Average meal expenses decreased from $33 to $10 (P < .001). Increasing food access on call is an impactful intervention to improve resident health and well-being.

Bereavement scheduling policy for emergency medicine residents: A descriptive pilot study

Background

The Accreditation Council for Graduate Medical Education has tasked residency programs to prioritize resident wellness, reduce trainee stress, and prevent burnout. Grief and bereavement can significantly impact residents' wellness during difficult clinical training schedules. There are no best practices on how to support residents during this time.

Methods

In a split academic county emergency medicine (EM) residency, this pilot study documents a resident-driven change to scheduling practices for bereavement leave. An advisory group of residents, chief residents, and program directors informally polled peer institutions to develop bereavement leave guidelines. Considerations were made to balance resident wellness, education, and patient care in developing a bereavement scheduling policy.

Results

The bereavement policy was adopted in January 2023, aiming to "support the resident during a difficult time and reduce concerns around shift coverage" following the death of a family member without impacting sick call. The number of covered days depended on the relationship of the resident to the deceased. Residents covering bereavement days for their peers were financially compensated. During the first 7 months following implementation, five residents utilized the policy. These residents noted this to be the most positive impact on the residency during the past year. Based on resident feedback, the scope was expanded to include grave medical illness of a family member as an implementation criterion.

Conclusions

This article outlines the creation, implementation, and benefits of a bereavement scheduling policy within an EM residency. Describing this approach will provide guidance for other residencies to adopt similar wellness-focused strategies.

Normative Perceptions and Medical Providers' Help-Seeking Behavior in a Rural Health Setting

Healthcare providers experience greater work stress and mental health concerns compared to the general population. This study aimed to better understand factors that promote engagement in help-seeking behaviors among rural medical providers. Considering a social norms perspective, this study examined: (a) the accuracy of medical providers' perceptions of injunctive (i.e., approval of) norms related to seeking time off for their own medical, mental, and social health care (b) determine whether greater self-other differences (SODs) predict a greater likelihood of help-seeking behavior, and (c) examine associations between self-valuation, SODs, and self-care behaviors. Electronic surveys were emailed to 805 rural medical providers (17.8% response rate). Findings suggested that providers believed that their coworkers were less approving of help-seeking behavior for a psychosocial or mental health reason than they actually were. Furthermore, self-other differences (SODs) of injunctive norms predicted help-seeking behavior, such that those with greater SODs reported less help-seeking behavior. Although this research provides some foundational evidence for the role of normative perceptions in self-care behaviors, larger systemic and organizational problems continue to drive these struggles and contribute to burnout. Future research might examine the interplay of normative interventions and organizational changes to enhance help-seeking behaviors among medical providers.

Resident Assessment of Clinician Educators According to Core ACGME Competencies

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) requires faculty to pursue annual development to enhance their teaching skills. Few studies exist on how to identify and improve the quality of teaching provided by faculty educators. Understanding the correlation between numeric scores assigned to faculty educators and their tangible, practical teaching skills would be beneficial.

OBJECTIVE

This study aimed to identify and describe qualities that differentiate numerically highly rated and low-rated physician educators.

DESIGN

This observational mixed-methods study evaluated attending physician educators between July 1, 2015, and June 30, 2021. Quantitative analysis involved descriptive statistics, normalization of scores, and stratification of faculty into tertiles based on a summary score. We compared the highest and lowest tertiles during qualitative analyses of residents' comments.

PARTICIPANTS

Twenty-five attending physicians and 111 residents in an internal medicine residency program.

MAIN MEASURES

Resident evaluations of faculty educators, including 724 individual assessments of faculty educators on 15 variables related to the ACGME core competencies.

KEY RESULTS

Quantitative analyses revealed variation in attending physician educators' performance across the ACGME core competencies. The highest-rated teaching qualities were interpersonal and communication skills, medical knowledge, and professionalism, while the lowest-rated teaching quality was systems-based practice. Qualitative analyses identified themes distinguishing high-quality from low-quality attending physician educators, such as balancing autonomy and supervision, role modeling, engagement, availability, compassion, and excellent teaching.

CONCLUSIONS

This study provides insights into areas where attending physicians' educational strategies can be improved, emphasizing the importance of role modeling and effective communication. Ongoing efforts are needed to enhance the quality of faculty educators and resident education in internal medicine residency programs.

Factors in turnover intention of cardiothoracic surgery residents

Increasing numbers of cardiothoracic surgery residents are resigning, without completing their training. This study analyzes how their turnover intention is related to the training environment, and individual psychological factors. Responses by 57 Korean cardiothoracic surgery residents were analyzed. Their levels of depression, anxiety, grit, and empathy, working conditions, the effect of someone's presence to discuss their concerns with, burnout, and turnover intention were identified as the research variables. Descriptive statistical analysis, correlation analysis, and structural equation modeling were used for data analysis. Burnout has the most significant relationship with turnover intention. It has a mediating effect on the influence of depression, grit (sustained interest), and working conditions, over turnover intention. Empathy, and the presence of someone to discuss concerns with, also affect turnover intention directly. The study also confirmed that grit and work satisfaction affect turnover intention indirectly, through burnout. The study identified both individual- and systemic-level factors for an effective training environment, to reduce cardiothoracic surgery residents' tendencies of leaving the residency program, and supporting them for greater satisfaction with their career choice. In order to resolve negative emotions such as burnout and depression, and foster empathy, a human resource development program for the residents' psychological support must be prepared. The program director should be adequately educated to take charge of the training program, oversee the residents' education and welfare, and perform the roles of role-model and mentor.

Radiology Residents' Perceptions of Artificial Intelligence: Nationwide Cross-Sectional Survey Study

BACKGROUND

Artificial intelligence (AI) is transforming various fields, with health care, especially diagnostic specialties such as radiology, being a key but controversial battleground. However, there is limited research systematically examining the response of "human intelligence" to AI.

OBJECTIVE

This study aims to comprehend radiologists' perceptions regarding AI, including their views on its potential to replace them, its usefulness, and their willingness to accept it. We examine the influence of various factors, encompassing demographic characteristics, working status, psychosocial aspects, personal experience, and contextual factors.

METHODS

Between December 1, 2020, and April 30, 2021, a cross-sectional survey was completed by 3666 radiology residents in China. We used multivariable logistic regression models to examine factors and associations, reporting odds ratios (ORs) and 95% CIs.

RESULTS

In summary, radiology residents generally hold a positive attitude toward AI, with 29.90% (1096/3666) agreeing that AI may reduce the demand for radiologists, 72.80% (2669/3666) believing AI improves disease diagnosis, and 78.18% (2866/3666) feeling that radiologists should embrace AI. Several associated factors, including age, gender, education, region, eye strain, working hours, time spent on medical images, resilience, burnout, AI experience, and perceptions of residency support and stress, significantly influence AI attitudes. For instance, burnout symptoms were associated with greater concerns about AI replacement (OR 1.89; P<.001), less favorable views on AI usefulness (OR 0.77; P=.005), and reduced willingness to use AI (OR 0.71; P<.001). Moreover, after adjusting for all other factors, perceived AI replacement (OR 0.81; P<.001) and AI usefulness (OR 5.97; P<.001) were shown to significantly impact the intention to use AI.

CONCLUSIONS

This study profiles radiology residents who are accepting of AI. Our comprehensive findings provide insights for a multidimensional approach to help physicians adapt to AI. Targeted policies, such as digital health care initiatives and medical education, can be developed accordingly.

KNOWLEDGE, ATTITUDES AND PERCEPTIONS OF REMEDIATION AMONG TRAINEES IN GRADUATE MEDICAL EDUCATION PROGRAMS

BACKGROUND

Remediation of medical trainees is a universal challenge, yet studies show that many residents will need remediation to improve performance. Current literature discusses the importance and processes of remediation and investigates how to recognize residents needing remediation. However, little is known about trainees' attitudes and perception of remediation.

OBJECTIVES

To assess trainees' knowledge of remediation as well as their attitudes and perceptions toward remediation and its process. We hypothesized that trainees have limited knowledge and a negative perception of remediation.

METHODS

A cross-sectional anonymous electronic survey was sent to all graduate medical education trainees at a single institution.

RESULTS

The survey was completed by 132/1095 (12.1%) trainees. Of the respondents, 7.6% were not familiar with the term "remediation." Trainees' knowledge of remediation processes was variable, and they reported overwhelmingly negative thoughts and attitudes toward remediation. Shame was felt by 97/132 (73.5%), 71/132 (53.8%) felt disadvantaged, and 121/132 (91.7%) viewed the term "remediation" negatively. Most trainees felt using a more positive term would improve perceptions, and 124/132 (93.9%) felt residents should be involved in creating individualized remediation plans. Open-ended responses on reactions to being placed on remediation included disappointment, shame, incompetency, anxiety and worry, embarrassment, unhappiness, suicidality, worthlessness, sense of failure, and doubting one's capabilities as a physician.

CONCLUSION

Trainees have limited knowledge and understanding of remediation and strong negative perceptions and attitudes toward the remediation process. Trainees suggested that reframing of remediation using more positive terminology and including residents in creating individualized plans, may improve attitudes and perceptions of this process.

Simple Interventions for Pediatric Residents' Moral Distress: A Randomized, Controlled Experiment

BACKGROUND AND OBJECTIVES

Pediatric residents are at high risk for moral distress, knowing the moral or ethically right thing to do but feeling unable to do it, which is associated with poor patient care and burnout. Researchers have proposed numerous interventions to reduce distress, but few (if any) have been supported by experimental evidence. In this study, we used an experimental method to provide proof-of-concept evidence regarding the effect of various simple supports on pediatric residents' reported degree of moral distress.

METHODS

We conducted a study of pediatric residents using a split sample experimental design. The questionnaire contained 6 clinical vignettes describing scenarios expected to cause moral distress. For each case, participants were randomly assigned to see 1 of 2 versions that varied only regarding whether they included a supportive statement. After reading each of the 6 cases, participants reported their level of associated moral distress.

RESULTS

Two hundred and twenty respondents from 5 residency programs completed the experiment. Cases were perceived to represent common scenarios that cause distress for pediatric residents. The addition of a supportive statement reduced moral distress in 4 of the 6 cases.

CONCLUSIONS

In this proof-of-concept study, simple yet effective interventions provided support by offering the resident empathy and shared perspective or responsibility. Interventions that were purely informational were not effective in reducing moral distress.

Resilience in Residency and Beyond

» Distinct from the burnout and wellness continuum, resilience is a developed and refined characteristic that propels an individual toward personal and professional success.» We propose a clinical resilience triangle consisting of 3 components that define resilience: grit, competence, and hope.» Resilience is a dynamic trait that should be built during residency and constantly fortified in independent practice so that orthopaedic surgeons may acquire and hone the skills and mental fortitude required to take on the overwhelming challenges that we all inevitably face.

Educational environment and mental wellbeing of medical and surgical postgraduate residents in Medellin, Colombia

INTRODUCTION

One of the most important moments in a doctor's life occurs when they do a medical residency. This period imposes stress and academic demands, which, together with the educational environment, allows for greater or lesser mental wellbeing. The objective of this study was to determine how the educational environment and mental wellbeing of medical residents are related.

METHODS

Analytical cross-sectional study, in residents of clinical-surgical specialties. The educational environment was assessed using the Postgraduate Hospital Educational Environment Measure (PHEEM), and mental wellbeing was assessed with the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS). Pearson's linear correlation was determined. Informed consent and approval by the university ethics committee were obtained.

RESULTS

The study population comprised 131 students, 43.8% male, with a median age of 28 years (interquartile range 4). In total, 87.9% of residents answered the survey. Of these, 65.9% were doing medical residencies and 34.1% surgical residencies. The mean PHEEM score was 107.96 ± 18.88, the positive emotions subscale was 29.32 ± 5.18 and positive functioning 23.61 ± 3.57, with a mean total mental wellbeing of 52.96 ± 8.44. A positive and moderate correlation was found between the total PHEEM score and each of the two mental wellbeing subscales (p < 0.001).

CONCLUSIONS

A positive correlation was found between a better perception of the educational environment and mental wellbeing by residents of clinical and surgical specialties with greater mental wellbeing.

Where Do We Go from here? Post-pandemic Planning and the Future of Graduate Medical Education

Background

As the pandemic wanes, there is an opportunity to reevaluate resultant changes in graduate medical education (GME), particularly from the viewpoints of those affected most. We aimed to assess both trainee and faculty perceptions on the educational changes and innovations resulting from the pandemic to inform future educational planning.

Methods

We surveyed trainees and core education faculty at three New York City children's hospitals. Surveys assessed perceived changes to educational activities, skills, scholarship, effectiveness of virtual teaching, future desirability, and qualitative themes.

Results

The survey was completed by 194 participants, including 88 (45.4%) faculty and 106 (54.6%) trainees. Trainees were more likely to report a negative impact of the pandemic compared with faculty (75.5% vs. 50%, p < 0.01). Most respondents reported a decrease in formal educational activities (69.8%), inpatient (77.7%) and outpatient (77.8%) clinical teaching. Despite this, most perceived clinical and teaching skills to have stayed the same. Most (93.4%) participated in virtual education; however, only 36.5% of faculty taught virtually. Only 4.2% of faculty had extensive training in virtual teaching and 28.9% felt very comfortable teaching virtually. In the future, most (87.5%) prefer a hybrid approach, particularly virtual didactic conferences and virtual grand rounds. Faculty themes included challenges to workflows and increased empathy for trainees, while trainee themes included increased work/life balance and support, but increased burnout.

Conclusion

Many changes and innovations resulted from the pandemic. Hospital systems and GME programs should consider this data and incorporate viewpoints from trainees and faculty when adapting educational strategies in the future.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01737-8.

Changing the Landscape of Remediation: The Creation and Implementation of an Institution-Wide Graduate Medical Education Performance Enhancement Program

Purpose Remediation is a daunting process for both residency leadership and trainees due to several factors including limited time and resources, variable processes, and negative stigma. Our objective was to transform the remediation process by creating a transparent institution-wide program that collates tools/resources, interdepartmental faculty mentors, and positive rebranding. Methods Education leadership across seven specialties created a process for trainees with professionalism and interpersonal-communication skills deficiencies. Formalized departmental program-based improvement plan (PIP) and an institutional house staff performance enhancement plan (HPEP) were developed by consensus of triggers/behaviors. Utilizing published literature, a toolkit was created and implemented. Trainees were enrolled in HPEP if PIP was unsuccessful or exhibited ≥1 major trigger. Wellness evaluations were incorporated into the process to screen for external contributing factors. Surveys were sent to the program director (PD), faculty mentor, and trainee one month and six months after participation. Results Between 2018 and 2021, 12 trainees were enrolled. Overall feedback from PDs and the trainees was positive. The main challenge was finding mutual time for the faculty mentor and trainee to meet. Six-month surveys reported no relapses in unprofessionalism. One-year follow-up of the trainees was limited. Conclusions Utilizing an institution-wide standardized process of performance improvement with the removal of negative stereotyping is a unique approach to remediation. Initial feedback is promising, and future outcome data are necessary to assess the utility. The HPEP may be adopted by other academic institutions and may shift the attitudes about remediation and allow trainees to see the process as an opportunity for professional growth.

Internal medicine trainee perspectives on back-up call systems and relationships to burnout

INTRODUCTION

As burnout within medicine escalates, residency programmes should strive to understand how training structures may contribute. Back-up call systems that address gaps in overnight resident call coverage are one possible contributing structure. However, the intersection between back-up call policies and burnout remains unclear. The authors explored residents' decision-making process when deciding whether or not to activate a back-up resident for call coverage, perspectives surrounding the legitimacy of call activations and the impact of back-up call systems on education and experienced burnout.

METHODS

Internal medicine residents at the University of Toronto were recruited through email. Eighteen semi-structured one-on-one interviews were conducted with residents from September 2019 to February 2020. Interviews explored participants' experiences and perceptions with back-up call and call activations. A constructivist grounded theory approach was used to develop a conceptual understanding of the back-up system as it relates to residents' decisions underlying activations, downstream impacts and relationships to burnout.

RESULTS

Residents described a complex thought process when deciding whether to activate back-up. Decisions were coloured by inner conflicts including sense of collegiality, need to maintain an image and time of year balanced against self-reported burnout. Residents described how back-up calls can lead to burnout, usually in the form of exhaustion, lowering their threshold to trigger future back-up activations. Impacts included anxiety of not knowing whether an activation would occur, decreased educational productivity and the 'domino effect' of increased workload for colleagues.

DISCUSSION

Residents weigh inner tensions when deciding to activate back-up. Their collective experience suggests that burnout is both a trigger and consequence of back-up calls, creating a cyclical relationship. Escalating rates of call activations may signal that burnout amongst residents is high, warranting educational leads to assess for resident wellness and to critically evaluate the structure of such systems with respect to unintended consequences.

Final-year medical student mental wellness during preparation for the examination for specialty in Turkey: a cross-sectional survey study

BACKGROUND

In Turkey, most final-year medical students prepare for the Examination for Specialty in Medicine in a high-stress environment. To the best of our knowledge, this is the first study on final-year medical student general psychological distress during preparation for the Examination for Specialty in Turkey. We aim to evaluate psychological distress and understand the variables associated with depression, anxiety, and stress levels among final-year medical students preparing for the Examination for Specialty.

METHODS

A self-reporting, anonymous, cross-sectional survey with 21 items consisting of demographic variables, custom variables directed for this study, and the DASS-21 was utilized. Survey results were expounded based on univariate analysis and multivariate linear regression analysis.

RESULTS

Our study revealed four variables associated with impaired mental wellness among final-year medical students during preparation for the examination for Specialty: attendance to preparatory courses, duration of preparation, consideration of quitting studying, and psychiatric drug usage/ongoing psychotherapy.

DISCUSSION

Considering that physician mental wellness is one of the most crucial determinants of healthcare quality, impaired mental wellness among future physicians is an obstacle to a well-functioning healthcare system. Our study targets researchers and authorities, who should focus on medical student mental wellness, and medical students themselves.

Normalising disclosure or reinforcing heroism? An exploratory critical discourse analysis of mental health stigma in medical education

INTRODUCTION

There has been a proliferation of initiatives targeted towards improving psychological wellbeing among medical learners. Yet many learners do not seek assistance due to stigma against help seeking. Understanding the prevailing discourses on the effects of mental health stigma in the context of medical education will improve insight on how to address stigma and improve wellbeing. In this study, the authors sought to explore discourses on stigma in medical education through a Foucauldian Critical Discourse Analysis.

METHODS

The authors assembled several sets of texts related to stigma in medical education. The initial archive consisted of social media discourse and was expanded to include digital news media. Next, the authors conducted semi-structured qualitative interviews with medical students, residents and faculty. Using principles of Critical Discourse Analysis informed by the writings of Michel Foucault, the authors analysed the archive to identify truth statements, representative statements and discursive effects.

RESULTS

Analysis revealed an emancipatory discourse of disclosure that normalised help-seeking, which conflicted with a discourse of performance. Results suggested that public disclosure remains challenging in private contexts due to a medical culture that rewards perfectionism and lauds heroism. Discourses on performance positioned disclosure as disruptive to the system's need to maintain its own hegemony. Overall, stigma was perceived as rooted within the structural power of the medical education system and society at large.

CONCLUSION

Discourses on stigma in medical education hold implications for the teaching, learning and overall wellbeing of medical learners. The tensions between discourses on disclosure and performance have the potential to perpetuate further distress for learners and worsen asymmetries in power. Interventions to address stigma would benefit from understanding and addressing the role of power and hierarchy in maintaining and dismantling stigma.

Improving resident well-being: a narrative review of wellness curricula

BACKGROUND

To improve wellness among residents, many graduate medical education programs have implemented formal wellness curricula. Curricular development has recently shifted focus from drivers of burnout to promotion of wellness. The specific components of successful wellness curricula, however, are not yet well defined.

OBJECTIVE

To review the published literature assessing core components of wellness curricula in graduate medical education programs.

METHODS

Searches were conducted through June 2020 in PubMed, Education Resources Information Center, Google Scholar and Web of Science using the search terms wellness curricula, wellness programs, well-being and graduate medical education. Additional articles were identified from reference lists. Curricula from primarily undergraduate medical education, singular interventions, non-peer-reviewed studies and non-English language studies were excluded.

RESULTS

Eighteen articles were selected and reviewed by three authors. Critical drivers of success included support from program leadership and opportunities for resident involvement in the curriculum implementation. Most curricula included interventions related to both physical and mental health. Curricula including challenging components of professionalisation, such as critical conversations, medical errors and boundary setting, seemed to foster increased resident buy-in. The most frequently used curricular assessment tools were the Maslach Burnout Inventory and resident satisfaction surveys.

CONCLUSIONS

Different specialties have different wellness needs. A resource or 'toolbox' that includes a variety of general as well as specialty-specific wellness components might allow institutions and programs to select interventions that best suit their individual needs. Assessment of wellness curricula is still in its infancy and is largely limited to single institution experiences.

Do programme coordinators contribute to the professional development of residents? an exploratory study

BACKGROUND

With the development of training programmes for health professions, the role of programme coordinators has become increasingly important. However, their role in providing educational support for the professional development of resident trainees has not been investigated well. This study aimed to qualitatively analyse the involvement of programme coordinators in educational support for residents.

METHODS

Semi-structured reflective writing on 'support for residents' was collected from programme coordinators in teaching hospitals in Japan in 2017-18 using a web-based questionnaire. Descriptions were qualitatively analysed thematically, using the professional identity formation (PIF) framework.

RESULTS

A total of 39 cases of "support for residents" by 31 coordinators were analysed. We found that residents most commonly faced prior personal problems, including mental health issues and insufficient social skills/unprofessional behaviour. A thematic analysis revealed that coordinators played a variety of educational roles: 1) requesting supervisors to reconsider their teaching; 2) protecting residents from the negative influence of clinical experiences; 3) facilitating residents' self-assessment and confidence; 4) creating a safer learning environment; 5) providing support for prior personal problems through 5-1) fostering a better atmosphere for the mental health of residents, and 5-2) intervening for residents with insufficient social skills/unprofessional behaviour; 6) providing support for isolated residents; and 7) preventing problems with peers.

CONCLUSIONS

This study identified seven educational roles of programme coordinators for residents from a standpoint of PIF of residents. Based on these findings, four valuable attributes for coordinators were established: non-hierarchical relationships with residents, parenting attitudes, sensitivity to residents' changes, and the perspective of the citizen and a member of the public. These attributes would underpin coordinators' educational roles and facilitate the professional development of residents. This study provides a basis for defining and revising the role profiles of programme coordinators, and for improving staff development.

ACGME Diagnostic Radiology Milestones 2.0: the Time is Now

The Accreditation Council for Graduate Medical Education oversees graduate medical education in the United States. Designed to provide broad based training in all aspects of imaging, the diagnostic radiology residency program must provide educational experiences that not only provide technical, professional, and patient centered training, but also meet accreditation standards. With the breadth of material to cover during training, carefully orchestrated educational experiences must be planned. This manuscript offers residency program leaders resources to meet the challenges of the new Accreditation Council for Graduate Medical Education Diagnostic Radiology Milestones 2.0 and highlights potential opportunities for future educational endeavors.

The Impact of the COVID-19 Pandemic on Pediatric Graduate Medical Education: Lessons Learned and Pathways Forward

In this article, the authors describe the impact of the COVID-19 pandemic on pediatric graduate medical education (GME), including the impact on clinical experiences for trainees, teaching methods used, trainee wellness, GME leader wellness and support, and the traditional interview process. A thorough literature review was done to identify impacts of the COVID-19 pandemic on pediatric GME. In addition, information was collected through Association of Pediatric Program Directors virtual cafes and conferences. Positive changes for GME from the COVID-19 pandemic included: the rapid transition to telehealth; asynchronous learning allowing for increased cross-program collaboration; innovative online teaching modalities; increased flexibility and decreased cost of online recruitment; and shared innovations across pediatric GME. Challenging aspects of the COVID-19 pandemic included: decreased learning about common childhood illnesses, such as bronchiolitis, acute otitis media, and influenza; decreased patient volumes and patient complexity in clinics and inpatient wards, leading to less practice developing efficiency, time management, and triaging skills; and an increased burden on trainees, including moral distress and decreased support from one another and other social supports. The COVID-19 pandemic has highlighted important opportunities in U.S. educational systems. As medical educators move forward, it will be important to learn from these while mitigating the negative impacts.

Dual and duelling purposes: An exploration of educators' perspectives on the use of reflective writing to remediate professionalism in residency

CONTEXT

Professionalism lapses have high stakes for learners and educators. Problems with professionalism, unless appropriately and effectively remediated, may portend serious problems in practice. Yet, remediation for unprofessional behaviour is particularly challenging-and understudied. Increasingly, educators are turning to reflective writing as a remediation strategy in residency, yet little is known about what educators expect reflective writing to accomplish, how they choose reflective writing tasks, why they use reflective writing, or how they evaluate whether a learner has met expectations. We aimed to understand why and how postgraduate medical educators use reflective writing as an educational intervention to remediate professionalism.

METHOD

In this constructivist grounded theory study, we interviewed 13 medical education professionals with experience using reflective writing to remediate professionalism across five Canadian medical schools. Data collection and analysis occurred iteratively using constant comparison to identify themes and to understand the relationships among them.

RESULTS

Medical educators reported using reflective writing as a learning tool to develop insight and as an assessment tool to unearth evidence of insight. The goal of learning may compete with the goal of assessment, creating tension that leads to uncertainty about the sincerity, quality and effectiveness of reflective writing as well as concerns about learner safety. Educators reported uncertainty about whether learners write to pass or to introspect and about how to judge the effectiveness of reflective writing as a learning tool. They expressed concern about creating a safe environment for learners-one that enables the genuine reflection required for insight development-while meeting requirements of remediation.

CONCLUSIONS

Educators express ambivalence about using reflective writing to remediate professionalism in residency. Understanding the potential and pitfalls of reflective writing may inform more tailored and effective approaches to remediate professionalism.

Toward Useful Interventions for Burnout in Academic Medical Faculty: The Case for Unit-Specific Approaches

INTRODUCTION

Despite a plethora of research on the topic of physician burnout, drivers and interventions are poorly understood. This study aimed to create a holistic picture of burnout drivers in academic medical faculty within a single department of a large, research university to better inform organization-sponsored interventions.

METHODS

The author used interpretive phenomenological analysis and the Job Demands-Resources model in this qualitative study. Full-time academic medical faculty completed two semistructured interviews approximately 6 months apart. Transcripts were coded using deductive and inductive coding.

RESULTS

Twenty-two faculty members participated in both interviews. Factors affecting burnout depended on individual and unit-level context, but interpersonal factors such as relationships with colleagues and interaction with learners created meaning for faculty or drove intention to leave the university. All participants reported personal coping mechanisms, and none participated in organization-sponsored, individual-level interventions.

DISCUSSION

In striving for meaningful burnout interventions, organizations should promote interpersonal factors (relationships with colleagues and meaningful interaction with learners) and provide protected time for faculty for their own personal coping. Research has suggested moving toward a universal burnout driver and intervention plan, but these data point toward the need for unit-specific study and interventions.

Trends in Depressive Symptoms and Associated Factors During Residency, 2007 to 2019 : A Repeated Annual Cohort Study

BACKGROUND

Efforts to address the high depression rates among training physicians have been implemented at various levels of the U.S. medical education system. The cumulative effect of these efforts is unknown.

OBJECTIVE

To assess how the increase in depressive symptoms with residency has shifted over time and to identify parallel trends in factors that have previously been associated with resident physician depression.

DESIGN

Repeated annual cohort study.

SETTING

U.S. health care organizations.

PARTICIPANTS

First-year resident physicians (interns) who started training between 2007 and 2019.

MEASUREMENTS

Depressive symptoms (9-item Patient Health Questionnaire [PHQ-9]) assessed at baseline and quarterly throughout internship.

RESULTS

Among 16 965 interns, baseline depressive symptoms increased from 2007 to 2019 (PHQ-9 score, 2.3 to 2.9; difference, 0.6 [95% CI, 0.3 to 0.8]). The prevalence of baseline predictors of greater increase in depressive symptoms with internship also increased across cohorts. Despite the higher prevalence of baseline risk factors, the average change in depressive symptoms with internship decreased 24.4% from 2007 to 2019 (change in PHQ-9 score, 4.1 to 3.0; difference, -1.0 [CI, -1.5 to -0.6]). This change across cohorts was greater among women (4.7 to 3.3; difference, -1.4 [CI, -1.9 to -0.9]) than men (3.5 to 2.9; difference, -0.6 [CI, -1.2 to -0.05]) and greater among nonsurgical interns (4.1 to 3.0; difference, -1.1 [CI, -1.6 to -0.6]) than surgical interns (4.0 to 3.2; difference, -0.8 [CI, -1.2 to -0.4]). In parallel to the decrease in depressive symptom change, there were increases in sleep hours, quality of faculty feedback, and use of mental health services and a decrease in work hours across cohorts. The decrease in work hours was greater for nonsurgical than surgical interns. Further, the increase in mental health treatment across cohorts was greater for women than men.

LIMITATION

Data are observational and subject to biases due to nonrandom sampling, missing data, and unmeasured confounders, limiting causal conclusions.

CONCLUSION

Although depression during physician training remains high, the average increase in depressive symptoms associated with internship decreased between 2007 and 2019.

PRIMARY FUNDING SOURCE

National Institute of Mental Health.

Parental leave policy information during residency interviews

BACKGROUND

During interviews, medical students may feel uncomfortable asking questions that might be important to them, such as parental leave. Parental leave policies may be difficult for applicants to access without asking the program director or other interviewers. The goal of this study is to evaluate whether parental leave information is presented to prospective residents and whether medical students want this information.

METHODS

Fifty-two program directors (PD's) at 3 sites of a single institution received a survey in 2019 to identify whether parental leave information is presented at residency interviews. Medical students received a separate survey in 2020 to identify their preferences. Fisher exact tests, Pearson χ² tests and Cochran-Armitage tests were used where appropriate to assess for differences in responses.

RESULTS

Of the 52 PD's, 27 responded (52%) and 19 (70%) indicated that information on parental leave was not provided to candidates. The most common reason cited was the belief that the information was not relevant (n = 7; 37%). Of the 373 medical students, 179 responded (48%). Most respondents (92%) wanted parental leave information formally presented, and many anticipated they would feel extremely or somewhat uncomfortable (68%) asking about parental leave. The majority (61%) felt that these policies would impact ranking of programs "somewhat" or "very much."

CONCLUSIONS

Parental leave policies may not be readily available to interviewees despite strong interest and their impact on ranking of programs by prospective residents.

Reflecting Before, During, and After the Heat of the Moment: A Review of Four Approaches for Supporting Health Staff to Manage Stressful Events

Being a healthcare professional in both paediatric and adult hospitals will mean being exposed to human tragedies and stressful events involving conflict, misunderstanding, and moral distress. There are a number of different structured approaches to reflection and discussion designed to support healthcare professionals process and make sense of their feelings and experiences and to mitigate against direct and vicarious trauma. In this paper, we draw from our experience in a large children's hospital and more broadly from the literature to identify and analyse four established approaches to facilitated reflective discussions. Each of the four approaches seeks to acknowledge the stressful nature of health professional work and to support clinicians from all healthcare professions to develop sustainable skills so they continue to grow and thrive as health professionals. Each approach also has the potential to open up feelings of uncertainty, frustration, sorrow, anguish, and moral distress for participants. We argue, therefore, that in order to avoid unintentionally causing harm, a facilitator should have specific skills required to safely lead the discussion and be able to explain the nature, scope, safe application, and limits of each approach. With reference to a hypothetical but realistic clinical case scenario, we discuss the application and key features of each approach, including the goals, underpinning theory, and methods of facilitation.

Voices from the Front Lines: An Analysis of Physicians' Reflective Narratives about Flaws with the 'System'

Physicians often express frustration with the 'system' in which they work. Over time, this frustration may put them at risk of burnout and disengagement, which may impact patient care. In this study, we aimed to understand the nature of the system flaws that physicians identified in their published narratives and to explore their self-representation as agents of change. We reviewed all reflective narratives published in four medical journals (NEJM, JAMA, CMAJ, Annals IM) between January 2015 and December 2017 (n = 282). By consensus, we identified those that addressed system flaws (n = 87). Using content and narrative analysis, we analyzed the types of flaws and the physicians' orientation to the flawed system. We identified seven recurring system flaws-five related to medical culture: failures of communication, erosive impact of the hidden curriculum, inadequate health advocacy, frenzied pace of work, and experience of stigma. Less frequently, physicians' narratives also exposed limited and disparate healthcare resources and restrictive institutional practices as impeding patient-centered care. Physicians expressed agency to create change foremost when writing about flaws related to medical culture. While physicians are challenged by system flaws, they strive to practice in ways that do not succumb to them. We saw tension between the elements outside the physician's control and those within it. This tension becomes a source of distress when the compromises that emerge from system flaws move physicians away from the values that define their professional identity.

The Impact of the COVID-19 Pandemic on Resident Physicians Well-Being in the Surgical and Primary Care Specialties in the United States and Canada

Purpose: The COVID-19 pandemic disrupted the professional, social, and spiritual activities of resident physicians around the world, impacting wellness and personal relationships. Moreover, social distancing caused significant limitations or shutdown of places of worship, including churches, synagogues, mosques, etc. Our goal was to survey resident physicians in primary care and surgical subspecialties in the United States (U.S.) and Canada and to examine the effect of the COVID-19 pandemic on their well-being.

Methods: An international cross-sectional study was performed in November 2020, using an anonymous survey of programs in the U.S. and Canada, containing 20 questions to assess the impact of the pandemic on resident participation in social and spiritual activities and the effects on their wellness, and personal relationships. The emails with survey links attached were sent to individual program coordinators from accredited residency training programs in the United States and Canada. This consisted of programs accredited by the American Osteopathic Association (AOA), The Royal College of Physicians and Surgeons of Canada (RCPSC), and the Accreditation Council of Graduate Medical Education (ACGME). The survey was evenly divided among surgical programs (General Surgery, Neurological Surgery, Orthopedic Surgery, Urological Surgery, and Integrated Surgical Residency Programs such as Plastic Surgery, Cardiothoracic Surgery, Pediatric Surgery, and Vascular Surgery) as well as primary care programs (Internal Medicine and Family Medicine).

Results: A total of 196 residents, 60 primary care residents, and 136 surgery residents participated in the study. Ninety-six participants (49%) were female, and 98 of the participants (50%) were male, with the remainder two residents identifying as “Other.” Of the primary care residents, the majority (39, 65%) were female. Conversely, the majority (77, 57%) of surgery residents were male.

Conclusion: The COVID-19 pandemic has affected the social lives, relationships, and spiritual well-being of both surgical and primary care resident physicians. However, primary care residents reported significantly greater engagement in personal relationships and were more likely to express feelings of mental and physical exhaustion, prohibiting social attendance.

MicrosimUC: Validation of a Low-Cost, Portable, Do-It-Yourself Microsurgery Training Kit

BACKGROUND

 Microsurgery depends largely on simulated training to acquire skills. Courses offered worldwide are usually short and intensive and depend on a physical laboratory. Our objective was to develop and validate a portable, low-cost microsurgery training kit.

METHODS

 We modified a miniature microscope. Twenty general surgery residents were selected and divided into two groups: (1) home-based training with the portable microscope (MicrosimUC, n = 10) and (2) the traditional validated microsurgery course at our laboratory (MicroLab, n = 10). Before the intervention, they were assessed making an end-to-end anastomosis in a chicken wing artery. Then, each member of the MicrosimUC group took a portable kit for remote skill training and completed an eight-session curriculum. The laboratory group was trained at the laboratory. After completion of training, they were all reassessed. Pre- and posttraining procedures were recorded and rated by two blind experts using time, basic, and specific scales. Wilcoxon's and Mann-Whitney tests were used to compare scores. The model was tested by experts (n = 10) and a survey was applied to evaluate face and content validity.

RESULTS

 MicrosimUC residents significantly improved their median performance scores after completion of training (p < 0.05), with no significant differences compared with the MicroLab group. The model was rated very useful for acquiring skills with 100% of experts considering it for training. Each kit had a cost of U.S. $92, excluding shipping expenses.

CONCLUSION

 We developed a low-cost, portable microsurgical training kit and curriculum with significant acquisition of skills in a group of residents, comparable to a formal microsurgery course.

Development of a taxonomy of unprofessional behavior in clinical learning environments using learner-generated critical incidents

PURPOSE

Few studies have examined medical residents' and fellows' (trainees) direct experience of unprofessional behavior in clinical learning environments (CLE). The purpose of this study was to create a taxonomy of unprofessional behavior in CLEs using critical incidents gathered from trainees.

METHOD

In step 1 (data collection), the authors collected 382 critical incidents from trainees at more than a dozen CLEs over a six-year period (2013-2019). In step 2 (model generation), nine subject matter experts (SMEs) sorted the incidents into homogenous clusters and this structure was tested with principal components analysis (PCA). In step 3 (model evaluation), two new groups of SMEs each re-sorted half of the incidents into the PCA-derived categories.

RESULTS

A 13-component solution accounted for 62.46% of the variance in the critical incidents collected. The SMEs who re-sorted the critical incidents demonstrated good agreement with each other and with the 13-component PCA solution. The resulting taxonomy included 13 dimensions, with 48.7% of behaviors focused on displays of aggression or discriminatory conduct.

CONCLUSIONS

Critical incident methodology can provide unique insights into the dimensionality of unprofessional behavior in the CLE. Future research should leverage the taxonomy created to inform professionalism assessment development in the CLE.

Empathy Among Orthopaedic Surgery Trainees

Background

It has been postulated that the process of-and stresses associated with-medical training may cause a loss of empathy among trainees. Because empathy is considered an important value for clinicians and may even be associated with better patient outcomes, we assessed the empathy of orthopaedic surgery trainees and identified factors associated with empathy.

Methods

Between June and September 2020, an anonymous survey was distributed electronically to trainees in 23 Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs via the Collaborative Orthopaedic Educational Research Group. The survey comprised the validated Short-Form 8-Item Empathy Quotient (EQ-8) questionnaire-scored on a scale of 0, least empathetic, to 16, most empathetic-and single-item measure of emotional exhaustion and depersonalization derived from the Maslach Burnout Index-scored using a frequency scale. In total, 438 of 605 (72%) trainees completed the survey. The scores were compared via one-way analysis of variance, with Bonferroni correction and Tukey post-hoc testing, α = 0.05.

Results

The mean (±SD) EQ-8 score among respondents was 11.3 ± 3.3. Women scored significantly higher (mean, 12.2 ± 2.8) than men (mean, 11.2 ± 3.3) (p = 0.02). Mean scores were significantly higher for trainees planning on a career in academic medicine (12.0 ± 2.9) than those intending to pursue private practice (10.9 ± 3.3) or those with a military commitment (10.4 ± 3.4) (p = 0.01). An inverse relationship was found between EQ-8 scores and single-item Maslach Burnout Index measures in depersonalization and emotional exhaustion (both, p < 0.01). No significant differences were found in EQ-8 scores across postgraduate year, program location, primary training setting, intended fellowship, relationship status, or whether they reported having children.

Conclusions

We found no association between postgraduate year and EQ-8 score. Women and those intending to pursue a career in academic medicine had significantly higher levels of empathy. A significant inverse relationship was found between burnout and empathy. Respondents with higher levels of emotional exhaustion and depersonalization had lower levels of empathy.

Maintaining Wellness and Instilling Resilience in General Surgeons

Obtaining wellness and enhancing resilience will be increasingly more important for General Surgeons. Although these concepts are not new, the increased complexity of health care delivery has elevated the importance of these essential attributes. Instilling these practices should be emphasized during surgery residency and be modeled by surgical educators and surgeon leaders. The enhanced emphasis of wellness and resiliency is a positive step forward; however, more must be accomplished to ensure the well-being of a particularly group of vulnerable physicians. This chapter discusses the history and scientific theory behind wellness and resiliency, as well as practical suggestions for consideration.

A Systematic Review of Wellness in Plastic Surgery Training

BACKGROUND

Physician and resident wellness has been increasingly emphasized as a means of improving patient outcomes and preventing physician burnout. Few studies have been performed with a focus on wellness in plastic surgery training.

OBJECTIVES

The aim of this study was to systematically review what literature exists on the topic of wellness in plastic surgery training and critically appraise it.

METHODS

A PubMed search was performed to identify journal articles related to wellness in plastic surgery residency. Seventeen studies (6 cohort and 11 cross-sectional) met inclusion criteria and were appraised with the Newcastle-Ottawa Quality Assessment Scale (NOQAS) to determine the quality of the studies based on selection, comparability, and outcome metrics.

RESULTS

Critical assessment showed that the studies were highly variable in focus. Overall, the quality of the data was low, with an average NOQAS score of 4.1. Only 2 studies focused on plastic surgery residents, examining work hours and social wellness, respectively; they were awarded NOQAS scores of 3 and 4 out of 10.

CONCLUSIONS

The results of this systematic review suggest that little research has been devoted to wellness in surgery training, especially in regard to plastic surgery residents, and what research that has been performed is of relatively low quality. The available research suggests a relatively high prevalence of burnout among plastic surgery residents. Evidence suggests some organization-level interventions to improve trainee wellness. Because outcomes-based data on the effects of such interventions are particularly lacking, further investigation is warranted.

Infertility insurance: What coverage exists for physician trainees?

INTRODUCTION

We aimed to describe infertility insurance coverage provided to male and female fellows working at institutions that offer advanced infertility training.

METHODS

Faculty and fellows working within U.S. and Canadian andrology or reproductive endocrinology and infertility (REI) programs were contacted and asked for a copy of their institutional health insurance summary of benefits. Documents were assessed for coverage of diagnosis and treatment, shared costs, and maximum lifetime coverage for infertility care.

RESULTS

Insurance policies from 24 institutions were reviewed; 16 of 24 (66%) institutions covered costs related to the diagnosis of infertility. Six institutions (25%) offered coverage for diagnosis but not treatment. There were 15 (62.5%) institutions that offered some amount of coverage for the treatment of infertility, and the average lifetime maximum was $16 100. Only six of 24 (25%) plans explicitly described a covered male-specific treatment, which included sperm extraction (12.5%), varicocele repair (4.2%), and sperm cryopreservation (8.3%).

CONCLUSIONS

For physician trainees, infertility insurance coverage is not universal, policies are not transparent, and treatment for male factor infertility is often omitted. With high costs of infertility treatment, variable insurance coverage, and debt and time constraints, residents and fellows are a particularly vulnerable population that may experience significant financial toxicity when faced with infertility.

Interventions to improve the well-being of medical learners in Canada: a scoping review

BACKGROUND

Medical education affects learner well-being. We explored the breadth and depth of interventions to improve the well-being of medical learners in Canada.

METHODS

We searched MEDLINE, EMBASE, CINAHL and PsycINFO from inception to July 11, 2020, using the Arksey-O'Malley, 5-stage, scoping review method. We included interventions to improve well-being across 5 wellness domains (i.e., social, mental, physical, intellectual, occupational) for medical learners in Canada, grouped as undergraduate or graduate nonmedical (i.e., health sciences) students, undergraduate medical students or postgraduate medical students (i.e., residents). We categorized interventions as targeting the individual (learner), program (i.e., in which learners are enrolled) or system (i.e., higher education or health care) levels.

RESULTS

Of 1753 studies identified, we included 65 interventions that aimed to improve well-being in 10 202 medical learners, published from 1972 through 2020; 52 (80%) were uncontrolled trials. The median year for intervention implementation was 2010 (range 1971-2018) and the median length was 3 months (range 1 h-48 mo). Most (n = 34, 52%) interventions were implemented with undergraduate medical students. Two interventions included only undergraduate, nonmedical students; none included graduate nonmedical students. Most studies (n = 51, 78%) targeted intellectual well-being, followed by occupational (n = 32, 49%) and social (n = 17, 26%) well-being. Among 19 interventions implemented for individuals, 14 (74%) were for medical students; of the 27 program-level interventions, 17 (63%) were for resident physicians. Most (n = 58, 89%) interventions reported positive well-being outcomes.

INTERPRETATION

Many Canadian medical schools address intellectual, occupational and social well-being by targeting interventions at medical learners. Important emphasis on the mental and physical well-being of medical learners in Canada warrants further exploration.

Educational program in onco-urology for young urologists: What are their needs?

PURPOSE

The emergence of new communication media such as digital contents are progressively replacing more traditional medias in the field of educational programs. Our purpose was to assess urologist in training aspirations regarding urological education.

METHODS

Members of a national urologist in training association were sent an anonymous online questionnaire regarding their medical formation in the field of urology. Responders interest for urological sub-specialty or education support (new tools and traditional support) were evaluated through a 5-point Likert scale.

RESULTS

Overall, 109 young urologists (26%) responded to the survey. Most of the respondents worked during their training in an academic hospital (n=89, 82%). The three favorite tools for training chosen by the responders were: videos, workshop or masterclass, and podcasts (responders very interested were respectively n=64 (58.7%), n=50 (45.9%), and n=49 (45%)). E-mail newsletters were reported as the less useful educational tool by participants (n=38, 34.9%). Participants were very interested in improving their surgical skills and their radiological knowledge. Responders who were the most attracted by PCa were much more looking to improve their systemic treatment and radiological knowledges.

CONCLUSIONS

Urologic-oncology was a priority regarding education for urologists in training. A majority of participants expressed a lack in their surgical education, revealing a reduced OR access and underlining utilization of new tools such as simulation. New digital contents such as social media or podcast achieved high interest for the participants, instead of more traditional media. There is a need that educational content evolve and uses new digital media.

LEVEL OF EVIDENCE

3.

Exploring the impact of the COVID-19 pandemic on medical learner wellness: a needs assessment for the development of learner wellness interventions

BACKGROUND

On March 11, 2020 the World Health Organization declared the novel coronavirus SARS-CoV-2 disease (COVID-19) a global pandemic. We sought to understand impact of COVID-19 on learner wellness at a large tertiary care academic institution to inform the future development of learner wellness interventions during the COVID-19 pandemic.

METHODS

A cross-sectional, internet-based survey collected quantitative and qualitative data from learners April-June 2020. Descriptive statistics and univariate analyses were reported for quantitative data. Open-ended, qualitative responses were analyzed deductively using thematic analysis.

RESULTS

Twenty percent of enrolled learners in that faculty of medicine (540/2741) participated including undergraduate [Bachelor's] students (25.7%), graduate [science] students (27.5%), undergraduate medical students (22.8%), and postgraduate resident physicians (23.5%). We found that learner wellness across all stages of training was negatively impacted and the ways in which learners were impacted varied as a result of their program's response to the COVID-19 pandemic.

CONCLUSIONS

Learners in health sciences and medical education report worsening well-being because of the programs and the systems in which they function with the added burden of the COVID-19 pandemic. Future interventions would benefit from a holistic framework of learner wellness while engaging in systems thinking to understand how individuals, programs and respective systems intersect. The importance of acknowledging equity, diversity and inclusion, fostering psychological safety and engaging learners as active participants in their journey during a pandemic and beyond are key elements in developing wellness interventions.