The incidence and predictors of job burnout in first-year internal medicine residents: a five-institution study

Resident Burnout, Wellness, Professional Development, and Engagement Before and After New Training Schedule Implementation

Importance

Burnout is a work-related syndrome of depersonalization (DP), emotional exhaustion (EE), and low personal achievement (PA) that is prevalent among internal medicine resident trainees. Prior interventions have had modest effects on resident burnout. The association of a new 4 + 4 block schedule (4 inpatient weeks plus 4 outpatient weeks) with resident burnout has not previously been evaluated.

Objective

To evaluate the association of a 4 + 4 block schedule, compared with a 4 + 1 schedule, with burnout, wellness, and self-reported professional engagement and clinical preparedness among resident physicians.

Design, Setting, and Participants

This nonrandomized preintervention and postintervention survey study was conducted in a single academic-based internal medicine residency program from June 2019 to June 2021. The study included residents in the categorical, hospitalist, and primary care tracks in postgraduate years 1 and 2 (PGY1 and PGY2). Data analysis was conducted from October to December 2022.

Intervention

In the 4 + 4 structure, resident schedules alternated between 4-week inpatient call-based rotations and 4-week ambulatory non-call-based rotations.

Main Outcomes and Measures

The primary outcome was burnout, assessed using the Maslach Burnout Inventory subcategories of EE (range, 0-54), DP (range, 0-30), and PA (range, 0-48), adjusted for sex and PGY. Secondary outcomes included In-Training Examination (ITE) scores and a questionnaire on professional, educational, and health outcomes. Multivariable logistic regression was used to assess the primary outcome, 1-way analysis of variance was used to compare ITE percentiles, and a Bonferroni-adjusted Kruskal Wallis test was used for the remaining secondary outcomes. The findings were reexamined with several sensitivity analyses, and Cohen's D was used to estimate standardized mean differences (SMDs).

Results

Of the 313 eligible residents, 216 completed the surveys. A total of 107 respondents (49.5%) were women and 109 (50.5%) were men; 119 (55.1%) were PGY1 residents. The survey response rates were 78.0% (85 of 109) in the preintervention cohort and 60.6% (63 of 104) and 68.0% (68 of 100) in the 2 postintervention cohorts. The PGY1 residents had higher response rates than the PGY2 residents (119 of 152 [78.2%] vs 97 of 161 [60.2%]; P < .001). Adjusted EE scores (mean difference [MD], -6.78 [95% CI, -9.24 to -4.32]) and adjusted DP scores (MD, -3.81 [95% CI, -5.29 to -2.34]) were lower in the combined postintervention cohort. The change in PA scores was not statistically significant (MD, 1.4 [95% CI, -0.49 to 3.29]). Of the 15 items exploring professional, educational, and health outcomes, a large positive association was observed for 11 items (SMDs >1.0). No statistically significant change in ITE percentile ranks was noted.

Conclusions and Relevance

In this survey study of internal medicine resident physicians, a positive association was observed between a 4 + 4 block training schedule and internal medicine resident burnout scores and improved self-reported professional, educational, and health outcomes. These results suggest that specific 4 + 4 block combinations may better improve resident burnout than a 4 + 1 combination used previously.

Burnout in residents during the first wave of the COVID-19 pandemic: a systematic review and meta-analysis

Introduction

The high prevalence of burnout in resident physicians is expected to have increased as a result of the expansion of the pandemic. We conducted a systematic review with a meta-analysis of studies conducted during the first wave of the COVID-19 pandemic on burnout in residents and potential associated risk factors.

Methods

The search was done in the Web of Science, MEDLINE, Scopus, and Lillac databases (April 2020-October 2021) using a priori protocol based on the PRISMA guidelines. The Newcastle Ottawa Scale was used to assess the risk of bias in the included studies. We estimated the pooled prevalence (95% CI) of burnout and the prevalence ratio (95% CI) of each risk factor associated.

Results

We included 23 studies from 451 potential initial articles and those written in the English language; all of the collected studies were cross-sectional with anonymous online surveys, involving 4,998 responders (34%), of which 53.2% were female responders, 51% were R1-2, and 71% were in direct contact with COVID-19 patients. Eighty-seven percent presented a low-to-moderate risk of bias. Publication bias was not shown. The estimated pooled prevalence of burnout was 40% (95% CI = 0.26 - 0.57). Burnout was associated with psychiatry history (PR = 4.60, 95% CI = 1.06 - 20.06). There were no differences by gender, civil status, children in-charge, year of residency, or time exposure to COVID-19.

Discussion

The overall prevalence of burnout in residents during the first wave of the pandemic was in line with the results described in this collective before the pandemic. The presence of a psychiatry history was a potential burnout risk factor, suggesting a high vulnerability during the peak of the stress period and the need to implement mental health surveillance for this subgroup.

Resident factors associated with American board of internal medicine certification exam failure

INTRODUCTION

Performance on the certifying examinations such as the American Board of Internal Medicine Certification Exam (ABIM-CE) is of great interest to residents and their residency programs. Identification of factors associated with certification exam result may allow residency programs to recognize and intervene for residents at risk of failing. Despite this, residency programs have few evidence-based predictors of certification exam outcome. The change to pass-or-fail score reporting of the USA Medical Licensing Exam (USMLE) Step 1 removes one such predictor.

MATERIALS AND METHODS

We performed a retrospective study of residents from a medium-sized internal medicine residency program who graduated from 1998 through 2017. We used univariate tests of associations between ABIM-CE result and various demographic and scholastic factors.

RESULTS

Of 166 graduates, 14 (8.4%) failed the ABIM-CE on the first attempt. Failing the first attempt of the ABIM-CE was associated with older median age on entering residency (29 vs 27 years; P = 0.01); lower percentile rank on the Internal Medicine In-Training Examination (IM-ITE) in each of the first, second, and third years of training (P < 0.001 for all); and lower scores on the USMLE Steps 1, 2 Clinical Knowledge, and 3 (P < 0.05 for all). No association was seen between a variety of other scholastic or demographic factors and first-attempt ABIM-CE result.

DISCUSSION

Although USMLE step 1 has changed to a pass-or-fail reporting structure, there are still other characteristics that allow residency programs to identify residents at risk of ABIM-CE first time failure and who may benefit from intervention.

Physician Perceptions of Performance Feedback and Impact on Personal Well-Being: A Qualitative Exploration of Patient Satisfaction Feedback in Neurology

BACKGROUND

To understand neurologists' experiences and perspectives on patient satisfaction feedback and its impact on personal well-being and behavior.

METHODS

From May to June 2021, the researchers conducted 19 semistructured interviews with neurologists from a large academic medical center. Clinical Performance Feedback Intervention Theory informed a combined inductive and deductive thematic analysis of the qualitative data, which focused on perceptions of current feedback practices, its impact on physician behavior, and recommendations for improvement.

RESULTS

Participants tended to be female (n = 12/19, 63.2%), aged 30-39 (n = 8/19, 42.1%), white (n = 9/19, 47.4%), and were 10+ years into clinical practice (n = 18/19, 94.7%). Physicians were receptive to feedback overall, but perceptions varied by feedback type. Physicians preferred informal feedback (delivered unprompted directly by patients), given its tendency toward actionability. They disliked formal feedback (derived from anonymous surveys) due to low actionability, bias and validity issues, lack of contextual considerations, delivery through public reports, and links to financial incentives. Nearly all physicians reported formal feedback programs had the potential to negatively affect well-being and were not beneficial to their practice; a few reported adjusting their clinical practice to improve patient satisfaction performance. Five recommendations to improve patient satisfaction feedback programs emerged: Align on feedback intent, acknowledge survey limitations during program administration, increase actionability of feedback through specificity and control, support direct patient-physician feedback and problem resolution, and support empathetic integration of feedback.

CONCLUSION

Understanding physician perceptions of current approaches to patient satisfaction feedback offers the opportunity to shape subsequent collection and distribution methods to improve physician performance and optimize professional fulfillment.

Assessing Leadership Behavior in Health Care: Introducing the Local Leadership Scale of the SCORE Survey

BACKGROUND

Engaged and accessible leadership is a key component of care excellence. However, the field lacks brief, reliable, and actionable measures of feedback and coaching-related behaviors of local leaders (for example, provides frequent feedback). The current study introduces a five-item Local Leadership (LL) scale by examining its psychometric properties, providing benchmarking across demographic factors and work settings, assessing its association with psychological safety, and testing whether LL predicts reports of restricted activities and absenteeism.

METHODS

In this cross-sectional study, 23,853 questionnaires were distributed across 31 Midwestern US hospitals. The survey included the LL scale, as well as safety culture and well-being scales. Psychometric analyses (Cronbach's α, confirmatory factor analysis [CFA] fit: root square mean error of the approximation [RMSEA], comparative fit index [CFI], Tucker-Lewis index [TLI]), Spearman correlations, t-tests, and analyses of variance (ANOVAs) were used to test the properties of the LL scale and differences by health care worker and work setting characteristics.

RESULTS

A total of 16,797 surveys were returned (70.4% response rate). The LL scale exhibited strong psychometric properties (Cronbach's α = 0.94; RMSEA = 0.079; CFI = 0.99; TLI = 0.98). LL scores differed by role, shift, shift length, and years in specialty. Of all roles, leaders (for example, managers) rated leaders most favorably. Nonclinical (vs. clinical) and nonsurgical (vs. surgical) work settings reported higher LL. LL scores correlated positively with psychological safety, absenteeism, and activities restricted due to illness.

CONCLUSION

The LL scale exhibits strong psychometric properties, convergent validity with psychological safety, and variation by work setting, work setting type, role, shift, shift length, and specialty. The study indicates that assessing leadership behaviors with the LL scale is useful and offers actionable behaviors for leaders to improve safety culture within teams.

Professional identity formation: linking meaning to well-being

Trainee distress and burnout continue to be serious concerns for educational programs in medicine, prompting the implementation of numerous interventions. Although an expansive body of literature suggests that the experience of meaning at work is critical to professional wellbeing, relatively little attention has been paid to how this might be leveraged in the educational milieu. We propose that professional identity formation (PIF), the process by which trainees come to not only attain competence, but additionally to "think, act and feel" like physicians, affords us a unique opportunity to ground trainees in the meaningfulness of their work. Using the widely accepted tri-partite model of meaning, we outline how this process can contribute to wellbeing. We suggest strategies to optimize the influence of PIF on wellbeing, offering curricular suggestions, as well as ideas regarding the respective roles of communities of practice, teachers, and formative educational experiences. Collectively, these encourage trainees to act as intentional agents in the making of their novel professional selves, anchoring them to the meaningfulness of their work, and supporting their short and long-term wellbeing.

The glass ceiling thickens: the impact of COVID-19 on academic medicine faculty in the United States

The inequities faced by women in academic Medicine before the COVID-19 pandemic are well established. However, there is little formal data regarding exactly how the pandemic has affected faculty. This cross-sectional study investigated the impact of the pandemic on responsibilities at home, work, and mental health according to gender identification, faculty rank, and faculty appointment. In February 2021, an online questionnaire was broadly distributed to academic medicine faculty. Respondents were asked to provide demographic data, answer questions about their responsibilities at home and work, mental health, and how the pandemic has influenced these. Respondents were also asked to document what their institution(s) can do to help faculty through the pandemic. Responses were analyzed via Pearson's chi-square tests and thematic analysis. Women faculty were more likely to be responsible for the care of others (70%, p = 0.014), and the impact was negative, especially for early career faculty (p = 0.019). Productivity in research, teaching, and clinical practice were negatively impacted, with women feeling this in clinical practice (p = 0.005), increased teaching load (p = 0.042), and inadequate work environment (p = 0.013). In the areas of self-care and mental health, women (p < 0.001), early career-faculty (p < 0.001), and clinical faculty (p = 0.029) were more negatively impacted. Early-career women were more likely to fear retribution. Five themes emerged, including Flexible Expectations, Support, Mental Health, Compensation, and Communication. Pre-pandemic stress and burnout were rampant, and this study demonstrates that academic medicine faculty are still suffering. It is the authors' hope that administrations can utilize these data to make informed decisions regarding policies enacted to assist populations who are most vulnerable to the effects of the pandemic.

Assessing Interpersonal Relationships in Medical Education: the Connection Index

OBJECTIVE

The relationship between a resident physician and his/her supervising attending is foundational to graduate medical education and may impact the clinical learning environment and resident well-being. This paper focuses on how to measure connection between a resident and their clinical supervisor. Connection includes the subdomains of psychological safety, empathy, educational alliance, and feedback.

METHODS

After reviewing the literature, the authors designed the 12-item, 7-point Connection Index (CI₁₂) to quantitatively measure connections between a resident and his/her supervisor during a 6-month period (supervision dyad), and based on educational alliance, empathy, psychological safety, and effective feedback. A 9-criteria evaluation framework was applied to assess its reliability and validity on a sample of psychiatry residents at a residency program, July 2016 through June 2018.

RESULTS

Out of a total possible number of 50 residents, 100% participated to rate 41 supervisors over 201 supervision dyads; the CI₁₂ satisfied all eight of the eight testable criteria, including high scalability (H = 0.78), consistency (alpha = 0.98), test-retest validity (ICC = 0.95), and construct validity where CI₁₂ was found to have statistically significant correlations with outcomes measures (greater connection was associated with less negative emotional experiences, less mistreatment or bias, less burnout, and higher attendance to supervision sessions).

CONCLUSION

The authors showed the CI₁₂ can be a valid and reliable instrument to quantify whether a resident and his/her supervisor connects during a 6-month supervision with respect to empathy, psychological safety, educational alliance, and feedback. We recommend assessing connections as part of the overall evaluation of a resident's experience with the clinical learning environment.

Prevalence of burnout in medical students: A systematic review and meta-analysis

BACKGROUND

Medical students are at a significant risk of experiencing psychological issues, such as burnout. Over the past few years, more studies have been conducted on this topic, producing different results.

AIMS

The purpose of this review was to determine the global pooled prevalence rate and risk factors associated with burnout and its components among undergraduate (pre-intern) medical students.

METHOD

From inception until 30 November 2021, nine electronic databases were used for an electronic search. Using random-effects meta-analysis, we pooled the estimates using the DerSimonian-Laird method. The prevalence of burnout in medical students was the primary outcome of interest. Data were analyzed globally, by country, by research measure. Age and sex were examined as confounders using meta-regression analysis.

RESULTS

A random-effects meta-analysis of 42 studies involving 26,824 evaluating the prevalence of burnout in medical students showed an overall prevalence rate 37.23% [32.66%; 42.05%], Q = 2,267.15(41), p < .0001, τ² = .42, τ = .65, I² = 98.2%; H = 7.5. Prevalence of emotional exhaustion, depersonalization, and personal accomplishment were 38.08% [30.67%; 46.10%], 35.07% [26.74%; 44.41%], and 37.23% [32.66%; 42.05%], respectively. Variations were observed between countries and research measures. Age (older) and sex (female) were both significant predictors of burnout.

CONCLUSION

The prevalence of burnout in medical students was estimated to be 37.23%. It is urgent that future studies serve as a basis for the development of prevention and treatment programs to prevent and treat burnout in students.

Temporal Associations Between EHR-Derived Workload, Burnout, and Errors: a Prospective Cohort Study

BACKGROUND

The temporal progression and workload-related causal contributors to physician burnout are not well-understood.

OBJECTIVE

To characterize burnout's time course and evaluate the effect of time-varying workload on burnout and medical errors.

DESIGN

Six-month longitudinal cohort study with measurements of burnout, workload, and wrong-patient orders every 4 weeks.

PARTICIPANTS

Seventy-five intern physicians in internal medicine, pediatrics, and anesthesiology at a large academic medical center.

MAIN MEASURES

Burnout was measured using the Professional Fulfillment Index survey. Workload was collected from electronic health record (EHR) audit logs and summarized as follows: total time spent on the EHR, after-hours EHR time, patient load, inbox time, chart review time, note-writing time, and number of orders. Wrong-patient orders were assessed using retract-and-reorder events.

KEY RESULTS

Seventy-five of 104 interns enrolled (72.1%) in the study. A total of 337 surveys and 8,863,318 EHR-based actions were analyzed. Median burnout score across the cohort across all time points was 1.2 (IQR 0.7-1.7). Individual-level burnout was variable (median monthly change 0.3, IQR 0.1-0.6). In multivariable analysis, increased total EHR time (β=0.121 for an increase from 54.5 h per month (25th percentile) to 123.0 h per month (75th percentile), 95%CI=0.016-0.226), increased patient load (β=0.130 for an increase from 4.9 (25th percentile) to 7.1 (75th percentile) patients per day, 95%CI=0.053-0.207), and increased chart review time (β=0.096 for an increase from 0.39 (25th percentile) to 0.59 (75th percentile) hours per patient per day, 95%CI=0.015-0.177) were associated with an increased burnout score. After adjusting for the total number of ordering sessions, burnout was not statistically associated with an increased rate of wrong-patient orders (rate ratio=1.20, 95%CI=0.76-1.89).

CONCLUSIONS

Burnout and recovery were associated with recent clinical workload for a cohort of physician trainees, highlighting the elastic nature of burnout. Wellness interventions should focus on strategies to mitigate sustained elevations of work responsibilities.

Burnout in Pediatric Emergency Medicine Physicians: A Predictive Model

OBJECTIVES

This study aims to determine the prevalence of and identify predictors associated with burnout in pediatric emergency medicine (PEM) physicians and to construct a predictive model for burnout in this population to stratify risk.

METHODS

We conducted a cross-sectional electronic survey study among a random sample of board-certified or board-eligible PEM physicians throughout the United States and Canada. Our primary outcome was burnout assessed using the Maslach Burnout Inventory on 3 subscales: emotional exhaustion, depersonalization, and personal accomplishment. We defined burnout as scoring in the high-degree range on any 1 of the 3 subscales. The Maslach Burnout Inventory was followed by questions on personal demographics and work environment. We compared PEM physicians with and without burnout using multivariable logistic regression.

RESULTS

We studied a total of 416 PEM board-certified/eligible physicians (61.3% women; mean age, 45.3 ± 8.8 years). Surveys were initiated by 445 of 749 survey recipients (59.4% response rate). Burnout prevalence measured 49.5% (206/416) in the study cohort, with 34.9% (145/416) of participants scoring in the high-degree range for emotional exhaustion, 33.9% (141/416) for depersonalization, and 20% (83/416) for personal accomplishment. A multivariable model identified 6 independent predictors associated with burnout: 1) lack of appreciation from patients, 2) lack of appreciation from supervisors, 3) perception of an unfair clinical work schedule, 4) dissatisfaction with promotion opportunities, 5) feeling that the electronic medical record detracts from patient care, and 6) working in a nonacademic setting (area under the receiver operating characteristic curve, 0.77). A predictive model demonstrated that physicians with 5 or 6 predictors had an 81% probability of having burnout, whereas those with zero predictors had a 28% probability of burnout.

CONCLUSIONS

Burnout is prevalent in PEM physicians. We identified 6 independent predictors for burnout and constructed a scoring system that stratifies probability of burnout. This predictive model may be used to guide organizational strategies that mitigate burnout and improve physician well-being.

What gets resident physicians stressed and how would they prefer to be supported? A best-worst scaling study

INTRODUCTION

Physician burnout has severe consequences on clinician well-being. Residents face numerous work-stressors that can contribute to burnout; however, given specialty variation in work-stress, it is difficult to identify systemic stressors and implement effective burnout interventions on an institutional level. Assessing resident preferences by specialty for common wellness interventions could also contribute to improved efficacy.

METHODS

This cross-sectional study used best-worst scaling (BWS), a type of discrete choice modelling, to explore how 267 residents across nine specialties (anaesthesiology, emergency medicine, internal medicine, neurology, obstetrics and gynaecology, pathology, psychiatry, radiology and surgery) prioritised 16 work-stressors and 4 wellness interventions at a large academic medical centre during the COVID-19 pandemic (December 2020).

RESULTS

Top-ranked stressors were work-life integration and electronic health record documentation. Therapy (63%, selected as 'would realistically consider intervention') and coaching (58%) were the most preferred wellness supports in comparison to group-based peer support (20%) and individual peer support (22%). Pathology, psychiatry and OBGYN specialties were most willing to consider all intervention options, with emergency medicine and internal medicine specialties least willing to consider intervention options.

CONCLUSION

BWS can identify relative differences in surveyed stressors, allowing for the generation of specialty-specific stressor rankings and preferences for specific wellness interventions that can be used to drive institution-wide changes to improve clinician wellness. BWS surveys are a potential methodology for clinician wellness programmes to gather specific information on preferences to determine best practices for resident wellness.

A Novel Mindful-Compassion Art-Based Therapy for Reducing Burnout and Promoting Resilience Among Healthcare Workers: Findings From a Waitlist Randomized Control Trial

Protecting the mental health of healthcare workers is an urgent global public health priority. Healthcare workers, especially those immersed in palliative care, are prone to burnout due to the intense emotions associated with end-of-life caregiving. This study examines the efficacy of a novel, multimodal, and group-based Mindful-Compassion Art-based Therapy (MCAT) that integrates reflective self-awareness with creative emotional expression for protecting healthcare workers' mental health. A dual-arm open-label waitlist randomized controlled trial was conducted. A total of 56 healthcare workers were recruited from the largest homecare hospice in Singapore and randomized to the immediate-treatment condition of a standardized 6-week, 18-hours MCAT intervention (n=29), or the waitlist-control condition (n=27). Self-administered outcome measures on burnout, resilience, emotional regulation, self-compassion, death attitudes, and quality of life were collected at baseline, post-intervention/second-baseline at 6weeks, and follow-up/post-intervention at 12weeks. Results from mixed model ANOVAs reveal that treatment group participants experienced significant reduction in mental exhaustion, as well as significant improvements in overall emotional regulation, nonreactivity to intrusive thoughts, approach acceptance of death, and afterlife belief as compared to waitlist-control immediately after MCAT completion. Effect sizes of these impacts ranged from medium to large (η 2=0.65 to 0.170). Results from one-way ANOVAs further reveal that the treatment gains of reduced mental exhaustion and increased emotional regulation were maintained among treatment group participants at 12-weeks follow-up compared to baseline, with new benefits identified. These include increased ability to observe and describe one's experiences, elevated overall self-compassion, greater mindful awareness, enhanced common humanity, and better quality of life. Effect sizes of these impacts were large (η 2=0.128 to 0.298). These findings reflect the robust effectiveness and positive residual effects of MCAT for reducing burnout, building resilience, nurturing compassion, fostering collegial support, and promoting mental wellness among healthcare workers. The clinical model and applicability of MCAT in larger and more diverse caregiving contexts, such as family dementia care, are discussed. Clinical Trial Registration: ClinicalTrials.gov # NCT03440606, #NCT04548089.

How Feedback Is Given Matters: A Cross-Sectional Survey of Patient Satisfaction Feedback Delivery and Physician Well-being

OBJECTIVE

To evaluate how variation in the way patient satisfaction feedback is delivered relates to physician well-being and perceptions of its impact on patient care, job satisfaction, and clinical decision making.

PARTICIPANTS AND METHODS

A cross-sectional electronic survey was sent to faculty physicians from a large academic medical center in March 29, 2019. Physicians reported their exposure to feedback (timing, performance relative to peers, or channel) and related perceptions. The Professional Fulfillment Index captured burnout and professional fulfillment. Associations between feedback characteristics and well-being or perceived impact were tested using analysis of variance or logistic regression adjusted for covariates.

RESULTS

Of 1016 survey respondents, 569 (56.0%) reported receiving patient satisfaction feedback. Among those receiving feedback, 303 (53.2%) did not believe that this feedback improved patient care. Compared with physicians who never received feedback, those who received any type of feedback had higher professional fulfillment scores (mean, 6.6±2.1 vs 6.3±2.0; P=.03) but also reported an unfavorable impact on clinical decision making (odds ratio [OR], 2.9; 95% CI, 1.8 to 4.7; P<.001). Physicians who received feedback that included one-on-one discussions (as opposed to feedback without this channel) held more positive perceptions of the feedback's impact on patient care (OR, 2.0; 95% CI, 1.3 to 3.0; P=.003), whereas perceptions were less positive in physicians whose feedback included comparisons to named colleagues (OR, 0.5; 95% CI, 0.3 to 0.8; P=.003).

CONCLUSION

Providing patient satisfaction feedback to physicians was associated with mixed results, and physician perceptions of the impact of feedback depended on the characteristics of feedback delivery. Our findings suggest that feedback is viewed most constructively by physicians when delivered through one-on-one discussions and without comparison to peers.

Association of Characteristics of the Learning Environment and US Medical Student Burnout, Empathy, and Career Regret

IMPORTANCE

Previous studies have shown that medical student mistreatment and burnout are common. However, few longitudinal data exist to describe how mistreatment and other learning environment experiences are associated with subsequent burnout and other student characteristics.

OBJECTIVE

To examine the association between mistreatment and perceptions of the learning environment with subsequent burnout, empathy, and career regret among US medical students.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data from the 2014-2016 Association of American Medical Colleges (AAMC) Medical School Year 2 Questionnaire (Y2Q) and 2016-2018 AAMC Graduation Questionnaire (GQ). Medical students from 140 allopathic medical schools who responded to both AAMC surveys were included in the analysis. Data were analyzed from December 1, 2019, to January 11, 2021.

EXPOSURES

Self-reported medical student mistreatment (eg, experiences of negative behaviors and discrimination related to sex, race/ethnicity, and sexual orientation) and perceptions of the learning environment (Medical School Learning Environment Survey subscales for faculty, emotional climate, and student-student interactions).

MAIN OUTCOMES AND MEASURES

Burnout, empathy, and career regret as measured by Oldenburg Burnout Inventory data for burnout, Interpersonal Reactivity Index scores for empathy, and a single item assessing career regret.

RESULTS

Data from 14 126 medical students were analyzed; 52.0% were women, and the mean (SD) age was 27.7 (2.9) years at graduation. Mistreatment was reported by 22.9% of respondents on the Y2Q. In multivariable analysis adjusted for Y2Q measures, mistreatment reported on the Y2Q was associated with a higher exhaustion score (1.81 [95% CI, 1.60-2.02]), a higher disengagement score (0.71 [95% CI, 0.58-0.84]), and higher likelihood of career regret on the GQ (186 of 989 [18.8%]; all P < .001). A more positive emotional climate reported on the Y2Q was associated with a lower exhaustion score (for each 1-point increase, -0.05 [95% CI, -0.08 to -0.02]; P = .001) and lower disengagement score (for each 1-point increase, -0.04 [95% CI, -0.06 to -0.02]; P < .001) on the GQ. More positive faculty interactions on the Y2Q were associated with higher empathy score on the GQ (for each 1-point increase, 0.02 [95% CI, 0.01-0.05]; P = .04). Better student-student interactions were associated with lower odds of career regret during year 4 of medical school (odds ratio for each 1-point increase, 0.97 [95% CI, 0.95-1.00]; P = .04).

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that medical students who experienced mistreatment and perceived the learning environment less favorably were more likely to develop higher levels of exhaustion and disengagement, lower levels of empathy, and career regret compared with medical students with more positive experiences. Strategies to improve student well-being, empathy, and experience should include approaches to eliminate mistreatment and improve the learning environment.

"I Have Nothing Else to Give": A Qualitative Exploration of Emergency Medicine Residents' Perceptions of Burnout

PHENOMENON:

Resident physicians experience high degrees of burnout. Medical educators are tasked with implementing burnout interventions, however they possess an incomplete understanding of residents' lived experiences with this phenomenon. Attempts to understand burnout using quantitative methods may insufficiently capture the complexities of resident burnout and limit our ability to implement meaningful specialty-specific interventions. Qualitative studies examining how residents conceptualize burnout have been briefly examined in other specialties, however the specific stressors that characterize emergency medicine training may lead residents to experience burnout differently. This study used qualitative methodology to explore emergency medicine trainees' perceptions of the complex phenomenon of burnout during their residency training years. Approach: In order to evaluate a novel wellness intervention at their emergency medicine residency program, the authors conducted four semi-structured focus groups with residents and recent alumni from May 2018 to August 2018. After the focus groups concluded, the authors noted that they lacked an insightful understanding of their residents' own experiences with physician burnout. Thus, they performed a secondary analysis of data initially gathered for the curricular evaluation. They followed a reflexive thematic analysis approach, analyzing all focus group transcripts in an iterative manner, discussing and refining codes, and developing thematic categories. Findings: Residents described individual-level manifestations of burnout in their day-to-day lives, a calloused view of patient suffering in the clinical environment, and a fatalistic view toward burnout during their training. They experienced a pervasive negativity, emotional fragility, and neglect of self that bled into their social environments. Clinically, burnout contributed to the erosion of the therapeutic physician-patient relationship. Residents perceived burnout as an inevitable and necessary element of their residency training years. Insights: Residents' lived experiences with burnout include nonclinical manifestations that challenge existing frameworks suggesting that burnout is restricted to the work domain. Burnout interventions in emergency medicine training programs may be more effective if educators inculcate habitual practices of self-monitoring in trainees and explicitly set resident expectations of patient acuity in the clinical environment.

Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1875833.

A Longitudinal Study Exploring Learning Environment Culture and Subsequent Risk of Burnout Among Resident Physicians Overall and by Gender

OBJECTIVE

To explore the relationship between learning environment culture and the subsequent risk of developing burnout in a national sample of residents overall and by gender.

METHODS

From April 7 to August 2, 2016, and May 26 to August 5, 2017, we surveyed residents in their second (R2) and third (R3) postgraduate year. The survey included a negative interpersonal experiences scale (score range 1 to 7 points, higher being worse) assessing psychological safety and bias, inclusion, respect, and justice; an unfair treatment scale (score range 1 to 5 points, higher being worse), and two items from the Maslach Burnout Inventory. Individual responses to the R2 and R3 surveys were linked.

RESULTS

The R2 survey was completed by 3588 of 4696 (76.4%) residents; 3058 of 3726 (82.1%) residents completed the R3 survey; and 2888 residents completed both surveys. Women reported more negative interpersonal experiences (mean [SD], 3.00 [0.83] vs 2.90 [0.85], P<.001) and unfair treatment (66.5% vs. 58.7%, P<.001) than men at R2. On multivariable analysis, women at R3 were more likely than their male counterparts to have burnout (odds ratio, 1.23; 95% CI, 1.02 to 1.48; P=.03). Both men and women who reported more negative interpersonal experiences at R2 were more likely to have burnout at R3 (odds ratio, 1.32; 95% CI, 1.14 to 1.52; P<.001). The factors contributing to burnout did not vary in effect magnitude by gender.

CONCLUSION

These findings indicate women residents are more likely to have burnout relative to men in the third year of residency. Negative culture predicted subsequent burnout 1 year later among both men and women. Differences in burnout were at least partly due to differing levels of exposure to negative interactions for men versus women rather than a negative interaction having a differential impact on the well-being of men versus women.

Grit Does Not Predict Burnout among First-Year Internal Medicine Residents

OBJECTIVES

Grit, defined as passion and perseverance for long-term goals, has been associated with the avoidance of burnout among residents in a number of specialties. We aimed to evaluate the relationship between grit and burnout among first-year Internal Medicine residents.

METHODS

During the 2018-2019 academic year, the authors recruited 75 first-year Internal Medicine residents within a large academic program to complete the Short Grit Scale (Grit-S) and the Maslach Burnout Inventory General Survey (MBI-GS) at baseline and after 6 and 12 months. The primary outcome was the association between baseline Grit-S and MBI-GS scores within the domains of emotional exhaustion (EE) or cynicism (CYN) over time using linear mixed models. Secondary outcomes included the association between grit and high burnout at 6 or 12 months, grit and persistently high burnout, and the association of baseline high burnout with later high scores at 6 and 12 months using logistic regression models and trends in grit over time using repeated-measures analysis of variance.

RESULTS

A total of 53 of 75 (71%) first-year residents completed the Grit-S and MBI-GS at baseline and at least one other time point. There was no association between grit and EE (P = 0.44) or CYN (P = 0.61) burnout domain scores. High baseline EE and high baseline CYN significantly increased the odds of later high burnout scores within each domain (EE odds ratio 9.66, 95% confidence interval 1.16-80.83; CYN odds ratio 13.37, 95% confidence interval 1.52-117.75). Grit scores and professional efficacy scores remained stable throughout the year (P = 0.15 and 0.46, respectively), while EE and CYN significantly increased (both P < 0.01).

CONCLUSIONS

In this single-center study, grit was not associated with burnout among first-year Internal Medicine residents; however, our findings highlight the value of baseline burnout scores in helping to identify first-year residents who may be at higher risk of later burnout.

Anxiety in Residents in China: Prevalence and Risk Factors in a Multicenter Study

PURPOSE

To explore the prevalence of major anxiety and its associated risk factors in residents in China.

METHOD

This multicenter, cross-sectional study was conducted from December 2019 to February 2020; 1,343 residents from 8 hospitals in Northeast China were included in the final analysis (effective response rate of 86.48%). Demographic characteristics, dietary habits, life-related factors, work-related factors, and psychological characteristics were collected from participants via a self-reported questionnaire. This questionnaire measured sleep quality, physical activity, anxiety, perceived organizational support, psychological capital, and burnout. Adjusted odds ratios (ORs) and 95% confidence intervals were determined using binary logistic regression. Cutoff values and the area under the curve were calculated for risk factors using receiver operating characteristic curve analysis.

RESULTS

Of participants, 441 (32.80%) reported anxiety symptoms and 133 (9.90%) reported major anxiety symptoms. Four independent risk factors for major anxiety were identified: poor sleep quality (OR = 1.282, P < .001) and 3 dimensions of burnout: higher emotional exhaustion (OR = 1.085, P < .001), higher depersonalization (OR = 1.064, P = .002), and reduced personal accomplishment (OR = 0.951, P < .001). The optimal cutoff values for these risk factors were 7, 10, 9, and 22 scores, respectively.

CONCLUSIONS

This study found a considerable prevalence of major anxiety symptoms in residents in China and identified poor sleep quality and higher levels of burnout as having a close association with major anxiety. These findings enrich the existing literature on anxiety and demonstrate a critical need for additional studies that investigate intervention strategies to improve sleep quality and combat burnout, which could improve the mental health of residents.

Burnout Syndrome during Residency Training in Jordan: Prevalence, Risk Factors, and Implications

Burnout syndrome is common among healthcare professions, including resident physicians. We aimed to assess the prevalence of burnout among resident physicians in Jordan, and a secondary aim was to evaluate the risk factors associated with the development of burnout syndrome in those residents, including gender, working hours, psychological distress, training sector, and specialty. In this cross-sectional study, 481 residents were recruited utilizing multistage stratified sampling to represent the four major health sectors in Jordan. Data were collected using an online questionnaire, where the Copenhagen Burnout Inventory (CBI) was used to assess the prevalence of burnout. The prevalence, group differences, and predictors of burnout were statistically analyzed using STATA 15. Overall, 373 (77.5%) residents were found to have burnout. Factors associated with higher levels of burnout were psychological stress (β = 2.34, CI = [1.88-2.81]), longer working hours (β = 4.07, CI = [0.52-7.62], for 51-75 h a week, β = 7.27, CI = [2.86-11.69], for 76-100 h a week and β = 7.27, CI = [0.06-14.49], for >100 h a week), and obstetrics/gynecology residents (β = 9.66, CI = [3.59-15.73]). Conversely, medical sub-specialty residents, as well as private and university hospital residents, had lower burnout levels. We concluded that decreasing the workload on residents, offering psychological counseling, and promoting a safety culture for residents might help in mitigating burnout consequences.

Burnout Prevalence and Its Associated Factors among Malaysian Healthcare Workers during COVID-19 Pandemic: An Embedded Mixed-Method Study

Coronavirus disease 2019 (COVID-19) has become a global health threat and has placed an extraordinary demand on healthcare workers around the world. In this study, we aim to examine the prevalence of burnout and its associated factors and experience among Malaysian healthcare workers during the COVID-19 pandemic through an embedded mixed-method study design. We found that more than half of Malaysian healthcare workers in this sample experienced burnout. Direct involvement in COVID-19 screening or treatment, having a medical condition, and less psychological support in the workplace emerged to be the significant factors in personal-, work-, and patient-related burnout. Participants described their workloads, uncertainties caused by the pandemic, challenging work-family balance, and stretched workplace relationships as the sources of burnout. Exhaustion appeared to be the major symptom, and many participants utilized problem-focused coping to deal with the adversities experienced during the pandemic. Participants reported physical-, occupational-, psychological-, and social-related negative impacts resulting from burnout. As the pandemic trajectory is yet unknown, these findings provide early insight and guidance for possible interventions.

Global prevalence of burnout among postgraduate medical trainees: a systematic review and meta-regression

BACKGROUND

Burnout among postgraduate medical trainees (PMTs) is increasingly being recognized as a crisis in the medical profession. We aimed to establish the prevalence of burnout among PMTs, identify risk and protective factors, and assess whether burnout varied by country of training, year of study and specialty of practice.

METHODS

We systematically searched MEDLINE, Embase, PsycINFO, the Cochrane Database of Systematic Reviews, Web of Science and Education Resources Information Center from their inception to Aug. 21, 2018, for studies of burnout among PMTs. The primary objective was to identify the global prevalence of burnout among PMTs. Our secondary objective was to evaluate the association between burnout and country of training, year of study, specialty of training and other sociodemographic factors commonly thought to be related to burnout. We employed random-effects meta-analysis and meta-regression techniques to estimate a pooled prevalence and conduct secondary analyses.

RESULTS

In total, 8505 published studies were screened, 196 met eligibility and 114 were included in the meta-analysis. The pooled prevalence of burnout was 47.3% (95% confidence interval 43.1% to 51.5%), based on studies published over 20 years involving 31 210 PMTs from 47 countries. The prevalence of burnout remained unchanged over the past 2 decades. Burnout varied by region, with PMTs of European countries experiencing the lowest level. Burnout rates among medical and surgical PMTs were similar.

INTERPRETATION

Current wellness efforts and policies have not changed the prevalence of burnout worldwide. Future research should focus on understanding systemic factors and leveraging these findings to design interventions to combat burnout.

STUDY REGISTRATION

PROSPERO no. CRD42018108774.

Physician Burnout: A Lifestyle Medicine Perspective

Physician burnout, as described in North America, is a multidimensional work-related syndrome that includes emotional exhaustion, depersonalization, and a low sense of accomplishment from work. More than 50% of physicians were reporting symptoms of burnout prior to the COVID-19 pandemic. This silent epidemic of burnout is bound to become less silent as the pandemic continues. Lifestyle medicine is an evidence-based discipline that describes how daily habits and health practices can affect overall health and well-being of individuals. Lifestyle Medicine can potentially play a significant role in preventing and ameliorating physician burnout. This article explores the burnout process, including the historical context, international definitions, symptoms, and imprecision of the clinical diagnosis. The systemic etiological issues are discussed, and the psychological underpinnings are explored, including physicians' personal vulnerabilities contributing to burnout. The stress response and lifestyle medicine's role in healthy coping are described. A prevention model for risk factor reduction is proposed, focusing on primordial, primary, secondary, and tertiary prevention. Lifestyle medicine clinicians' role in prevention, treatment, and advocacy to ameliorate the potential for burnout is discussed along with specific recommendations.

Natural history of burnout, stress, and fatigue in a pediatric resident cohort over three years

BACKGROUND

Burnout is known to be high amongst physician trainees. Factors such as stress, fatigue, social environment, and resilience could affect burnout. Cross-sectional data describe burnout in pediatric residents, but the trajectory of burnout in a cohort of residents followed longitudinally through the full course of residency training has not been reported. We prospectively examined the prevalence and trajectory of burnout, stress, fatigue, social connectedness, and resilience in a pediatric resident cohort from orientation through three years of residency. The cohort (N = 33) was surveyed six times between 2015-2018 using the Abbreviated Maslach Burnout Inventory (AMBI), Perceived Stress Scale (PSS), Epworth Sleepiness Scale (ESS), Social Connectedness Scale-Revised (SCS-R), and Connor-Davidson Resilience Scale (CD-RISC10). Data were analyzed using repeated measures mixed effects models. Significant change from baseline was considered to be adjusted p < 0.05. Response rate was >50% at each timepoint; 69% of trainees completed surveys ≥4 times. Scores were significantly worse than baseline in all surveys, at every timepoint, with the exception of AMBI-PA (personal accomplishment) at the PGY1/PGY2 transition and SCS-R and CD-RISC10 at the end of training. The most significant changes from baseline occurred mid-PGY1 to mid-PGY2. At least 65% of residents demonstrated worse scores than baseline on 36/40 (90%) follow-up surveys. Furthermore, ≥65% met criteria for emotional exhaustion and moderate stress at every timepoint. SCS-R was the only survey measure to improve at residency completion compared to baseline.

CONCLUSION

Within 6 months of starting residency this pediatric resident cohort became burned out, stressed, fatigued, less socially connected, and less resilient. Burnout is only one factor that indicates impaired resident well-being. To fully address this, a comprehensive examination of how residents are trained is needed to identify effective interventions.

ABBREVIATIONS

MBI - Maslach Burnout Inventory; AMBI - Abbreviated Maslach Burnout Inventory; AMBI-EE - Emotional Exhaustion; AMBI-D - Depersonalization; AMBI-PA - Personal Accomplishment; AMBI-SAT - Satisfaction with Medicine; LCH - Ann & Robert H. Lurie Children's Hospital of Chicago/Lurie Children's Hospital; P/CN - Pediatrics/Child Neurology; PSS - Perceived Stress Scale; ESS - Epworth Sleepiness Scale; CD-RISC10 - Resilience; SCS-R - Social Connectedness Scale Revised; PGY - Post-Graduate Year.

Burnout among medical students in Cyprus: A cross-sectional study

OBJECTIVES

The primary aim was to estimate the burnout prevalence among all medical students at the Medical School of the University of Cyprus. Secondary aims were to ascertain the predictors of burnout and its relationship with lifestyle habits, sleep quality and mental health.

BACKGROUND

Burnout in the healthcare sector has drawn significant scientific attention over the last few years. Recent research underscored the large burden of profession-related burnout among medical students.

MATERIALS AND METHODS

An anonymous questionnaire was administered to all 189 eligible candidates. This included demographic and lifestyle characteristics. Sleep quality was assessed via the Pittsburg Sleep Quality Index, mental health was assessed via the mental health (MH) domain of the 36-item Short Form Health Survey (SF-36) and burnout with the Maslach Burnout Inventory-Student Survey (MBI-SS).

RESULTS

Overall response rate was 96.3%. The burnout prevalence was 18.1%. There was a significant linear effect of between the year of studies and the burnout frequency [F(1) = 5.09, p = 0.024], implying that with increasing academic year there were more students with burnout, especially after the 4th year of education which signifies the beginning of clinical education. Students with burnout were more likely to have poor sleep quality (90.9% vs. 60.8%, odds ratio 4.33, p = 0.023) and worse mental health (MH score 40.2 ± 17.7 vs 62.9 ± 20.3, p<0.001). Alcohol consumers had more symptoms of cynicism and less feelings of efficacy than non-alcohol consumers. Moreover, less feelings of efficacy were significantly associated with more alcohol consumption among alcohol consumers.

CONCLUSIONS

Burnout is prevalent in medical students and increases significantly during the clinical years. Students with burnout have worse sleep and mental health and might use alcohol as a coping mechanism. Implementing prevention strategies of burnout may be beneficial.

Assessment of burnout prevention and wellness programs for US-based neurosurgical faculty and residents: a systematic review of the literature

OBJECTIVE

Neurosurgeon burnout is a serious and prevalent issue that has been shown to impact professionalism, physician health, and patient outcomes. Interventions targeting physician burnout primarily focus on improving physician wellness. Many academic neurosurgery programs have established wellness curricula to combat burnout and improve wellness. No official recommendations exist for establishing a wellness program that effectively targets sources of burnout. The aim of this review was to examine measures of burnout and report objective results of wellness interventions for neurosurgical faculty and residents.

METHODS

Two systematic literature reviews were performed in parallel, in accordance with PRISMA 2009 guidelines. Following removal of duplicates, a query of PubMed/MEDLINE, Scopus, Ovid, Cochrane, and EMBASE databases yielded 134 resident-related articles and 208 faculty-related articles for abstract screening. After abstract screening, 17 articles with a primary focus of resident wellness and 10 with a focus on faculty wellness met criteria for full-text screening. Of the total 27 screened articles, 9 (6 resident, 2 faculty, 1 both resident and faculty) met criteria and were included in the final analysis. Article quality was assessed using the Joanna Briggs Institute critical appraisal tools for cohort studies.

RESULTS

Included studies reported burnout rates for neurosurgery residents of 30%-67%. Work-life imbalance, imbalance of duties, inadequate operative exposure, and hostile faculty were contributors to burnout. The 2 included studies reported burnout rates for neurosurgery faculty members of 27% and 56.7%. Psychosocial stressors, relational stressors, and financial uncertainty were generally associated with increased feelings of burnout. Of the 4 studies reporting on outcomes of wellness initiatives included in this review, 3 reported a positive impact of the wellness interventions and 1 study reported no significant improvement after implementing a wellness initiative.

CONCLUSIONS

Burnout among neurosurgical faculty and residents is prevalent and permeates the daily lives of neurosurgeons, negatively affecting patient outcomes, career satisfaction, and quality of life. Many neurosurgery programs have instituted wellness programs to combat burnout, but few have published evidence of improvement after implementation. While studies have shown that residents and faculty recognize the importance of wellness and look favorably on such initiatives, very few studies have reported objective outcomes.

Burnout Levels and Patterns in Postgraduate Medical Trainees: A Systematic Review and Meta-Analysis

PURPOSE

Postgraduate medical trainees experience high rates of burnout; however, inconsistencies in definitions of burnout characterize this literature. The authors conducted a systematic review and meta-analysis examining burnout levels and patterns in postgraduate medical trainees, using a continuous conceptualization of burnout, consistent with the Maslach Burnout Inventory (MBI) framework.

METHOD

The authors searched 5 electronic databases (Cochrane Library, Embase, ERIC, Ovid MEDLINE, Ovid PsycINFO) between January 1981 and July 2019 for studies reporting postgraduate medical trainees' burnout levels using the MBI-Human Services Survey. They examined study reporting quality using the QualSyst quality appraisal tool and calculated standardized mean differences (Hedges' g), comparing trainees' data with MBI norms for medicine and the overall population using a random effects model. They explored between-study heterogeneity using subgroup analyses (i.e., by training level and specialty). Finally, they studied the combined contribution of these 2 variables (and year of study publication) to burnout levels, using meta-regression.

RESULTS

The authors identified 2,978 citations and included 89 independent studies in their review. They pooled the data for the 18,509 postgraduate trainees included in these studies for the meta-analyses. Reporting quality was generally high across the included studies. The meta-analyses revealed higher burnout levels among trainees compared with medicine and overall population norms, particularly for the depersonalization subscale. The authors also identified statistically significant differences between nonsurgical and surgical registrars (specialty trainees), with trainees from 12 individual specialties exhibiting unique burnout patterns.

CONCLUSIONS

There is a need to reduce and prevent burnout early in medical training. Given the differences in burnout levels and patterns across specialties, interventions must focus on the unique patterns exhibited by each specialty in the target population using a multidimensional approach. Standardizing the definition of burnout in accordance with the MBI framework will facilitate progression of this work.

Quality and Safety in Healthcare, Part LXI: Burnout and Wellness in Residents

Some of the causes for resident burnout and other impairments of wellness are the same as for other physicians, but some are quite different. For example, residents have much less autonomy and control, are under more pressure to learn a huge amount of information quickly, are more frequently evaluated, have stress from taking more examinations, and have more financial pressure than a typical physician who has graduated from formal training. Residency education also involves oversight from the Accreditation Council of Graduate Medical Education, which seeks to decrease some of the pressures of residency, but an unintended consequence of their limitation of work hours has been, in some programs, the phenomenon of "work compression."

Depression, anxiety, and burnout among medical students and residents of a medical school in Nepal: a cross-sectional study

BACKGROUND

Medical students and residents were found to have suffered from depression, anxiety, and burnout in various studies. However, these entities have not been adequately explored in the context of Nepal. We proposed to determine the prevalence of depression, anxiety, burnout, their associated factors, and identify their predictors in a sample of medical students and residents in a Nepalese medical school.

METHODS

It was a cross-sectional study with 651 medical students and residents chosen at random between December 2018 and February 2019. The validated Nepali version of Hospital Anxiety and Depression Scale, the Copenhagen Burnout Inventory, and Medical Students' Stressor Questionnaire were used to assess depression, anxiety, burnout, and stressors respectively. We used univariate and multivariable logistic regression analyses to identify the correlation of predictor variables with depression, anxiety, and burnout.

RESULTS

The overall prevalence of burnout (48.8%; 95% CI 44.9-52.7) and anxiety (45.3%; 95% CI 41.4-49.2) was more than that of depression (31%; 95% CI 27.5-34.7). Burnout and depression were more prevalent in residents than in medical students (burnout: 64.5% vs 37.6%, P-value < 0.0001; depression: 33.7% vs 29.1%, P-value 0.21). Whereas, medical students were found more anxious than residents (46.3% versus 43.96%, P-value 0.55). Academic related stressors caused high-grade stress to participants. Multivariable model for depression significantly showed anxiety, personal burnout, and work-related burnout as risk enhancing correlates; satisfaction with academic performance as a protective correlate. Similarly, the multivariate model for anxiety significantly identified female gender, depression, personal burnout, teaching and learning related stressors, and past history of mental illness as risk enhancing correlates; being satisfied with academic performance, getting adequate sleep, and being a second-year resident as protective correlates. The logistic model for burnout significantly showed being a first-year resident, depression, anxiety, and drive and desire related stressors as positive predictors. None of the variables were identified as significant negative predictors of burnout.

CONCLUSIONS

A high prevalence of depression, anxiety, and burnout was seen among medical students and residents. Most of them were stressed with academic-related factors. A strong correlation between teaching and learning-related stressors with depression and anxiety may be a call for an efficient and more student-friendly curriculum.

Reducing Burnout and Promoting Health and Wellness Among Medical Students, Residents, and Physicians in Alberta: Protocol for a Cross-Sectional Questionnaire Study

Background

Burnout is an increasingly common and insidious phenomenon experienced by workers in many different fields, although it is of particular concern among physicians and trainees due to the nature of their work. It is estimated that one-third of practicing physicians will experience burnout during their career, and this rate is expected to continue to increase. Burnout has significant implications, as it has been identified as a contributor to increased medical errors, decreased patient satisfaction, substance use, workforce attrition, and suicide.

Objective

This study will evaluate the prevalence and impact of burnout on physicians, residents, and medical students in Alberta.

Methods

Quantitative and qualitative data collected through self-administered, anonymous, online questionnaires will be used in this cross-sectional provincial study design. Data collection tools were developed based on published literature and questions from previously validated instruments. The tools capture relevant demographic information, mental health status, and rates of burnout, as well as factors contributing to both burnout and resilience among respondents. We anticipate a sample size of 777 medical students, 959 residents, and 1961 physicians to represent the respective ratios of trainees and practicing physicians in the province of Alberta.

Results

Study recruitment will begin in September 2020, with 4 weeks of data collection. The results of this study are anticipated within 12 months from the end of data collection. It is expected that the results will provide an overview of the prevalence of burnout among those training and working in medicine in Alberta, identify contributors to burnout, and help develop interventions aimed at reducing burnout.

Conclusions

This study’s aim is to examine burnout prevalence and contributing factors among medical trainees and physicians in Alberta. It is expected that the results will identify and examine individual and organizational practices that contribute to burnout and help develop strategies and interventions focused on mitigating burnout and its sequelae.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16285

The impact of entrustment assessments on feedback and learning: Trainee perspectives

CONTEXT

Assessment for and of learning in workplace settings is at the heart of competency-based medical education. In postgraduate medical education (PGME), entrustable professional activities (EPAs) and entrustment scales are increasingly used to assess competence. However, the educational impacts of these assessment approaches remain unknown. Therefore, this study aimed to explore trainee perceptions regarding the impacts of EPAs and entrustment scales on feedback and learning processes in the clinical setting.

METHODS

Four focus groups were conducted with postgraduate trainees in anaesthesia, emergency medicine, general internal medicine and nephrology at McMaster University in Hamilton, Ontario, Canada. Data collection and analysis were informed by principles of constructivist grounded theory.

RESULTS

Entrustable professional activities representing well-defined tasks are perceived as potentially effective drivers for feedback and learning. Use of EPAs and entrustment scales, however, may augment existing tensions between developmental (for learning) and decision-making (of learning) assessment functions. Three key dilemmas seem to influence the impact of EPA-based assessment approaches on residents' learning: (a) standardisation of outcomes versus flexibility in assessment to align with individual learning experiences; (b) assessment tasks focusing on performance standards versus opportunities for learning, and (c) feedback focusing on numeric entrustment scores versus narrative and dialogue. Use of entrustment as an assessment outcome may impact trainees' motivation and feelings of self-efficacy, further enhancing tensions between learning and performance.

CONCLUSIONS

Entrustable professional activities and entrustment scales may support assessment for learning in PGME. However, their successful implementation requires the careful management of dilemmas that arise in EPA-based assessment in order to support competence development.

Socioeconomic Factors Associated With Burnout Among Oncology Trainees

PURPOSE:

Burnout in the medical workforce leads to early retirement, absenteeism, career changes, financial losses for medical institutions, and adverse outcomes for patients. Recent literature has explored burnout in different specialties of medicine. This article examines burnout among medical oncology trainees and identifies factors associated with burnout and professional dissatisfaction, including socioeconomic factors.

METHODS:

US medical oncology programs were sent a survey that included the Maslach Burnout Index–Human Services Survey as well as demographic, socioeconomic, and program-specific questions tailored to medical oncology fellowship. Primary binary end points included burnout, satisfaction with being a physician, and satisfaction with being a medical oncologist. Binomial logistic models determined associations between various characteristics and end points.

RESULTS:

Overall, 261 US fellows completed the survey. Seventy percent of international medical graduates reported no educational debt, whereas only 36% of US graduates reported no educational debt. Eighty-two percent of survey respondents reported their mother had at least a bachelor’s degree, and 87% of respondents reported their father had at least a bachelor’s degree. At least 27% of respondents had symptoms of burnout. Factors inversely associated with burnout on multivariable analysis included having a mother who graduated college (odds ratio [OR], 0.27), reporting an adequate perceived balance between work and personal life (OR, 0.22), feeling that faculty care about educational success (OR, 0.16), and being in the final year of training (OR, 0.45). Having debt ≥ $150,000 (OR, 2.14) was directly associated with burnout.

CONCLUSION:

Symptoms of burnout are common among medical oncology fellows and are associated with educational debt and socioeconomic factors.

Resident physician burnout: insights from a Canadian multispecialty survey

BACKGROUND

Burnout results from chronic exposure to stress: comprising emotional exhaustion (EE), depersonalisation (DP) and a reduced sense of personal achievement (PA). Only a few studies have examined burnout in Canadian residents, and no multispecialty studies using the Maslach Burnout Inventory-Health Sciences Survey (MBI-HSS) exist. The purpose of our study is to identify burnout prevalence, contributory factors and solutions.

METHODS

A prospective 62-item survey, including the 22-item MBI-HSS, was sent to all Alberta residents, with a resident population of 1745. The association between burnout, EE, DP and PA with items in the survey was performed. Continuous data were evaluated using Student's t-test or analysis of variance. Ordinal data were evaluated using Spearman's correlation coefficient and Mann-Whitney U test. Nominal data were evaluated using χ² test.

RESULTS

Response rate was 41.1% (n=718), with burnout prevalence of 69.4%. 61.6% of residents demonstrated high EE, 47.8% high DP and 29.0% low PA. More hours worked, poor work-life balance, poor service-education balance, poor mental health support, experiencing intimidation/harassment and being unhappy with programme and with career choice were associated with higher burnout (p<0.001). 53.5% of residents experienced intimidation/harassment. Solutions to burnout included improved teaching, improved call/working hours, more wellness days and a change in medicine culture.

CONCLUSION

High prevalence of burnout in Canadian residents with contributory factors and solutions identified. We hope programmes across the world can use this information to improve the burden of burnout among residents.

Changes in Health and Well-Being during Residents' Training

OBJECTIVES

Previous studies have characterized the negative effects of graduate medical education on physicians; however, there is limited longitudinal data on how physicians' well-being changes during their training. This study aimed to demonstrate and quantify changes to trainees' wellness and health habits during the course of their first 2 years of graduate medical education.

METHODS

A longitudinal survey study of postgraduate year 1 trainees at the Cleveland Clinic was administered at 3 time points: the initial survey during orientation week, a second survey at 1 year, and a final survey at 2 years.

RESULTS

Of the 170 trainees contacted, 59 (35%) completed the initial survey and 34 (58%) completed the first follow-up survey. Between the initial survey and the first follow-up survey, respondents reported that their health was worse than the prior year (P < 0.001). They also reported sleeping on average 1 hour less per night and exercising on average one fewer day per week. The number of individuals who reported not eating breakfast increased by 22%, whereas the number of individuals eating out at lunch more than doubled. Twenty-seven people completed the second follow-up survey. Between the first follow-up survey and the final survey, respondents gained on average 2.12 lb (P = 0.039). Breakfast, lunch, and sleeping habits persisted through the second follow-up survey.

CONCLUSIONS

Residents' health and wellness habits deteriorated during internship and did not improve in the second year of residency. Efforts to promote healthy habits in this population should be a priority.

The association of job demands and resources with burnout among emergency medical services professionals

OBJECTIVE

Although burnout has been linked to negative workplace-level effects, prior studies have primarily focused on individuals rather than job-related characteristics. This study sought to evaluate variation in burnout between agencies and to quantify the relationship between burnout and job-related demands/resources among emergency medical services (EMS) professionals.

METHODS

An electronic questionnaire was sent to all licensed, practicing EMS professionals in South Carolina. Work-related burnout was measured using the Copenhagen Burnout Inventory. Multivariable generalized estimating equations were used to estimate odds ratios (ORs) for specific job demands and resources while adjusting for confounding variables. Composite scores were used to simultaneously assess the relationship between burnout and job-related demands and resources.

RESULTS

Among 1271 EMS professionals working at 248 EMS agencies, the median agency-level burnout was 35% (interquartile range [IQR]: 13% to 50%). Job-related demands, including time pressure, were associated with increased burnout. Traditional job-related resources, including pay and benefits, were associated with reduced burnout. Less tangible job resources, including autonomy, clinical performance feedback, social support, and adequate training demonstrated strong associations with reduced burnout. EMS professionals facing high job demands and low job resources demonstrated nearly a 10-fold increase in odds of burnout compared with those exposed to low demands and high resources (adjusted OR [aOR]: 9.50, 95% confidence interval [CI]: 6.39-14.10). High job resources attenuated the impact of high job demands.

CONCLUSION

The proportion of EMS professionals experiencing burnout varied substantially across EMS agencies. Job resources, including those reflective of organizational culture, were associated with reduced burnout. Collectively, these findings suggest an opportunity to address burnout at the EMS agency level.

Institutional Factors Associated With Burnout Among Assistant Professors

Phenomenon: Factors related to individual circumstance and organizational climate are contributing to a worsening burnout problem among providers in healthcare settings. In the academic health center, junior faculty may be at particular risk for burnout given intersecting responsibilities of clinical expertise, research rigor, teaching commitments, and service expectations. To date, much of the focus on preventing and mitigating burnout has been located at the individual level, addressing lifestyle modification and self-regulation skills. We sought to examine relationships between institutional context and burnout qualities as a means to identify opportunities for organizational leadership to address faculty burnout. Approach: Data are from a baseline survey of assistant professors (faculty with diverse ratios for clinical, research, and teaching responsibilities) located within a pediatrics department in an academic medical center. Pearson correlation coefficients and logistic regression models were used to examine relationships between institutional factors (mentorship, collaboration opportunities, feelings of empowerment, value, and support of well-being) and experiences of burnout as measured by the original 22-item Maslach Burnout Inventory (subscales: Emotional Exhaustion, Depersonalization, and Low Personal Accomplishment). Findings: Three perceived institutional characteristics were significantly associated with all three dimensions of burnout, particularly emotional exhaustion, which decreased with increasing perception of (a) empowerment to communicate professional needs, (b) feeling valued for contributions to the department, and (c) department commitment to support faculty well-being. In multivariate logistic regression models, adjusted for gender identity and years since training, increased positive perceptions of these three institutional characteristics were associated with significantly lower odds of burnout. For example, for each unit increase along a 5-point rating scale in feeling empowered to communicate needs and feeling valued for contributions to the department, the odds of meeting cutoff scores for burnout were reduced by 78% (p = .002) to 84% (p = .002), respectively. Insights: Although much of the focus on addressing burnout in healthcare settings has been on promoting coping skills and building resilience at the individual level, our findings add to a growing literature documenting a significant role for institutional leadership in identifying and facilitating strategies to promote faculty well-being. Findings also support leadership's role for improving institutional climate via creating opportunities to increase faculty perceptions of empowerment and value in the department.

Conceptual models for understanding physician burnout, professional fulfillment, and well-being

Physician burnout is a highly complex phenomenon whose origins are multifactorial. As the medical profession works to better understand and reduce physician burnout, conceptual models can offer a framework to guide research and practice in the field of physician well-being. Conceptual models represent complex systems in a simplified fashion that facilitates understanding of and communication about those systems. This paper reviews seven conceptual models of physician well-being and discusses their strengths and limitations.

Burnout among postgraduate doctors in Colombo: prevalence, associated factors and association with self-reported patient care

BACKGROUND

Postgraduate doctors are prone to burnout due to occupational and educational stressors. Sri Lankan situation is unknown. This study determines burnout among postgraduate doctors in Colombo: Prevalence, associated factors, and association with self-reported patient care.

METHODS

A cross-sectional study was conducted among 278 postgraduate doctors from eight specialties working in Colombo district, attached to the main postgraduate training institute for medical professionals. A self-administered questionnaire was used. It comprised of the Copenhagen Burnout Inventory and an author-developed questionnaire, which was used to assess, associated factors and self-reported patient care. Prevalence of burnout was calculated. Associations were analysed using chi-square and binary logistic regression.

RESULTS

The response rate was 88.1% (n = 245). The prevalence of personal, work-related and client-related burnout was 41.6% (95% CI = 35.5-47.8%), 30.6% (95% CI = 24.8-36.4%), 8.9% (95% CI = 5.4-12.5%) respectively. Personal burnout was positively associated with, the trainee being a female, having a chronic disease, being involved in frequent unhealthy habits, having doctor parents, having home-work demands and having emotional demands. It was negatively associated with, having frequent healthy habits, being satisfied with skill development opportunities, and frequent use of deep studying. Work-related burnout was positively associated with, female gender, being involved in frequent unhealthy habits, having home-work demands and having emotional demands. It was negatively associated with, frequent use of deep methods of studying. Client-related burnout was positively associated with having emotional demands and negatively associated with being satisfied with training. The frequent self-reported, suboptimal patient-care practices: poor communication, poor clinical practice, poor response to patient's needs and poor communication during handing over were associated positively with client-related burnout.

CONCLUSIONS

Most postgraduate doctors in Colombo have high personal and work-related burnout but client-related burnout is less. The factors associated with burnout need to be addressed by the programme managers of the postgraduate courses. Preventive measures should be introduced to reduce burnout among future postgraduate trainees of Colombo.

Effects of a resiliency program on burnout and resiliency in family medicine residents

Research has highlighted the prevalence of burnout in medical residents and the relative rarity of evidence-based structured programs to build resiliency. This was a controlled study of an 8-h program designed to increase resiliency and decrease burnout that focused on personal awareness, improving coping skills, building social connection, and maintaining balance. The project was approved by the institutional review board. Thirty-two family medicine residents signed the consent form. Structured assessment tools were administered to the intervention group at pre-program, immediately post-program and at one- and two-year follow-up. The control group completed the same pre- and post-assessments. Post-intervention comparison of the two groups demonstrated that the intervention group showed significantly lower scores in depersonalization and emotional exhaustion on the Maslach Burnout Inventory immediately after the program. There was no significant difference in the outcomes in year1 and year 2 follow-up. Residents evaluated the program positively. Resiliency programs can be incorporated into a family medicine residency and participants benefit by lowering indicators of burnout.

[Burnout among caregivers in the Yaounde Central Hospital, Cameroon]

Introduction

Le burnout ou syndrome d'épuisement professionnel des soignants est un problème de santé publique au Cameroun. Il se manifeste par un épuisement émotionnel, une dépersonnalisation et une diminution de l'accomplissement personnel du sujet. Il touche la plupart des personnels soignants et les conséquences sont nombreuses. Au Cameroun en général et à l'Hôpital Central de Yaoundé (HCY) en particulier, toutes ces dernières années, les soignants n'ont cessés d'exprimer leur mécontentement face à leurs conditions de travail à travers des grèves et menaces de divers ordres. La prise en charge des patients se fait de façon impersonnelle et on assiste à des conséquences dramatiques et des problèmes déontologiques.

Méthodes

Notre étude transversale analytique avait pour objectif de déterminer les facteurs qui sont associés au burnout dans cette population des soignants de l'HCY. Pour ce faire, pendant un mois, nous avons administré auprès de ces soignants notre questionnaire conçu selon les modèles théoriques de Maslach et Siegrist. Nous avons pu obtenir des informations recherchées auprès de 104 personnels soignants; la saisie et l'analyse des données se sont faites avec SPSS 20.

Résultats

Les résultats montrent auprès des soignants de quatre unités de soins de l'HCY des manifestations similaires à celles trouvées dans la littérature et une prévalence du Burnout (BO) de 63% parmi ces soignants. Sept facteurs y ont été associés de façon statistiquement significative: il s'agit du pavillon d'exercice (OR= 3.93; 1.16-13.24; p-value=0.027); le statut matrimonial (OR: 2.56; 1.22 - 5.39; p-value=0,049); le ratio effort/récompenses déséquilibré (OR: 2.31; 1.10 - 4.84; p-value=0.026 ); avoir été menacé physiquement ou verbalement (OR: 3,75; 1,49 - 9,41; 0,005); le maintien de l'équilibre entre vie privée et vie professionnelle (OR: 3,41; 1,19- 10,7; p-value=0,038); la fréquence des oublis (OR: 4,25 -1,33; 7,91; p-value=0,002) l'attribution des erreurs aux conditions de travail (OR: 2,05;1,52 - 24,0; p-value=0,011).

Conclusion

Le burnout est présent au sein des populations soignantes de l'HCY et risque de s'accroitre si rien n'est fait. Des stratégies de prévention et de promotion de la santé au travail sont vivement nécessaires dans les aspects de l'amélioration des conditions de travail; les prises de bonnes décisions politique et managériales; l'amélioration des relations entre soignants et soignant-hiérarchie et la recherche constante, le suivi et contrôle des facteurs de risque.

Residency Program Factors Associated With Depressive Symptoms in Internal Medicine Interns: A Prospective Cohort Study

PURPOSE

To investigate the associations between program-level variables such as organizational structure, workload, and learning environment and residents' development of depressive symptoms during internship.

METHOD

Between 2012 and 2015, 1,276 internal medicine interns from 54 U.S. residency programs completed the Patient Health Questionnaire-9 (PHQ-9) before internship, and then quarterly throughout the internship. The training environment was assessed via a resident questionnaire and average weekly work hours. The authors gathered program structural variables from the American Medical Association Fellowship and Residency Electronic Interactive Database (FREIDA online) and program research rankings from Doximity. Associations between program-level variables and change in depressive symptoms were determined using stepwise linear regression modeling.

RESULTS

Mean program PHQ-9 scores increased from 2.3 at baseline to 5.9 during internship (mean difference 3.6; SD 1.4; P < .001), with the mean increase ranging from -0.3 to 8.8 (interquartile range 1.1) among included programs. In multivariable models, faculty feedback (β = -0.37; 95% CI: -0.62, -0.12; P = .005), learning experience in inpatient rotations (β = -0.28; 95% CI: -0.54, -0.02; P = .030), work hours (β = 0.34; 95% CI: 0.13, 0.56; P = .002), and research ranking position (β = -0.25; 95% CI: -0.47, -0.03; P = .036) were associated with change in depressive symptoms.

CONCLUSIONS

Poor faculty feedback and inpatient learning experience, long work hours, and high institutional research rankings were associated with increased depressive symptoms among internal medicine interns. These factors may be potential targets for interventions to improve wellness and mental health among these professionals.

"Rebuilding what has eroded": a descriptive, survey-based study of near-peer instructors' experiences in a critical pedagogy-based sociomedical course

Purpose: Near-peer assisted learning has been deployed in numerous settings within medical education with promising results. However, there is very little experience utilizing near-peers in sociomedical or cultural competency training. We recently described a novel model for sociomedical learning based on Introduction to Medicine and Society (IMS), a critical pedagogy-based course at the Perelman School of Medicine at the University of Pennsylvania (PSOM). Near-peer facilitation, by senior medical students, is central to this model. The aim of this descriptive study is to examine how facilitating within this curriculum impacts senior medical students' self-reported attitudes toward course content, medical education, as well as self-care and medical practice. Methods: At the conclusion of the course, near-peer facilitator attitudes were assessed in three key domains through an anonymous survey. Attitudes were rated according to a 5-point Likert scale. Data from subgroups were analyzed using standard two-tailed t-tests. Optional narrative data were also collected. Results: Twenty six of 34 (76%) eligible facilitators completed the survey. Strong majorities of facilitators felt that their experience facilitating IMS had a favorable effect on attitudes related to course content (sociomedical issues and communication skills). A majority also endorsed favorable changes in their attitudes toward teaching and medical education. Large proportions of facilitators endorsed positive changes in a number of domains linked to trainee resilience. Conclusions: Our descriptive data suggest that acting as a near-peer facilitator as a senior medical student within a critical pedagogy-based course could help to fill multiple important curricular gaps at the transition from medical school to residency. Moreover, we find that a sociomedical facilitation experience during this important transition may increase enthusiasm for careers in medical education and undo some of the negative impacts of clinical training during medical school.

Prevalence of Burnout in Medical and Surgical Residents: A Meta-Analysis

The burnout syndrome is characterized by emotional exhaustion, depersonalization, and reduced personal achievement. Uncertainty exists about the prevalence of burnout among medical and surgical residents. Associations between burnout and gender, age, specialty, and geographical location of training are unclear. In this meta-analysis, we aimed to quantitatively summarize the global prevalence rates of burnout among residents, by specialty and its contributing factors. We searched PubMed, PsycINFO, Embase, and Web of Science to identify studies that examined the prevalence of burnout among residents from various specialties and countries. The primary outcome assessed was the aggregate prevalence of burnout among all residents. The random effects model was used to calculate the aggregate prevalence, and heterogeneity was assessed by I² statistic and Cochran's Q statistic. We also performed meta-regression and subgroup analysis. The aggregate prevalence of burnout was 51.0% (95% CI: 45.0-57.0%, I² = 97%) in 22,778 residents. Meta-regression found that the mean age (β = 0.34, 95% CI: 0.28-0.40, p < 0.001) and the proportion of males (β = 0.4, 95% CI = 0.10-0.69, p = 0.009) were significant moderators. Subgroup analysis by specialty showed that radiology (77.16%, 95% CI: 5.99-99.45), neurology (71.93%, 95% CI: 65.78-77.39), and general surgery (58.39%, 95% CI: 45.72-70.04) were the top three specialties with the highest prevalence of burnout. In contrast, psychiatry (42.05%, 95% CI: 33.09-51.58), oncology (38.36%, 95% CI: 32.69-44.37), and family medicine (35.97%, 95% CI: 13.89-66.18) had the lowest prevalence of burnout. Subgroup analysis also found that the prevalence of burnout in several Asian countries was 57.18% (95% CI: 45.8-67.85); in several European countries it was 27.72% (95% CI: 17.4-41.11) and in North America it was 51.64% (46.96-56.28). Our findings suggest a high prevalence of burnout among medical and surgical residents. Older and male residents suffered more than their respective counterparts.

Implementing a Narrative Medicine Curriculum During the Internship Year: An Internal Medicine Residency Program Experience

INTRODUCTION

Narrative medicine develops professional and communication skills that align with Accreditation Council for Graduate Medical Education competencies. However, little is known about a narrative medicine curriculum's impact on physicians in training during residency. Implementing a narrative medicine curriculum during residency can be challenging because of time constraints and limited opportunity for nonclinical education.

METHODS

Six sessions were implemented throughout one academic year to expose first-year internal medicine residents (interns) to narrative medicine. Attendance and participation were documented. At the end of the year, interns completed an open-ended survey to gauge their perception of their experience with the sessions.

RESULTS

In total, 17 interns attended at least 1 narrative medicine session, and each session averaged 5.4 attendees. Thirteen eligible interns completed the survey. Thematic analysis identified 3 predominant themes: Mindfulness, physician well-being, and professionalism.

DISCUSSION

Overall, the narrative medicine sessions were well attended and the curriculum was well received. This intervention demonstrates the value of a narrative medicine curriculum during medical resident training. Large prospective studies are necessary to identify the long-term benefits of such a curriculum.

The role of feedback in ameliorating burnout

PURPOSE OF REVIEW

Assessment of the current literature surrounding interventions directed toward the prevention of burnout in the field of medicine and particularly in anesthesiology.

RECENT FINDINGS

Recently, burnout has been noted to lead to medication errors and subsequently increased harm to our patients. On a personal level, burnout can lead to depression and even suicide amongst physicians. Strategies to prevent burnout amongst anesthesiologists that have been studied in the literature include multisource feedback, mentorship and early recognition.

SUMMARY

There remains no clear or definitive intervention to prevent burnout for physicians. However, changing our environment to embrace mentorship, the continual exchange of feedback and the fostering self-care could startlingly improve our work environment.

Prevalence of anxiety and depressive symptoms among medical residents in Tunisia: a cross-sectional survey

OBJECTIVE

To assess the prevalence of anxiety and depressive symptoms and the associated risk factors among Tunisian medical residents.

DESIGN

Cross-sectional survey.

SETTING

Faculty of Medicine, Tunis.

PARTICIPANTS

All Tunisian medical residents brought together between 14 and 22 December 2015 to choose their next 6-month rotation.

INTERVENTION

The items of the Hospital Anxiety and Depression (HAD) questionnaire were employed to capture the prevalence of anxiety and/or depression among the residents. The statistical relationships between anxiety and depression (HAD score) and sociodemographic and work-related data were explored by Poisson regression.

RESULTS

1700 out of 2200 (77%) medical residents (mean age: 28.5±2 years, female: 60.8%) answered the questionnaire. The mean working hours per week was 62±21 hours; 73% ensured a mean of 5.4±3 night shifts per month; and only 8% of them could benefit from a day of safety rest. Overall, 74.1% of the participating residents had either definite (43.6%) or probable (30.5%) anxiety, while 62% had definite (30.5%) or probable (31.5%) depression symptoms, with 20% having both definite anxiety and definite depression. The total HAD score was significantly associated with the resident's age (OR=1.014, 95% CI 1.006 to 1.023, p=0.001); female gender (OR=1.114, 95% CI 1.083 to 1.145, p<0.0001); and the heavy burden of work imposed on a weekly or monthly basis, as reflected by the number of night shifts per month (OR=1.048, 95% CI 1.016 to 1.082, p=0.03) and the number of hours worked per week (OR=1.008, 95% CI 1.005 to 1.011, p<0.0001). Compared with medical specialties, the generally accepted difficult specialties (surgical or medical-surgical) were associated with a higher HAD score (OR=1.459, 95% CI 1.172 to 1.816, p=0.001).

CONCLUSION

Tunisian residents experience a rate of anxiety/depression substantially higher than that reported at the international level. This phenomenon is worrying as it has been associated with an increase in medical errors, work dissatisfaction and attrition. The means of improving the well-being of Tunisian medical residents are explored, emphasising those requiring immediate implementation.

Proposed Performance-Based Metrics for the Future Funding of Graduate Medical Education: Starting the Conversation

Graduate medical education (GME) in the United States is financed by contributions from both federal and state entities that total over $15 billion annually. Within institutions, these funds are distributed with limited transparency to achieve ill-defined outcomes. To address this, the Institute of Medicine convened a committee on the governance and financing of GME to recommend finance reform that would promote a physician training system that meets society's current and future needs. The resulting report provided several recommendations regarding the oversight and mechanisms of GME funding, including implementation of performance-based GME payments, but did not provide specific details about the content and development of metrics for these payments. To initiate a national conversation about performance-based GME funding, the authors asked: What should GME be held accountable for in exchange for public funding? In answer to this question, the authors propose 17 potential performance-based metrics for GME funding that could inform future funding decisions. Eight of the metrics are described as exemplars to add context and to help readers obtain a deeper understanding of the inherent complexities of performance-based GME funding. The authors also describe considerations and precautions for metric implementation.

The learning environment and resident burnout: a national study

INTRODUCTION

Concerns exist about the negative impact of burnout on the professional and personal lives of residents. It is suggested that the origins of burnout among residents are rooted in the learning environment. We aimed to evaluate the association between the learning environment and burnout in a national sample of Dutch residents.

METHODS

We conducted a cross-sectional online survey among all Dutch residents in September 2015. We measured the learning environment using the three domain scores on content, organization, and atmosphere from the Scan of Postgraduate Educational Environment Domains (SPEED) and burnout using the Dutch version of the Maslach Burnout Inventory (UBOS-C).

RESULTS

Of 1,231 responding residents (33 specialties), 185 (15.0%) met criteria for burnout. After adjusting for demographic (age, gender and marital status) and work-related factors (year of training, type of teaching hospital and type of specialty), we found a consistent inverse association between SPEED scores and the risk of burnout (aOR 0.54, 95% CI 0.46 to 0.62, p < 0.001).

DISCUSSION

We found a strong and consistent inverse association between the perceived quality of the learning environment and burnout among residents. This suggests that the learning environment is of key importance in preventing resident burnout.