A narrative review on burnout experienced by medical students and residents

Ready Day One: What Residents and Program Directors Think is Needed for a Successful Transition to Residency

OBJECTIVE

To evaluate perceived gaps in preparedness, current on-boarding practices, and need for specialty wide resources in the transition to residency training in obstetrics and gynecology (OB/GYN) DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional survey of current U.S. OB/GYN residents and program directors (PDs) at the time of the resident in-training exam was conducted in 2022. Both groups provide demographic information and identified specific knowledge, skills, and abilities in need of more preparation at the start of residency. PDs were queried on perceptions of readiness for their current first year class, educational on-boarding practices, and their preference for standardized curricular materials and assessment tools. Chi-squared and Kruskal-Wallis tests were used to compare perceptions of skills deficits between PDs and residents, and the relationship of preparedness to program type and resident year in training.

RESULTS

Response rates for residents and program directors were 64.9% and 72.6% respectively. A majority (115/200, 57.5%) of program directors agreed or strongly agreed with the statement, "In general, I feel that my new interns are well prepared for residency when they arrive at my program." Both groups agreed that basic suturing and ultrasound skills were deficits. Residents identified a need for better preparation in management of inpatient issues while PDs identified time management skills as lacking. There was considerable heterogeneity of program on-boarding practices across the specialty. Most PDs agreed or strongly agreed that a standardized curriculum (80.5%, 161/200) and assessment tools (75.3%, 150/199) would be helpful.

CONCLUSION

OBGYN PDs feel that not all residents arrive prepared for residency and overwhelmingly support the development of standardized transition curricular and assessment tools, similar to the curriculum developed in general surgery. Based on input from PDs and residents, early curricular efforts should focus on basic surgical, ultrasound, and time management skills and on management of inpatient issues.

The race that never slows: Otolaryngology - Head and Neck Surgery residency applicant parameters over time

Background

There has been an increasing number of Canadian medical graduates who have gone unmatched in the residency selection process. Medical students have been engaging in extracurricular activities outside the formal curriculum which may help to distinguish themselves from their peers in the selection process. To understand how competitiveness in residency selection shapes applicant demographic characteristics and behaviours, this study set out to explore the demographic characteristics and prevalence of reported extra-curricular activities by applicants to Canadian Otolaryngology - Head & Neck Surgery (OTL-HNS) residency across time.

Methods

A retrospective, descriptive study reviewed specific sections of the curriculum vitae (CV) of applicants to OTL-HNS programs in Canada. These sections were self-reported, and included research productivity, involvement in volunteer and leadership activities, membership in associations, and honours or awards granted. Data was quantified and analyzed descriptively.

Results

Between 2013 to 2017, a total of 267 applicants reported a median of 12.6 research publications, 9.6 volunteer activities, six leadership activities, six association memberships and 9.8 honours/awards. Applicants were younger over time, with proportions of applicants over 30 years old decreasing from 56% in 2013 to 9% in 2017.

Conclusion

Applicants to Canadian OTL-HNS residency programs are reporting consistently high numbers of extracurricular activities and were of increasingly younger ages. Medical students are investing significant time and energy to pursue these activities which are above and beyond the formal curriculum, possibly contributing to decreased diversity in applicants for competitive residencies, increasing the likelihood of misrepresentation in residency applications, and likely contributing to medical student burnout.

A study on measure of resilience and impact of demanding clinical training on young medical professional's burnout in a tertiary care hospital, Andhra Pradesh

BACKGROUND

The psychological state of medical students gaining concern on the part of medical institutions in several countries. Numerous studies are being conducted to study stress, burnout, and depression in medical students in India and globally. However, little is known about medical student resilience, particularly in India. The objectives of this study were to study the resilience, self-perceptions of stress coping skills, and burnout among medical students in clinical training in a tertiary care health center, to study factors associated with resilience among medical students in clinical training in a tertiary care health center and to study the relationship between resilience and self-perceptions of stress coping skills and symptoms of burnout.

MATERIALS AND METHODS

This cross-sectional study was conducted in a tertiary healthcare hospital in district Guntur, Andhra Pradesh from November 2020 to December 2020, among 186 adult male and female medical students, aged more than 20 years, enrolled in the regular degree course and part of patient care or at least last three months. Participants were randomly selected and a structured questionnaire with Connor Davidson Resilience Scale 10 was used for interviewing. Descriptive and inferential statistics were conducted to measure associations between outcome and explanatory variables. We used multiple linear regression to examine the association between dependent and independent variables. A P value less than. 05 was considered significant.

RESULTS

In the present study, 109 (58.0%) were females. The mean age of the study participants was 25.4 years (standard deviation 2.78). The mean score resilience score of the study participants using Connor Davidson Resilience Scale 10 was 25.1 (standard deviation 7.97). Of the total 44 (23.7%) of the study, participants reported the presence of burnout. A significant positive correlation was between resilience and self-perceptions of stress-coping skills with a Pearson Correlation coefficient of 0.393. Among the study participants, the mean resilience score was higher among those not having any symptoms of burnout. In the hierarchical stepwise multiple linear regression analysis, male gender (P value = .014), financial independence (P value = .044), and absence of burnout symptoms (P value = .004) were significantly associated with higher resilience scores. Psychiatric medicine usage was significantly associated with a lower resilience score with P < .05.

CONCLUSION

Our study samples had higher resilience and lower burnout prevalence compared to the West. The stressful clinical event experienced by medical students demands training and innovative strategies to foster communication and teamwork skills among medical teams.

Factors in turnover intention of cardiothoracic surgery residents

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

Psychological distress among early medical residents: A 2-year longitudinal cohort study over seven years in Japan

BACKGROUND

Early medical residents are expected to have a higher prevalence of burnout due to physical and psychological stressors. However psychological distress associated with burnout has not been adequately investigated in a longitudinal manner. We therefore examined the longitudinal trajectory of depression and its associated factors among early medical residents.

METHODS

In this cohort study, medical residents (n = 215) who started rotation at the University of Yamanashi Hospital during 2012 to 2018 were recruited and asked to complete the Brief Job Stress Questionnaire (BJSQ), Center for Epidemiologic Studies Depression Scale (CESD), Brief Scale for Coping Profile (BSCP) and Athens Insomnia Scale (AIS) at the time of exit from each clinical department for up to two years over seven years. Factors associated with the CES-D scores were statistically explored, with a cutoff score of 16 to denote depression.

RESULTS

The CES-D was completed by 205 residents. The average CES-D score was 10.3 ± 8.0 and the scores were lower in the 2nd versus 1st year of residency (11.3 ± 6.7 versus 9.2 ± 7.0). Multiple regression analysis of BJSQ/BSCP/AIS on CES-D revealed that insomnia had a significant impact on the CES-D scores. Apart from insomnia, avoidance and suppression and peer support had significant effects. Resilient residents, who showed the maximum CES-D score of under 16 consistently throughout the residency, was better in terms of changing a point of view, active solution and changing mood. Women were more likely to express emotions to others, while they reported more job control in the first year.

CONCLUSIONS

Our results have high clinical relevance to challenge psychological burnout among early medical residents, offering some possible clues for prevention such as reduced burden, more flexibility during the first year and strengthening coworker support. Insomnia exerted moderate to strong effects on depression and monitoring of sleep appears indispensable in this specific population.

Constructing "Burnout": A Critical Discourse Analysis of Burnout in Postgraduate Medical Education

PURPOSE

In 1974, Dr. Herbert Freudenberger coined the term burnout. With the creation of the Maslach Burnout Inventory in 1984, burnout went from a pop psychology term to a highly studied phenomenon in medicine. Exponential growth in studies of burnout culminated in its adoption into the International Classification of Diseases-11 in 2022. Yet, despite increased awareness and efforts aimed at addressing burnout in medicine, many surveys report burnout rates have increased among trainees. The authors aimed to identify different discourses that legitimate or function to mobilize burnout in postgraduate medical education (PGME), to answer the question: Why does burnout persist in PGME despite efforts to ameliorate it?

METHOD

Using a Foucauldian discourse analysis, this study examined the socializing period of PGME as an entry point into burnout's persistence. The archive from which the discourses were constructed included over 500 academic articles, numerous policy documents, autobiographies, videos, documentaries, social media, materials from conferences, and threads in forums including Reddit.

RESULTS

This study identified 3 discourses of burnout from 1974-2019: burnout as illness, burnout as occupational stress, and burnout as existentialism. Each discourse was associated with statements of truth, signs and signifiers, roles that individuals play within the discourse, and different institutions that gained visibility as a result of differing discourses.

CONCLUSIONS

Burnout persists despite effort to ameliorate it because it is a productive construct for organizations. In its current form, it depoliticizes issues of health in favor of wellness and gives voice to the challenge of making meaning from the experience of being a clinician.

From helplessness to transformation: An analysis of clinician narratives about the social determinants of health and their implications for training and practice

BACKGROUND

Medical curricula are attempting to prepare trainees to address the social determinants of health, however the life circumstances of patients are often beyond physician control. Little is known about how physicians cope with this dilemma; we sought to examine their perspectives when faced with this challenge to help better prepare trainees for practice.

METHODS

We undertook a critical analysis of physician narratives from January 2018 to June 2020. In total, 268 physician-written narrative social determinant of health pieces from four high impact medical journals were screened and 47 met the inclusion criteria and were analysed.

RESULTS

We identified four storylines that described the physician experience and strategies for coping with the social determinants of health. While Helplessness stories described authors' experiences of emotional distress when unable to support their patients, the other story types described ways they could make a difference. In Shortcoming and Transformation stories, the realisations about shortcomings led to transformation. In Doctor-patient relationship stories, authors described its importance in theirs and patients' lives, and in System advocacy stories, they described the need for greater advocacy to help change broken systems.

CONCLUSIONS

Current approaches to teaching the social determinants of health often focus on the role of physicians in recognising and altering social circumstances. However, the realities of practice do not easily allow physicians to do so and, for some, may lead to distress and burnout. There are other ways to cope and make a difference by improving ourselves, investing in getting to know our patients, and advocating. These results can help better support trainees and physicians for the realities of practice.

Exploring the relationship between simulation-based team training and sick leave among healthcare professionals: a cohort study across multiple hospital sites

OBJECTIVE

Burnout and mental illness are frequent among healthcare professionals, leading to increased sick leave. Simulation-based team training has been shown to improve job satisfaction and mental health among healthcare professionals. This study seeks to investigate the relationship between simulation-based team training and sick leave.

DESIGN

Cohort study.

SETTING AND INTERVENTION

Five Danish hospitals.

PARTICIPANTS

A total of 15 751 individuals were screened for eligibility. To meet the eligibility criteria, individuals had to be employed in the same group (intervention or control) for the whole study period. A total of 14 872 individuals were eligible for analysis in the study.

INTERVENTION

From 2017 to 2019, a simulation-based team training intervention was implemented at two hospital sites. Three hospital sites served as the control group.

OUTCOME MEASURES

Data on sick leave from 2015 to 2020 covered five hospital sites. Using a difference-in-difference analysis, the rate of sick leave was compared across hospital sites (intervention vs control) and time periods (before vs after intervention).

RESULTS

Significant alterations in sick leave were evident when comparing the intervention and control groups. When comparing groups over time, the increase in sick leave was -0.3% (95% CI -0.6% to -0.0%) lower in the intervention group than in the control group. The difference-in-difference for the complete case analysis showed that this trend remained consistent, with analysis indicating a comparable lower increase in sick leave by -0.7% (95% CI -1.3% to -0.1%) in the intervention group.

CONCLUSION

The increase in sick leave rate was statistically significantly lower in the intervention group, implying that simulation-based team training could serve as a protective factor against sick leave. However, when investigating this simulation intervention over 5 years, other potential factors may have influenced sick leave, so caution is required when interpreting the results.

"It's All About the Trust And Building A Foundation:" Evaluation of a Longitudinal Medical Student Coaching Program

Coaching is increasingly implemented in medical education to support learners' growth, learning, and wellbeing. Data demonstrating the impact of longitudinal coaching programs are needed.

We developed and evaluated a comprehensive longitudinal medical student coaching program designed to achieve three aims for students: fostering personal and professional development, advancing physician skills with a growth mindset, and promoting student wellbeing and belonging within an inclusive learning community. We also sought to advance coaches' development as faculty through satisfying education roles with structured training. Students meet with coaches weekly for the first 17 months of medical school for patient care and health systems skills learning, and at least twice yearly throughout the remainder of medical school for individual progress and planning meetings and small-group discussions about professional identity. Using the developmental evaluation framework, we iteratively evaluated the program over the first five years of implementation with multiple quantitative and qualitative measures of students' and coaches' experiences related to the three aims.

The University of California, San Francisco, School of Medicine, developed a longitudinal coaching program in 2016 for medical students alongside reform of the four-year curriculum. The coaching program addressed unmet student needs for a longitudinal, non-evaluative relationship with a coach to support their development, shape their approach to learning, and promote belonging and community.

In surveys and focus groups, students reported high satisfaction with coaching in measures of the three program aims. They appreciated coaches' availability and guidance for the range of academic, personal, career, and other questions they had throughout medical school. Students endorsed the value of a longitudinal relationship and coaches' ability to meet their changing needs over time. Students rated coaches' teaching of foundational clinical skills highly. Students observed coaches learning some clinical skills with them - skills outside a coach's daily practice. Students also raised some concerns about variability among coaches. Attention to wellbeing and belonging to a learning community were program highlights for students. Coaches benefited from relationships with students and other coaches and welcomed the professional development to equip them to support all student needs.

Students perceive that a comprehensive medical student coaching program can achieve aims to promote their development and provide support. Within a non-evaluative longitudinal coach relationship, students build skills in driving their own learning and improvement. Coaches experience a satisfying yet challenging role. Ongoing faculty development within a coach community and funding for the role seem essential for coaches to fulfill their responsibilities.

Burnout phenomenon in Saudi dermatology residents: a national assessment of prevalence and contributing factors

A cross-sectional study was conducted between March and August 2021; an electronic survey was administered to all dermatology residents (n=79) in all centers with the Saudi Board Dermatology Training Program in the western, eastern and southern regions. Participation was voluntary, and written informed consent was obtained before the study. The survey was completed by 70 dermatology residents, for an 88.61% response rate. All the participants were aware of the study's aims, and their informed consent was obtained. The study design complied with the Declaration of Helsinki ethical standards and was approved by the Institutional Review Board at Imam Muhammad Ibn Saud Islamic University in Saudi Arabia. A total of 70 respondents completed the questionnaire. High emotional exhaustion (EE) was present in 47.1% of respondents, low personal accomplishment (PA) was present in 65.7%, and high depersonalization (DP) was the least prevalent (24.3%) across all burnout dimensions of dermatology residents. Overall burnout was present in 21.4% of the dermatology residents. Multivariate analysis showed that the odds of EE were significantly lower in males than females [odds ratio (OR)=0.2, P=0.016] and the higher number of patients seen per clinic (OR=1.09, P=0.032) was associated with higher odds of having a high risk of EE, while higher satisfaction with work-life balance was associated with lower odds of a high risk of EE (OR=0.47, P=0.005). A higher number of study hours/week was associated with lower odds of low PA (OR=0.95, P=0.02). Similarly, higher satisfaction with career was associated with lower odds of low PA (OR=0.35, P=0.042). Multivariate analysis showed that only exercise (OR=0.21, P=0.05) and satisfaction with work-life balance (OR=0.42, P=0.008) were associated with a lower risk of burnout. Our study adds the burnout rates among dermatology residents in Saudi Arabia, in addition to possible risk factors that can predict burnout, to the literature. These findings can be applied to improve training programs and reduce the burnout rate among residents.

Technostress as source of physician burnout: An exploration of the associations between technology usage and physician burnout

BACKGROUND

The cause of physician burnout is multifactorial. Health care systems pressures, excessive workloads, fatigue, poor self-care, administrative burdens, work hours, technological advancements, and work-home life conflicts, are all prominent themes throughout the literature. To date, little is known about whether, and to what extent, stressors related to the use of information and communication technology (ICT) use, other than electronic health records, outside of working hours, contribute to physician burnout.

PURPOSE

The purpose of this study was to explore whether work related ICT use outside of working hours is associated with physician burnout.

METHOD

A cross-sectional survey delivered online using The Maslach Burnout Inventory (MBI), a Physician Technology Usage Scale (PTUS) (and 7 personal characteristics questions. Data were analyzed using bivariate correlations, analysis of variance (ANOVA) and t-tests, and multiple linear regression.

RESULTS

Of 2,108 participants invited to complete the survey, 403 responded to and completed the survey (19% response rate). Results identified two significant factors associated with physician burnout: work related technology use outside of working hours, and the number of years in practice.

CONCLUSION

This research highlights the need for additional in-depth research into areas such as: 1. work-home life issues and how the use of technology outside of work hours may affect or be affected by burnout; 2. physician age and experience and burnout; 3. The differences between specialties and whether and how specialty-specific factors are related to burnout.

How often do medical students change career preferences over the course of medical school?

INTRODUCTION

During the preclinical years, students typically do not have extensive exposure to clinical medicine. When they begin their clinical rotations, usually in the third year, the majority of the time is spent on core rotations with limited experience in other fields of medicine. Students then must decide on their careers early in their fourth year. We aimed to analyze how often medical students change their career preferences between the end of their second and their fourth year.

METHODS

We conducted a retrospective, cohort study using the American Association of Medical Colleges Year 2 Questionnaire (Y2Q) and Graduating Questionnaire (GQ) from 2016 to 2020.

RESULTS

20,408 students answered both surveys, but 2,165 had missing values on the career choice question and were excluded. Of the remaining students, 10,233 (56%) changed their career choice between the Y2 and GQ surveys. Fields into which students preferentially switched by the GQ survey included anesthesia, dermatology, ENT, family medicine, OB/GYN, pathology, PM&R, psychiatry, radiology, urology, and vascular surgery. Many characteristics, including future salary, the competitiveness of the field, and the importance of work-life balance, were significantly associated with a higher likelihood of changing career choices. On the other hand, having a mentor and the specialty content were associated with a lower likelihood of change.

CONCLUSION

A majority of students switched their career preferences from the Y2Q to the GQ. Additional research should be focused on curricular design that optimizes student satisfaction with career decisions. This may include early integration of a variety of specialties.

Effects of coaching on medical student well-being and distress: a systematic review protocol

INTRODUCTION

Medical students experience higher rates of distress and burnout compared with their age-similar peers overall. Coaching has been proposed as one means of combating distress and burnout within the medical profession. The purpose of this systematic review is to synthesise the current evidence on the effects of coaching interventions on medical student well-being, including engagement, resilience, quality of life, professional fulfilment and meaning in work and distress, including burnout, anxiety and depressive symptoms.

METHODS AND ANALYSIS

We will conduct a systematic review of interventional and observational comparative studies that assess the effects of coaching interventions on well-being, including engagement, resilience, quality of life, professional fulfilment and meaning in work and distress, including burnout, anxiety and depressive symptoms among undergraduate medical students internationally. We will search PubMed (MEDLINE), Embase (OVID), PsycINFO (OVID), Scopus, ERIC, Cochrane Database of Systematic Reviews (OVID) and Cochrane Central Register of Controlled Trials (OVID) from their respective inception dates using the following search terms: (medical students OR medical student OR undergraduate medical education) AND (coach OR coaching OR coaches). Studies in any language will be eligible. Studies that report one or more outcomes of distress or well-being among medical students who receive a coaching intervention will be included. Data on participant and intervention characteristics, outcomes and instruments used will be collected as well as quality/risk of bias assessments. Two reviewers will screen studies against the inclusion criteria and perform data extraction. We will conduct a narrative synthesis, with meta-analysis if evidence permits quantitative pooling of results. Heterogeneity of results across studies according to study design, learner level and study risk of bias will be evaluated, as well as publication bias.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. Results will be disseminated by publication in a scientific journal.

PROSPERO REGISTRATION NUMBER

CRD42022322503.

When I say … burnout

In the world of wellness, 'burnout' might as well be a God term. But what do we really mean when we say, "I'm burned out." And is this one little word enough?

Behavioral and psychosocial factors related to mental distress among medical students

Introduction

Physicians die by suicide at rates higher than the general population, with the increased risk beginning in medical school. To better understand why, this study examined the prevalence of mental distress (e.g., depressive symptoms and suicide risk) and behavioral and psychosocial risk factors for distress, as well as the associations between mental distress and risk factors among a sample of medical students in a pre-COVID-19-era.

Methods

Students enrolled in a large California medical school in 2018-2019 (N = 134; 52% female) completed questionnaires assessing sociodemographic characteristics, depression and suicide family history, health behaviors, and psychosocial wellbeing. Assessment scores indexing mental distress (e.g., depressive symptoms, thoughts of suicide in the past 12 months, suicide risk, and history of suicidality) and risk factors (e.g., stress, subjective sleep quality, alcohol use, impostor feelings, and bill payment difficulty) were compared across biological sex using chi-squared tests, and associations between mental distress and risk factors were determined through logistic regression.

Results

Elevated mental distress indicators were observed relative to the general public (e.g., 16% positive depression screen, 17% thought about suicide in previous 12 months, 10% positive suicide risk screen, and 34% history of suicidality), as well as elevated risk factors [e.g., 55% moderate or high stress, 95% at least moderate impostor feelings, 59% poor sleep quality, 50% screened positive for hazardous drinking (more likely in females), and 25% difficulty paying bills]. A positive depression screen was associated with higher stress, higher impostor feelings, poorer sleep quality, and difficulty paying bills. Suicidal ideation in the previous 12 months, suicide risk, and a history of suicidality were independently associated with higher levels of impostor feelings.

Discussion

Higher scores on assessments of depressive symptoms and suicidal thoughts and behaviors were related to several individual-level and potentially modifiable risk factors (e.g., stress, impostor feelings, sleep quality, and bill payment difficulties). Future research is needed to inform customized screening and resources for the wellbeing of the medical community. However, it is likely that the modification of individual-level risk factors is limited by the larger medical culture and systems, suggesting that successful interventions mitigate suicide risk for medical providers need to address multiple socio-ecological levels.

Moving the Field Forward: Using Self-Determination Theory to Transform the Learning Environment in Medical Education

Issue: The learning environment (LE) is known to be the main determinant of physician distress, yet most wellness interventions continue to focus on the learner. Additionally, few wellness interventions that focus on the LE have derived from well-established theory. These limitations represent major barriers in our progress toward improving the LE and supporting medical learner wellness in an evidence-based, humanistic, and scalable way. Evidence: To remedy the situation, I highlight a cross-section of promising experimental research in self-determination theory (SDT) and its potential applications in medical education. Implications: I propose that we incorporate SDT-based faculty development workshops to improve leaders' awareness and motivating style with learners. These interventions are known to improve the LE and thus learners' engagement, performance, and wellness. SDT-trained personnel would be needed to train medical faculty, including about the reciprocal benefits of being autonomy-supportive.

Veterinarian burnout demographics and organizational impacts: a narrative review

Burnout is a work-related syndrome of physical and emotional exhaustion secondary to prolonged, unresolvable occupational stress. Individuals of different demographic cohorts may have disparate experiences of workplace stressors and burnout impacts. Healthcare organizations are adversely affected by burnt out workers through decreased productivity, low morale, suboptimal teamwork, and potential impacts on the quality of patient care. In this second of two companion reviews, the demographics of veterinary burnout and the impacts of burnout on affected individuals and work environments are summarized, before discussing mitigation concepts and their extrapolation for targeted strategies within the veterinary workplace and profession.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cultural adaptation and validation of Japanese medical resident version of the workplace social capital scale: a cross-sectional study

BACKGROUND

The Workplace Social Capital (WSC) Scale is the most frequently used tool for measuring social capital at work in Western countries. However, there are no corresponding tools for assessing WSC among medical trainees in Japan. Thus, this study was conducted to develop the Japanese medical resident version of the WSC (JMR-WSC) Scale and examine its validity and reliability.

METHODS

The Japanese version of the WSC Scale by Odagiri et al. was reviewed and the scale was partially modified for use in the Japanese context of postgraduate medical education. To verify the validity and reliability of the JMR-WSC Scale, a cross-sectional survey was performed in 32 hospitals across Japan. Postgraduate trainees (years 1-6) at the participating hospitals responded to the online questionnaire on a voluntary basis. We tested the structural validity through confirmatory factor analysis. We also examined criterion-related validity and internal consistency reliability of the JMR-WSC Scale.

RESULTS

In all, 289 trainees completed the questionnaire. The results of confirmatory factor analysis supported the JMR-WSC Scale's structural validity on the same two-factor model as that of the original WSC Scale. Logistic regression analysis showed that, after adjustment for gender and postgraduate years, trainees with good self-rated health had a significantly elevated odds ratio for good WSC. Cronbach's alpha coefficients showed acceptable internal consistency reliability.

CONCLUSIONS

We successfully developed the JMR-WSC Scale and examined its validity and reliability. Our scale could be used to measure social capital in postgraduate medical training settings in Japan to help prevent burnout and reduce patient safety incidents.

The impact of global health outreach experiences on medical student burnout

BACKGROUND

Student burnout during medical education is a prevalent and critical problem. Burnout has reaching consequences, including negative health outcomes for students, financial loss for schools, and worsened patient care as students transition to practice. Global Health Outreach Experiences (GHOEs), known to enhance cultural awareness and clinical knowledge among medical students, are offered in most programs. Prior studies document that GHOEs benefit physicians suffering from burnout, with effects demonstrating improvement over 6 months. No study, to our knowledge, has assessed the influence GHOEs may have on medical student burnout with a comparable control group. This study examines whether participation in a GHOE, compared to a standard break from school, has a positive effect on burnout.

METHODS

A case control study utilizing the Copenhagen Burnout Inventory was conducted on medical students. 41 students participated in a one-week, spring break GHOE and 252 were randomly selected as non-participating students in a control group. Assessments were gathered 1 week prior, 1 week after, and 10 weeks after spring break. Response across the surveys in chronological order included 22, 20, 19 GHOE and 70, 66, 50 control participants.

RESULTS

A significant reduction in personal burnout (PB) (P = 0.0161), studies related burnout (SRB) (P = 0.0056), and colleagues related burnout (CRB) (P = 0.0357) was found among GHOE attendees compared to control participants at 10-weeks after spring break. When modeled with potential confounders, CRB and SRB reductions remained significant.

CONCLUSION

GHOEs may be a potential tool for institutions to combat burnout rates in their students. The benefits of GHOEs appear to enhance over time.

Disability, program access, empathy and burnout in US medical students: A national study

OBJECTIVE

The objective of this study is to investigate whether self-disclosed disability and self-reported program access are associated with measures of empathy and burnout in a national sample of US medical students.

METHODS

The authors obtained data from students who responded to the Association of Medical Colleges (AAMC) Year 2 Questionnaire (Y2Q) in 2019 and 2020. Data included demographic characteristics, personal variables, learning environment indicators, measures of burnout (Oldenburg Burnout Inventory for Medical Students), empathy (Interpersonal Reactivity Index) and disability-related questions, including self-reported disability, disability category and program access. Associations between disability status, program access, empathy and burnout were assessed using multivariable logistic regression models accounting for YQ2 demographic, personal-related and learning environment measures.

RESULTS

Overall, 23 898 (54.2%) provided disability data and were included. Of those, 2438 (10.2%) self-reported a disability. Most medical students with disabilities (SWD) self-reported having program access through accommodations (1215 [49.8%]) or that accommodations were not required for access (824 [33.8%]). Multivariable models identified that compared with students without disabilities, SWD with and without program access presented higher odds of high exhaustion (1.50 [95% CI, 1.34-1.69] and 2.59 [95% CI, 1.93-3.49], respectively) and lower odds of low empathy (0.75 [95% CI, 0.67-.85] and 0.68 [95% CI, 0.52-0.90], respectively). In contrast, multivariable models for disengagement identified that SWD reporting lack of program access presented higher odds of high disengagement compared to students without disabilities (1.43 [95% CI, 1.09-1.87], whereas SWD with program access did not (1.09 [95% CI, 0.97-1.22]).

CONCLUSIONS

Despite higher odds of high exhaustion, SWD were less likely to present low empathy regardless of program access, and SWD with program access did not differ from students without disabilities in terms of disengagement. These findings add to our understanding of the characteristics and experiences of SWD including their contributions as empathic future physicians.

The impact of perceived social support and coping on distress in a sample of Atlantic Canadian health professional students during COVID-19 compared to pre-COVID peers

PURPOSE

Students pursuing higher education and health professional (HP) programs (e.g., nursing, pharmacy, social work, medicine) experience stressors including academic pressures, workload, developing professional competencies, professional socialization, the hidden curriculum, entering clinical practice and navigating relationships with colleagues. Such stress can have detrimental effects on HP students physical and psychological functioning and can adversely affect patient care. This study examined the role of perceived social support and resilience in predicting distress of Atlantic Canadian HP students during the COVID-19 pandemic and compared the findings to a pre-COVID population of age and sex matched Canadians.

METHOD

Second year HP students (N = 93) completed a survey assessing distress, perceived social support, and resilience and open-ended questions on student awareness of supports and counselling available to them, their use/barriers to the services, and the impact of COVID-19 on their personal functioning. HP student responses were also compared with age and sex matched Canadian peers from data collected prior to COVID-19.

RESULTS

It was found that HP students reported moderate to severe psychological distress, and while they reported high levels of social support on a measure of perceived social support they also reported that the COVID-19 pandemic made them feel isolated and that they lacked social support. It was found that the sample of HP students reported significantly higher psychological distress than the mean scores of the age and sex matched sample of Canadian peers.

CONCLUSIONS

These findings call for creation of more tailored interventions and supports for HP students.

The relationship between the burnout syndrome and academic success of medical students: a cross-sectional study

The burnout syndrome may affect academic achievement, but research on burnout and academic success of medical students is sparse. This research aimed to estimate the prevalence of high risk of burnout in students of medicine and to investigate its association with academic performance. It included 760 full-time medical students who completed the survey (response rate = 90.9 %). A significant independent predictor for high burnout risk in students with lower grade point average (GPA) was male gender (adjusted OR=2.44; 95 % CI=1.14-5.23; P=0.022). Among students with higher GPA, high burnout risk was associated with the use of sedatives (adjusted OR=6.44; 95 % CI=1.80-22.99; P=0.004).

Hybrid Delivery of Mindfulness Meditation and Perceived Stress in Pediatric Resident Physicians: A Randomized Clinical Trial of In-Person and Digital Mindfulness Meditation

Physicians are experiencing epidemic levels of work-related stress and burnout. Determine efficacy of mindfulness meditation delivered as a hybrid (in-person and digital) format to reduce perceived stress in pediatric residents. Pediatric residents (n = 66) were block randomized to a hybrid Mindful Awareness Practices (MAPs) intervention, comprised of one in-person 60-min session and 6-week access to a digitally delivered MAPs curriculum (n = 27) or wait-list control (n = 39). Perceived Stress Scale (PSS) was administered at baseline and post-intervention as the primary outcome measure. A priori secondary outcomes were measured using the Abbreviated Maslach Burnout Inventory-9, Beck Depression Inventory, Beck Anxiety Inventory, UCLA Loneliness Scale, and Pittsburgh Sleep Quality Index. After the first session, 58% participated at least one digital session (M = 2.0; SD = 1.3). MAPs participants showed significant decrease in PSS compared to controls, with between-group mean difference of 2.20 (95% CI 0.47-3.93) at post-intervention (effect size 0.91; 0.19-1.62). No secondary outcome group differences were detected. Exposure to a hybrid mindfulness intervention was associated with improvement in perceived stress among pediatric residents.Trial Registration: NCT03613441.

Resident Physician Perspectives on Mindfulness Education in Residency: A Multispecialty Qualitative Assessment of Clinical Care Impact

Background

Mindfulness training positively influences residents personally and professionally. Routine integration into residency may be impacted by limited understanding of the ways in which mindfulness training enhances clinical care.

Objective

We explored residents' direct experience and personal application of mindfulness in their clinical work following 10 hours of mindfulness training.

Methods

Mindfulness training sessions were facilitated between 2017 and 2019 for 5 groups of residents: pediatrics, ophthalmology, postgraduate year (PGY)-1 anesthesiology, and 2 different years of PGY-1 family medicine residents. Training was integrated into resident protected didactic time and attendance was expected, although not mandated, with the exception of pediatrics, in which the department mandated the training. Qualitative evaluation was conducted using a voluntary, semi-structured, de-identified phone interview within 2 months post-training. Reviewers independently coded the transcripts and then dialogued to reach consensus around emergent themes.

Results

Thirty-six of 72 residents (50%) who participated in the training completed interviews. Themes were similar across specialties. All residents acknowledged the potential usefulness of mindfulness training during residency. Six residents (17%) reported they had not applied the mindfulness training to their daily work by the end of the course. There were 4 emergent themes related to clinical application of mindfulness training: integrating brief moments of mindfulness practice, self-awareness, relational presence with patients, and maintaining perspective during clinical encounters and residency training as a whole.

Conclusions

After completing a 10-hour mindfulness training program, residents reported enhanced perspective-taking and relationship-building with themselves and their patients in clinical settings across medical and procedural specialties.

Profiles of Military Medical Students' Well-being, Burnout, and Retention

BACKGROUND

Well-being concerns among medical students are more prevalent than their age-matched peers in the United States. It remains unknown, however, if individual differences in well-being exist among U.S. medical students serving in the military. In this study, we sought to identify profiles (i.e., subgroups) of well-being in military medical students and examine the associations between these well-being profiles and burnout, depression, and intended retention in military and medical fields.

METHODS

Using a cross-sectional research design, we surveyed military medical students and then conducted latent class analysis to explore profiles of well-being, and applied the three-step latent class analysis method to assess predictors and outcomes of well-being profiles.

RESULTS

Heterogeneity in well-being was identified among the 336 military medical students surveyed, portraying medical students' falling into three distinct subgroups: High well-being (36%), low well-being (20%), and moderate well-being (44%). Different subgroups were associated with different risks of outcomes. Students in the subgroup of low well-being were at the highest risk of burnout, depression, and leaving medicine. In contrast, students in the moderate well-being group were at the highest risk of leaving military service.

CONCLUSIONS

These subgroups may be clinically important as burnout, depression, and intention to leave medical field and/or military service occurred with varying likelihoods among medical students across the different well-being subgroups. Military medical institutions may consider improving recruitment tools to identify the best alignment between students' career goals and the military setting. Besides, it is crucial for the institution to address diversity, equity, and inclusion issues that may lead to alienation, anxiety, and a sense of wanting to leave the military community.

The mediating role of psychological flexibility in the association of autistic-like traits with burnout and depression in medical students during clinical clerkships in Japan: a university-based cross-sectional study

BACKGROUND

Burnout and depression among medical students is linked to serious problems that require appropriate solutions. Subthreshold autism traits or autistic-like traits (ALTs) may be possible factors associated with burnout and depression. The effectiveness of acceptance and commitment therapy (ACT) for burnout and depression has been widely reported. The treatment aims to improve psychological flexibility, a concept indicating engagement in personal value-based behaviors without avoiding uncomfortable private experiences. This study examined whether ALTs were associated with burnout or depression among medical students during clinical clerkships in Japan, and then investigated what psychological flexibility processes might mediate these associations.

METHODS

A cross-sectional survey was administered to 284 medical students at Nagoya City University School of Medical Sciences who had been in clinical clerkships for 10 months or longer. Linear multiple regressions were performed with each burnout factor or depression as the outcome variable using validated tools measuring burnout (Maslach Burnout Inventory), anxiety and depression (Hospital Anxiety and Depression Scale), ALT (Autism-Spectrum Quotient Japanese version-21), and psychological flexibility processes (Cognitive Fusion Questionnaire-7 and Valuing Questionnaire). Additionally, a mediation analysis was conducted using structural equation modeling.

RESULTS

A linear multiple regression analysis that controlled for age and gender found that ALTs were significantly associated with lower personal accomplishment, a factor of burnout, and depression. Lower personal accomplishment was also associated with males and lower progress toward values of the psychological flexibility process. Depression was also associated with males and higher cognitive fusion, lower progress towards values, and higher obstruction to values of the psychological flexibility process. Surprisingly, emotional exhaustion and depersonalization were not significantly associated with ALTs. The mediation analysis revealed that the relationship between ALTs and personal accomplishment was partially mediated by a process of progress toward values, while the relationship between ALTs and depression was partially mediated by both processes of progress toward values and cognitive fusion.

CONCLUSIONS

ALTs were significantly associated with lower personal accomplishment of burnout and depression among medical students in clinical clerkships. Consideration should be given to the psychological flexibility processes that focus on interventions targeting psychological flexibility for medical students with ALTs to reduce burnout and depression.

Racial and Gender Differences in Medical Student Burnout: A 2021 National Survey

OBJECTIVE

To measure racial and gender differences in medical student burnout and identify possible contributing factors.

PATIENTS AND METHODS

Electronic surveys were distributed to medical students at 9 US medical schools from December 27, 2020, through January 17, 2021. Questions covered demographic characteristics, stressors contributing to burnout, and the 2-item Maslach Burnout Inventory.

RESULTS

Of 5500 invited students, 1178 (21%) responded (mean age, 25.3 years; 61% identified as female). Fifty-seven percent of respondents identified as White, 26% as Asian, and 5% as Black. Overall, 75.6% of students met the criteria for burnout. Women reported more burnout (78% vs 72%; P=.049). There were no differences in burnout prevalence by race. Students commonly reported that lack of sleep (42%), decreased engagement in hobbies or self-care (41%), stress about grades (37%), feeling socially disconnected (36%), and lack of exercise (35%) contributed to burnout. Compared with students of other races, Black students reported that their feelings of burnout were affected significantly more by lack of sleep and poor diet, and Asian students more by stress about grades, residency, and publishing pressure (all P<.05). Female students were more affected than male students by stress about grades, poor diet, and feelings of social disconnectedness and inadequacy (all P<.05).

CONCLUSION

Burnout (75.6%) was higher than historical norms, and female students reported higher burnout than male students. There was no difference in burnout prevalence by race. There were racial and gender differences in self-identified contributors of burnout. Additional research is needed to confirm whether stressors were contributors to or consequences of burnout, as well as how to address them.

A national longitudinal cohort study of factors contributing to UK medical students' mental ill-health symptoms

Background

The mental health of current medical students is predictive of their mental health as future doctors. The prevalence of anxiety, depression and burnout is high among medical students, but less is known about the occurrence of other mental ill-health symptoms, such as eating or personality disorders, and factors contributing to mental ill-health.

Aims

(1) To explore the prevalence of various mental ill-health symptoms in medical students and (2) to investigate what medical school factors and students' attitudes contribute to these mental ill-health symptoms.

Methods

Between November 2020 and May 2021, medical students from nine geographically spread medical schools in the UK participated by completing online questionnaires at two points in time, approximately 3 months apart.

Results

Of the 792 participants who filled in the questionnaire at baseline, over half experienced medium to high somatic symptoms (50.8%; 402) and drank alcohol at hazardous levels (62.4%; 494). Adjusted longitudinal data analysis of 407 students who completed the follow-up questionnaire demonstrated that less supportive educational climates that were more competitive and less centralised around the students, lower feelings of belongingness, greater stigma towards mental ill-health and lower intentions to seek help for mental ill-health, all contributed to students' mental ill-health symptoms.

Conclusions

Medical students experience a high prevalence of various mental ill-health symptoms. This study suggests that medical school factors and students' attitudes towards mental ill-health are significantly associated with students' mental health.

Experiences of burnout, anxiety, and empathy among health profession students in Qatar University during the COVID-19 pandemic: a cross-sectional study

BACKGROUND

The prevalence of burnout and anxiety is constantly increasing among health profession students worldwide. This study evaluates the prevalence of burnout and its relationship to anxiety and empathy during the COVID-19 pandemic among health profession students in the main governmental institution in Doha, Qatar using validated instruments.

METHODS

A cross-sectional survey of health profession students using validated instruments was employed. The Maslach Burnout Inventory-General Students Survey (MBI-GS(S)) to measure burnout; The Generalized Anxiety Disorder (GAD-7) to measure anxiety; and Interpersonal Reactivity Index (IRI) to measure empathy were utilized. Descriptive statistics and multivariable linear regression were used.

RESULTS

Of the 1268 eligible students, 272 (21.5%) completed the online survey. Burnout was found to be prevalent amongst the students. The mean scores for the MBI-GS(S) subscales of emotional exhaustion, cynicism, and professional efficacy were 4.07, 2.63, and 3.97, respectively. Anxiety was found to be a strong predictor for burnout and burnout was positively associated with empathy.

CONCLUSIONS

Findings from this study demonstrated relationships between health profession students' burnout, anxiety, and empathy. These findings might have an impact on the development of curriculum interventions to enhance student well-being. More burnout awareness and management programs that cater to the specific needs of health profession students are needed. Furthermore, findings of this study may have implications for future educational interventions during times of crisis or how this can be used to improve student experiences in normal times.

Evolution and Treatment of Academic Burnout in Nursing Students: A Systematic Review

AIM

To analyse the scientific literature related to the evolution of burnout syndrome during nursing studies and the interventions for the treatment or prevention of this syndrome in nursing students.

METHODS

A systematic review of the PubMed, Scopus, and CINAHL databases was performed in August 2022 using the search phrase "burnout AND nursing students" to extract experimental and longitudinal studies.

RESULTS

Eleven relevant studies were obtained for analysis. Four were experimental, and seven were cohort studies. According to these studies, the interventions reduced burnout overall, but on occasion, the burnout scores for some aspects increased, as did the prevalence. Psychological and work environment-related variables were the most important factors predicting burnout.

CONCLUSION

Burnout (i.e., emotional exhaustion and depersonalisation) tends to increase during nursing studies. Related factors include personality, coping strategies, life satisfaction, and the work environment. Interventions such as progressive muscle relaxation, behavioural therapy, and recreational music may alleviate burnout.

Why Do We Feel Like Intellectual Frauds? A Self-Determination Theory Perspective on the Impostor Phenomenon in Medical Students

Theory: Impostor phenomenon (IP) refers to people's feelings of intellectual fraudulence and fear of being "discovered," despite contradicting evidence of success. Due to its association with burnout and distress, it is progressively being studied in medicine. While various explanations for IP have been discussed in the literature, the role of motivation has largely been neglected. Hypotheses: Using self-determination theory (SDT) as a lens, it was hypothesized that different general causality orientations (impersonal, control, autonomy), domain-specific types of motivation (autonomous vs. controlled) toward going to medical school, and levels of satisfaction of basic psychological needs (autonomy, competence, relatedness) in the medical program, would each predict severity of IP symptoms. Method: A total of 1,450 medical students from three Canadian institutions were invited to complete a survey containing the Clance Impostor Phenomenon Scale and scales derived from SDT's mini theories: basic psychological needs theory, causality orientations theory, and organismic integration theory. We explored the prevalence of IP among the students and used regression to capture variable relationships, accounting for gender effects. Results: Data from 277 (19.1%) students were assessed, 73% of whom reported moderate or worse IP symptoms. Having an impersonal general causality orientation, more controlled motivation toward going to medical school, and lower need satisfaction in the medical program, each related to increased IP severity. Together, these motivational factors accounted for 30.3%, 13.6%, and 21.8% of the variance in students' IP severity, respectively. Conclusions: Findings from this study suggest that students who are more self-determined (both in general and in medical school), and whose basic psychological needs are more supported in their medical program, will experience less frequent and severe IP symptoms. Preliminary explanations and implications of these findings are discussed within the medical education context.

Restorative yoga therapy for third-year medical students in pediatrics rotation: Working to improve medical student well-being

BACKGROUND

Stress experienced by medical students is a well-documented and widespread phenomenon that may have physical and psychological effects on their well-being. One solution is to provide students with the tools to recognize and cope with stress. The aim of this study was to incorporate restorative yoga training-a well-recognized tool for stress reduction-in the third-year medical student pediatrics clerkship and assess the intervention's impact on students' well-being.

MATERIALS AND METHOD

Restorative yoga, as a prospective intervention, was offered to third-year medical students at Texas Tech University Health Sciences Center during their pediatrics rotation. The study was between March and August 2020. Each yoga session lasted 45-minutes, once a week for six weeks. Participants completed anonymous questionnaires before and after the intervention via the Warwick-Edinburgh Mental Well-being Scale (WEMWBS).

RESULT

Over the six-month study period, 25 (71%) of 35 medical students, having been given the option, chose to participate. The WEMWBS contains 14 statements on well-being, and all but one from the list showed a positive increase in average rating from pre intervention to post intervention. The statements "I've been feeling more relaxed" and "I've been thinking clearly" showed the greatest average increase. Following Chi-squared testing, two statements were found to be significantly different (P < 0.05) before intervention and after intervention: "I've been feeling more relaxed" and "I've been feeling good about myself."

CONCLUSION

Students' well-being is paramount to medical schools. Restorative yoga offers hopeful outcomes for effective mitigation of the stresses of medical education and may be recommended for wider use.

Fear, health impacts, and life delays: residents' certification exam year experience

BACKGROUND

Residency training is associated with risks of burnout and impaired well-being. This may be due to multiple factors, including navigating various transitions. Chief among these is the transition to independent practice which, in Canada, involves a certification exam administered by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. This qualitative study explored the experience of residents in their examination year, including residents impacted by pandemic-related examination postponment, to understand how these experiences may impact residents' well-being.

METHODS

Qualitative description methodology was used for this study. Participants were residents and physicians in independent practice from McMaster University and the University of Toronto. In depth, semi-structured, one-on-one interviews were conducted by one of the investigators. Each was transcribed, reviewed, and coded by two members of the investigating team.

RESULTS

Five themes were identified. Examinations were perceived to be a significant stressor, and the extent of preparation involved was viewed as a threat to one's physical and mental well-being. Participants identified a culture of fear surrounding the exam, as well as a perception that exam preparation requires significant sacrifice which can exacerbate the impacts of the exam year. Personal and professional supports were identified as important protective factors.

CONCLUSION

This study has identified unique challenges in the examination year, and its impact on the well-being of residents immediately before they enter independent practice. Residents also experienced significant learning and a sense of accomplishment through their preparation for the examination. The COVID-19 pandemic had a unique impact on one cohort of residents. This should prompt medical education institutions to examine the support provided to residents, the culture surrounding certification examinations, and mitigation strategies for future examination disruptions.

Academic Burnout of Polish Students: A Latent Profile Analysis

According to Maslach and Leiter, burnout syndrome consists of three elements: exhaustion, cynicism, and a sense of ineffectiveness experienced by individuals in the work environment. However, burnout does not only apply to professional activity but can also be experienced by students pursuing higher education. This is important because the consequences of student burnout can be related to students' mental and physical health. Until recently, the dominant diagnostic trend in the studies of burnout syndrome was based on a variable-focused approach. This approach focuses primarily on identifying subgroups in the population and presents different configurations of the various dimensions of burnout. However, there is emerging research using a person-centered approach and including the analysis of latent profiles to study professional and student burnout. This approach allows us to isolate subgroups of individuals in the study sample who have a similar burnout pattern. It focuses on the differences between individuals, which helps us to look at the phenomenon of professional burnout from a different perspective and shows the individuality of its experience. Our research aimed at identifying latent profiles, was conducted on a sample of 1519 Polish students, and partly confirms reports from other countries. We identified four profiles: low burnout, moderate below-average burnout, moderate above-average burnout, and very high burnout groups.

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

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

The art of seeing: The impact of a visual arts course on medical student wellbeing

PURPOSE

Medical student burnout is becoming increasingly common. The Art of Seeing is a visual arts elective at one US medical school. The purpose of this study was to determine the effect of this course on attributes that are foundational to wellbeing: mindfulness, self-awareness, and stress.

METHODS

A total of 40 students participated in this study from 2019 through 2021. Fifteen students participated in the pre-pandemic, in-person course, and 25 students participated in the post-pandemic, virtual course. Pre and post-tests included open-ended responses to works of art, which were coded for themes, and standardized scales: mindful attention awareness scale (MAAS), situational self-awareness scale (SSAS), and perceived stress questionnaire (PSQ).

RESULTS

The students had statistically significant improvements on the MAAS (p < .01), the SSAS (p < .01), and the PSQ (p = 0.046). Improvements in the MAAS and the SSAS did not depend on class format. Students also demonstrated increased focus on the present moment, emotional awareness, and creative expression in the post test free responses.

CONCLUSIONS

This course significantly improved mindfulness, self-awareness, and stress levels in medical students, and can be used to help enhance wellbeing and mitigate burnout in this population, both in-person and virtually.

Burnout symptoms and workplace satisfaction among veterinary emergency care providers

OBJECTIVES

To measure symptoms of burnout among veterinary emergency care providers (VECPs), determine how burnout symptoms among VECPs compare to human emergency care providers, and identify what demographic and workplace variables are associated with these symptoms.

DESIGN

Cross-sectional study using an online survey and convenience sampling.

SUBJECTS

A total of 1204 VECPs including mostly veterinarians and technicians.

INTERVENTIONS

An online questionnaire using the Maslach Burnout Inventory and Areas of Worklife Survey was distributed between May and July 2018 via an email list and social media. VECPs working less than part-time (<20 h/week) and incomplete survey responses were excluded.

MEASUREMENTS AND MAIN RESULTS

VECPs had higher total emotional exhaustion and depersonalization scores and lower total personal accomplishment scores compared to emergency department human healthcare professionals (P < 0.001). Subsets of VECPs with the highest burnout symptom scores included females, residents, those working in private or corporate referral hospitals, and those with off-shift duties. Workplace variables positively associated with burnout symptom scores among these groups typically included perceptions of an unmanageable workload, lack of control over work, little reward (recognition) for work, or an unfair allocation of resources at work. Conversely, VECPs working >20 years and those married or with children at home had lower burnout symptom scores. Workplace variables negatively associated with burnout symptom scores among respondents included perceptions of having a manageable workload, control over work, reward for work, or a fair allocation of resources at work. Multivariable analysis revealed that the variable most positively associated with emotional exhaustion and depersonalization was workload, whereas reward was most positively associated with personal accomplishment (P < 0.001).

CONCLUSIONS

Burnout symptom scores are higher among VECPs compared to human emergency department teams. Targeting workplace variables such as workload and reward is warranted in future studies to determine strategies for reducing burnout among VECPs.

Digital Training Resources in the Dutch Surgical Residency Curricula and the Perspectives of Residents: A Thematic Analysis of Resident Interviews

BACKGROUND

Digital training resources show great promise in augmenting traditional surgical education - especially in times of social distancing and limited surgical caseload. Embedding digital resources in surgical curricula is however not current, nor common practice in Dutch hospitals. While the digital world has become part of a resident's everyday life, surprisingly little is known about surgical residents' experiences and expectations towards use of digital resources for their own surgical education. This study aims to identify digital resources currently used in Dutch surgical curricula and to describe surgical residents' perspectives towards digital education.

METHODS

A series of semi-structured interviews with Dutch surgical residents were conducted until data sufficiency occurred. The interviews consisted of two parts: 1) current surgical training and implemented digital resources, and 2) future surgical training and the role of digital resources therein. All interviews were digitally recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Sixteen surgical residents were interviewed - two out of each of the eight educational regions for surgery in the Netherlands. Five digital resource categories were identified and four general educational themes (requirements, advantages, disadvantages, and general education themes), overarching 13 sub-themes. In general, residents were enthusiastic with regard to using digital resources, especially when the perceived advantages supported their autonomy.

CONCLUSIONS

Dutch surgical residents indicate that digital resources may support their educational experiences, but state that ideally they must be combined with much appreciated on-the-job training, and be offered to them tailored to their individual needs. No resources are considered to be a "magic bullet" in itself. The specific needs of residents and educators need to be addressed clearly in order to successfully adopt and implement digital resources on a larger scale.

Burnout, wellbeing and how they relate: A qualitative study in general practice trainees

PURPOSE

Although research has explored burnout risk factors among medical trainees, there has been little exploration of the personal experiences and perceptions of this phenomenon. Similarly, there has been little theoretical consideration of trainee wellbeing and how this relates to burnout. Our study aimed to conceptualise both constructs.

METHOD

We situated this study within a post-positivist epistemology using grounded theory to guide the research process. Participants were recruited from one Australian General Practice training organisation. Fourteen trainees completed interviews, while a further five focus groups explored the views of 33 supervisors, educators and training coordinators. Data collection and analysis occurred concurrently, drawing upon constant comparison and triangulation. Template analysis, using an iterative process of coding, was employed to generate conceptual models of the phenomena of interest.

RESULTS

Participants described burnout as an insidious syndrome lying on a spectrum, with descriptions coalescing under seven themes: altered emotion, compromised performance, disengagement, dissatisfaction, exhaustion, overexertion and feeling overwhelmed. Wellbeing was perceived to comprise personal and professional domains that interacted and were fuelled by an underlying 'reservoir'. Both constructs were linked by the degree of a trainee's value fulfilment, with burnout occurring when a trainee's wellbeing reservoir was depleted.

CONCLUSIONS

Participants in this study characterised burnout and wellbeing as multifaceted, connected constructs. Given the complexity of these constructs, preventive interventions should target both person and workplace-focused factors, with value fulfilment proposed as the basic change mechanism. A novel model that synthesises and advances previous research is offered based on these findings.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Burnout among Residents: Prevalence and Predictors of Depersonalization, Emotional Exhaustion and Professional Unfulfillment among Resident Doctors in Canada

BACKGROUND

Burnout in the medical profession has garnered a lot of attention over recent years. It has been reported across all specialties and all stages of medical education; however, resident doctors in particular are at risk for burnout throughout their years of training. This study was aimed at evaluating the prevalence and correlates of burnout among resident doctors in Alberta.

METHODS

Through a descriptive cross-sectional study design, a self-administered questionnaire was used to gather data from resident doctors at two medical schools in Alberta, Canada. The Maslach Burnout Inventory was used as the assessment tool. Chi-squared and multivariate binary logistic regression analyses were used.

RESULTS

Overall burnout prevalence among residents was 58.2%, and for professional fulfilment index, it was 56.7% for work exhaustion and interpersonal disengagement and 83.5% for lack of professional fulfillment. Working more than 80 h/week (OR = 16.437; 95% CI: 2.059-131.225), being dissatisfied (OR = 22.28; 95% CI: 1.75-283.278) or being neither satisfied nor dissatisfied with a career in medicine (OR = 23.81; 95% CI: 4.89-115.86) were significantly associated with high depersonalization. Dissatisfaction with efficiency and resources (OR = 10.83; CI: 1.66-70.32) or being neither satisfied nor dissatisfied with a career in medicine (OR = 5.14; CI: 1.33-19.94) were significantly associated with high emotional exhaustion. Working more than 80 h/week (OR = 5.36; CI: 1.08-26.42) and somewhat agreeing that the residency program has enough strategies aimed at resident well-being in place (OR = 3.70; CI: 1.10-12.46) were significantly associated factors with high work exhaustion and interpersonal disengagement. A young age of residents (≤30 years) (OR = 0.044; CI: 0.004-0.445) was significantly associated with low professional fulfillment.

CONCLUSION

Burnout is a serious occupational phenomenon that can degenerate into other conditions or disrupt one's professional performance. Significant correlates were associated with high rates of burnout. Leaders of medical schools and policymakers need to acknowledge, design, and implement various strategies capable of providing continuous effective mental health support to improve the psychological health of medical residents across Canada.

Evaluation of an App-Delivered Psychological Flexibility Skill Training Intervention for Medical Student Burnout and Well-being: Randomized Controlled Trial

BACKGROUND

Physician burnout is a common problem, with onset frequently occurring during undergraduate education. Early intervention strategies that train medical students in psychological flexibility skills could support well-being and mitigate burnout risks associated with unmodifiable career stressors. There is a need for randomized controlled trials to assess effectiveness. As psychological flexibility varies contextually and among individuals, tailoring interventions may improve outcomes. Smartphone apps can facilitate individualization and accessibility, and the evaluation of this approach is an identified research priority.

OBJECTIVE

This study aimed to evaluate the effectiveness of a stand-alone app-delivered Acceptance and Commitment Training intervention for improving medical students' self-reported burnout, well-being, psychological flexibility, and psychological distress outcomes. We aimed to explore whether an individualized app would demonstrate benefits over a nonindividualized version.

METHODS

This parallel randomized controlled trial was conducted with a sample of medical students from 2 Australian universities (N=143). Participants were randomly allocated to 1 of 3 intervention arms (individualized, nonindividualized, and waitlist) using a 1:1:1 allocation ratio. Individualized and nonindividualized participants were blinded to group allocation. The 5-week intervention included an introductory module (stage 1) and on-demand access to short skill training activities (stage 2), which students accessed at their own pace. Stage 2 was either nonindividualized or individualized to meet students' identified psychological flexibility training needs.

RESULTS

The mean differences in change from baseline between the intervention groups and the waitlist group were not statistically significant for burnout outcomes: exhaustion (primary; individualized: -0.52, 95% CI -3.70 to 2.65, P=.75; nonindividualized: 1.60, 95% CI -1.84 to 5.03, P=.37), cynicism (individualized: -1.26, 95% CI -4.46 to 1.94, P=.44; nonindividualized: 1.00, 95% CI -2.45 to 4.46, P=.57), and academic efficacy (individualized: 0.94, 95% CI -0.90 to 2.79, P=.32; nonindividualized: 2.02, 95% CI 0.02-4.03, P=.05). Following the intervention, the individualized group demonstrated improved psychological flexibility (0.50, 95% CI 0.12-0.89; P=.01), reduced inflexibility (0.48, 95% CI -0.92 to -0.04; P=.04), and reduced stress (-6.89, 95% CI -12.01 to 5.99; P=.01), and the nonindividualized group demonstrated improved well-being (6.46, 95% CI 0.49-12.42; P=.04) and stress (-6.36, 95% CI -11.90 to -0.83; P=.03) compared with waitlist participants. Between-group differences for the individualized and nonindividualized arms were not statistically significant. High attrition (75/143, 52.4%) was observed.

CONCLUSIONS

This trial provides early support for the potential benefits of Acceptance and Commitment Training for medical student well-being and psychological outcomes and demonstrates that psychological flexibility and inflexibility can be trained using a smartphone app. Although postintervention burnout outcomes were not statistically significant, improvements in secondary outcomes could indicate early risk mitigation. Replication studies with larger samples and longer-term follow-up are required, and future research should focus on improving implementation frameworks to increase engagement and optimize individualization methods.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry 12621000911897; https://tinyurl.com/2p92cwrw.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/32992.

One test to rule them all: A qualitative study of formal, informal, and hidden curricula as drivers of USMLE "exam mania"

High-stakes examinations are an integral part of medical education. To practice in the United States (U.S.), students must pass the U.S. Medical Licensing Examinations (USMLE). With the transition of USMLE Step 1 to pass/fail scoring on January 26, 2022, a worldwide debate regarding how residency program directors will view the Step 2 Clinical Knowledge (CK) exam emerged. Here, the authors explore the role of formal, informal, and hidden curricula related to USMLE, with broader implications for high-stakes examinations. Six focus groups of fourth-year students who recently took Step 2 CK and a supplemental curricular content analysis were conducted to explore students' decision-making and emotions regarding the exam, including how the formal, informal, and hidden curricula influence their perspectives. Participants highlighted how informal and hidden curricula drive the belief that high-stakes examinations are the single most important factor in medical school. Prior experience with Step 1 drives behaviors and attitudes when preparing for Step 2 CK. Pressures from these examinations have unintended consequences on burnout, professional identity, specialty choice, and interpersonal interactions. Both interpersonal interactions within medical education as well as subconscious, unintended messaging can influence medical student approaches to and perspectives about high-stakes examinations. Within the context of U.S. medical training, with the transition to a new era of a pass/fail Step 1 examination, careful consideration to prevent shifting the current "Step 1 mania" to a "Step 2 CK mania" is warranted. More broadly, medical educators must examine the unintended yet potentially damaging pressures institutions generate in their medical trainees in relation to high-stakes examinations.

Blue Skies With Clouds: Envisioning the Future Ideal State and Identifying Ongoing Tensions in the UME-GME Transition

The transition from medical school to residency in the United States consumes large amounts of time for students and educators in undergraduate and graduate medical education (UME, GME), and it is costly for both students and institutions. Attempts to improve the residency application and Match processes have been insufficient to counteract the very large number of applications to programs. To address these challenges, the Coalition for Physician Accountability charged the Undergraduate Medical Education to Graduate Medical Education Review Committee (UGRC) with crafting recommendations to improve the system for the UME-GME transition. To guide this work, the UGRC defined and sought stakeholder input on a "blue-skies" ideal state of this transition. The ideal state views the transition as a system to support a continuum of professional development and learning, thus serving learners, educators, and the public, and engendering trust among them. It also supports the well-being of learners and educators, promotes diversity, and minimizes bias. This manuscript uses polarity thinking to analyze 3 persistent key tensions in the system that require ongoing management. First, the formative purpose of assessment for learning and growth is at odds with the use of assessment data for ranking and sorting candidates. Second, the function of residents as learners can conflict with their role as workers contributing service to health care systems. Third, the current residency Match process can position the desire for individual choice-among students and their programs-against the workforce needs of the profession and the public. This Scholarly Perspective presents strategies to balance the upsides and downsides inherent to these tensions. By articulating the ideal state of the UME-GME transition and anticipating tensions, educators and educational organizations can be better positioned to implement UGRC recommendations to improve the transition system.