A systematic review of physician leadership and emotional intelligence

Effective physician leaders: an appreciative inquiry into their qualities, capabilities and learning approaches

Purpose

The aim of this study was to explore the qualities and capabilities effective physician leaders attribute to their success in leading change and how they developed these.

Method

The authors interviewed 20 emerging and senior leaders using a semistructured interview guide informed by appreciative inquiry. Data were subjected to an inductive qualitative content analysis to identify themes related to qualities, capabilities and learning approaches.

Results

The qualities identified were clarity of purpose to improve care, endurance, a positive outlook and authenticity. They were considered innate or developed during participants’ upbringing. Capabilities were to ground management in medicine, engage others, catalyse systems by acting on interdependencies and employ a scientific approach to understand problems and measure progress. Capabilities were developed through cross-pollination from a diversity of work experiences, reflection, when education was integrated with practice and when their organisational environment nurtured ambition and learning.

Conclusions

This study reframes current leadership thinking by empirically identifying qualities, capabilities, and learning approaches that can contribute to effective physician leadership. Instead of merely adapting leadership development programmes from other domains, this study suggests there are capabilities unique to effective physician leadership: ground management in medicine and employ a scientific approach to problem identification and solution development. The authors outline practical implications for individuals and organisations to support leader development as a cohesive organisational strategy for learning and change.

Emotional intelligence and leadership traits among family physicians

OBJECTIVES

High emotional intelligence and leadership traits are essential for physicians in managing their responsibilities and thus building successful interactions with patients. This study explored the relationship between emotional intelligence and leadership traits among family physicians.

METHODS

Participants (2975 men, 972 women, mean = 42.0 ages, SD = 7.47) were family physicians working at family health-care centers across the seven geographical regions of Turkey who were contacted by e-mail. The Trait Emotional Intelligence Questionnaire (TEIQue) and Leadership Traits Tool were used to collect data. Data were analyzed concerning physicians' sex, age, health-care experience, and geographical region. The correlation between Trait Emotional Intelligence (TEI) and leadership was also being examined.

RESULTS

Our findings suggest that family physicians' TEI differs based on sex, age, health-care experience, and the geographical region where they work. Women had higher mean values than did men for well-being, emotionality, and global TEI. Physicians aged younger than 29 years had the lowest mean values for emotional intelligence. As physicians' health-care experience increased, they received higher scores for emotional intelligence. Physicians working in the Mediterranean had the highest mean TEI scores. There was a positive correlation between family physicians' emotional intelligence and leadership traits. Higher emotional intelligence was correlated with increased leadership traits.

CONCLUSION

Emotional intelligence and leadership traits play crucial roles in increasing physicians' personal and professional development. This may also increase physicians' caregiving competencies and thus the quality of health services, as well as potentially decreasing physicians' burnout and health-related costs.

Critical Role of the Surgeon–Anesthesiologist Relationship for Patient Safety

Teamwork is now recognized as important for safe, high-quality perioperative care. The relationship in each surgeon–anesthesiologist dyad is perhaps the most critical element of overall team performance. A well-functioning relationship is conducive to safe, effective care. A dysfunctional relationship can promote unsafe conditions and contribute to an adverse outcome. Yet, there is little research about this relationship, about what works well or not well, what can be done to optimize it. This article explores functional and dysfunctional aspects of the relationship, identifies some negative stereotypes each profession has of the other and calls for research to better characterize and understand how to improve working relationships. Suggestions are given for what an ideal relationship might be and actions that surgeons and anesthesiologists can take to improve how they work together. The goal is safer care for patients, and more joy and meaning in work for surgeons and anesthesiologists.

Critical Role of the Surgeon-Anesthesiologist Relationship for Patient Safety

Teamwork is now recognized as important for safe, high-quality perioperative care. The relationship in each surgeon-anesthesiologist dyad is perhaps the most critical element of overall team performance. A well-functioning relationship is conducive to safe, effective care. A dysfunctional relationship can promote unsafe conditions and contribute to an adverse outcome. Yet, there is little research about this relationship, about what works well or not well, what can be done to optimize it. This article explores functional and dysfunctional aspects of the relationship, identifies some negative stereotypes each profession has of the other and calls for research to better characterize and understand how to improve working relationships. Suggestions are given for what an ideal relationship might be and actions that surgeons and anesthesiologists can take to improve how they work together. The goal is safer care for patients, and more joy and meaning in work for surgeons and anesthesiologists.

Discipline-specific competency-based curricula for leadership learning in medical specialty training

Purpose Doctors play a central role in leading improvements to healthcare systems. Leadership knowledge and skills are not inherent, however, and need to be learned. General frameworks for medical leadership guide curriculum development in this area. Explicit discipline-linked competency sets and programmes provide context for learning and likely enhance specialty trainees' capability for leadership at all levels. The aim of this review was to summarise the scholarly literature available around medical specialty-specific competency-based curricula for leadership in the post-graduate training space. Design/methodology/approach A systematic literature search method was applied using the Medline, EMBASE and ERIC (education) online databases. Documents were reviewed for a complete match to the research question. Partial matches to the study topic were noted for comparison. Findings In this study, 39 articles were retrieved in full text for detailed examination, of which 32 did not comply with the full inclusion criteria. Seven articles defining discipline-linked competencies/curricula specific to medical leadership training were identified. These related to the areas of emergency medicine, general practice, maternal and child health, obstetrics and gynaecology, pathology, radiology and radiation oncology. Leadership interventions were critiqued in relation to key features of their design, development and content, with reference to modern leadership concepts. Practical implications There is limited discipline-specific guidance for the learning and teaching of leadership within medical specialty training programmes. The competency sets identified through this review may aid the development of learning interventions and tools for other medical disciplines. Originality/value The findings of this study provide a baseline for the further development, implementation and evaluation work required to embed leadership learning across all medical specialty training programmes.

How to improve healthcare? Identify, nurture and embed individuals and teams with "deep smarts"

Purpose Unlocking and transferring skills and capabilities in individuals to the teams they work within, and across, is the key to positive organisational development and improved patient care. Using the "deep smarts" model, the purpose of this paper is to examine these issues. Design/methodology/approach The "deep smarts" model is described, reviewed and proposed as a way of transferring knowledge and capabilities within healthcare organisations. Findings Effective healthcare delivery is achieved through, and continues to require, integrative care involving numerous, dispersed service providers. In the space of overlapping organisational boundaries, there is a need for "deep smarts" people who act as "boundary spanners". These are critical integrative, networking roles employing clinical, organisational and people skills across multiple settings. Research limitations/implications Studies evaluating the barriers and enablers to the application of the deep smarts model and 13 knowledge development strategies proposed are required. Such future research will empirically and contemporary ground our understanding of organisational development in modern complex healthcare settings. Practical implications An organisation with "deep smarts" people - in managerial, auxiliary and clinical positions - has a greater capacity for integration and achieving improved patient-centred care. Originality/value In total, 13 developmental strategies, to transfer individual capabilities into organisational capability, are proposed. These strategies are applicable to different contexts and challenges faced by individuals and teams in complex healthcare organisations.

Grace Under Pressure: Leadership in Emergency Medicine

Physicians in general, including emergency physicians (EPs), are trained in the diagnostic, therapeutic, and administrative aspects of patient care but not so much in the theoretical and practical aspects of assuming and delivery of leadership. EPs are always taught to focus on their performance, to excel and achieve, to be accountable for their own clinical decisions, and to appreciate feedback and peer-to-peer review. Currently, if there are some semblances of formal or semi-formal leadership instruction, the organized theoretical curriculum often does not formally include very structured and planned departmental leadership and management elements. Leadership is a process for a person (“the leader”) to lead, influence, and engage a group or organization to accomplish their objectives and mission. To do this, the leader must understand a variety of issues of working, interacting, and integrating with people, the environment and both, the intrinsic and extrinsic factors, and elements that have an impact on the industry or area he/she is leading in. Leadership in emergency medicine (EM) is even more challenging, with its unique focus, issues, and trajectory, moving into the new century, with new considerations. No single strategy is sufficient to ace EM leadership and no single specific leadership model is complete. This paper shares some current views on medical/EM leadership. The author shares her views and some suggested proposals for more formal and structured leadership, implementation, and succession to help nurture and groom Eps who will become leaders in EM in the near future.

Predictors and correlations of emotional intelligence among medical students at King Abdulaziz University, Jeddah

Objectives:

To determine the predictors of Emotional Intelligence (EI), and its relationship with academic performance, leadership capacity, self-efficacy and the perceived stress between medical students at King Abdulaziz University, Jeddah, Saudi Arabia.

Methods:

A cross-sectional study was done among 540 students selected through a multi-stage stratified random sampling method during 2015/2016. A standardized, confidential data collection sheet was used. It included Schutte Self-Report Emotional Intelligence (SSREI) scale, Authentic Leadership questionnaire, General Self-Efficacy Scale and the short version of Perceived Stress Scale (PSS-4). Both descriptive and inferential statistics were done, and a multiple linear regression model was constructed.

Results:

The predictors of high EI were gender (female), increasing age, and being non-smoker. EI was positively associated with better academic performance, leadership capacity and self-efficacy. It was negatively correlated to perceived-stress.

Conclusion:

Female gender, age, non-smoking were the predictors of high EI. Conduction of holistic training programs on EI, leadership and self-efficacy are recommended. More smoking control programs and stress management courses are required.

Goleman's Leadership styles at different hierarchical levels in medical education

BACKGROUND

With current emphasis on leadership in medicine, this study explores Goleman's leadership styles of medical education leaders at different hierarchical levels and gain insight into factors that contribute to the appropriateness of practices.

METHODS

Forty two leaders (28 first-level with limited formal authority, eight middle-level with wider program responsibility and six senior- level with higher organizational authority) rank ordered their preferred Goleman's styles and provided comments. Eight additional senior leaders were interviewed in-depth. Differences in ranked styles within groups were determined by Friedman tests and Wilcoxon tests. Based upon style descriptions, confirmatory template analysis was used to identify Goleman's styles for each interviewed participant. Content analysis was used to identify themes that affected leadership styles.

RESULTS

There were differences in the repertoire and preferred styles at different leadership levels. As a group, first-level leaders preferred democratic, middle-level used coaching while the senior leaders did not have one preferred style and used multiple styles. Women and men preferred democratic and coaching styles respectively. The varied use of styles reflected leadership conceptualizations, leader accountabilities, contextual adaptations, the situation and its evolution, leaders' awareness of how they themselves were situated, and personal preferences and discomfort with styles. The not uncommon use of pace-setting and commanding styles by senior leaders, who were interviewed, was linked to working with physicians and delivering quickly on outcomes.

CONCLUSIONS

Leaders at different levels in medical education draw from a repertoire of styles. Leadership development should incorporate learning of different leadership styles, especially at first- and mid-level positions.

Developing a model for effective leadership in healthcare: a concept mapping approach

Purpose

Despite increasing awareness of the importance of leadership in healthcare, our understanding of the competencies of effective leadership remains limited. We used a concept mapping approach (a blend of qualitative and quantitative analysis of group processes to produce a visual composite of the group’s ideas) to identify stakeholders’ mental model of effective healthcare leadership, clarifying the underlying structure and importance of leadership competencies.

Methods

Literature review, focus groups, and consensus meetings were used to derive a representative set of healthcare leadership competency statements. Study participants subsequently sorted and rank-ordered these statements based on their perceived importance in contributing to effective healthcare leadership in real-world settings. Hierarchical cluster analysis of individual sortings was used to develop a coherent model of effective leadership in healthcare.

Results

A diverse group of 92 faculty and trainees individually rank-sorted 33 leadership competency statements. The highest rated statements were “Acting with Personal Integrity”, “Communicating Effectively”, “Acting with Professional Ethical Values”, “Pursuing Excellence”, “Building and Maintaining Relationships”, and “Thinking Critically”. Combining the results from hierarchical cluster analysis with our qualitative data led to a healthcare leadership model based on the core principle of Patient Centeredness and the core competencies of Integrity, Teamwork, Critical Thinking, Emotional Intelligence, and Selfless Service.

Conclusion

Using a mixed qualitative-quantitative approach, we developed a graphical representation of a shared leadership model derived in the healthcare setting. This model may enhance learning, teaching, and patient care in this important area, as well as guide future research.

Resident Physicians Improve Nontechnical Skills When on Operating Room Management and Leadership Rotation

BACKGROUND

Anesthesiology residency primarily emphasizes the development of medical knowledge and technical skills. Yet, nontechnical skills (NTS) are also vital to successful clinical practice. Elements of NTS are communication, teamwork, situational awareness, and decision making.

METHODS

The first 10 consecutive senior residents who chose to participate in this 2-week elective rotation of operating room (OR) management and leadership training were enrolled in this study, which spanned from March 2013 to March 2015. Each resident served as the anesthesiology officer of the day (AOD) and was tasked with coordinating OR assignments, managing care for 2 to 4 ORs, and being on call for the trauma OR; all residents were supervised by an attending AOD. Leadership and NTS techniques were taught via a standardized curriculum consisting of leadership and team training articles, crisis management text, and daily debriefings. Resident self-ratings and attending AOD and charge nurse raters used the Anaesthetists' Non-Technical Skills (ANTS) scoring system, which involved task management, situational awareness, teamwork, and decision making. For each of the 10 residents in their third year of clinical anesthesiology training (CA-3) who participated in this elective rotation, there were 14 items that required feedback from resident self-assessment and OR raters, including the daily attending AOD and charge nurse. Results for each of the items on the questionnaire were compared between the beginning and the end of the rotation with the Wilcoxon signed-rank test for matched samples. Comparisons were run separately for attending AOD and charge nurse assessments and resident self-assessments. Scaled rankings were analyzed for the Kendall coefficient of concordance (ω) for rater agreement with associated χ and P value.

RESULTS

Common themes identified by the residents during debriefings were recurrence of challenging situations and the skills residents needed to instruct and manage clinical teams. For attending AOD and charge nurse assessments, resident performance of NTS improved from the beginning to the end of the rotation on 12 of the 14 NTS items (P < .05), whereas resident self-assessment improved on 3 NTS items (P < .05). Interrater reliability (across the charge nurse, resident, and AOD raters) ranged from ω = .36 to .61 at the beginning of the rotation and ω = .27 to .70 at the end of the rotation.

CONCLUSIONS

This rotation allowed for teaching and resident assessment to occur in a way that facilitated resident education in several of the skills required to meet specific milestones. Resident physicians are able to foster NTS and build a framework for clinical leadership when completing a 2-week senior elective as an OR manager.

Nursing and pharmacy students' use of emotionally intelligent behaviours to manage challenging interpersonal situations with staff during clinical placement: A qualitative study

AIMS AND OBJECTIVES

To identify challenging interpersonal interactions experienced by nursing and pharmacy students during clinical placement, and strategies used to manage those situations.

BACKGROUND

Healthcare students and staff experience elevated stress when exposed to dynamic clinical environments, complex care and challenging professional relationships. Emotionally intelligent behaviours are associated with appropriate recognition and management of emotions evoked by stressful experiences and development of effective relationships. Nursing and pharmacy students' use of emotionally intelligent behaviours to manage challenging interpersonal situations is not well known.

DESIGN

A qualitative design, using semi-structured interviews to explore experiences of challenging interpersonal situations during clinical placement (Phase two of a larger mixed-methods study). Final-year Australian university nursing and pharmacy students (n = 20) were purposefully recruited using a range of Emotional Intelligence scores (derived in Phase one), measured using the GENOS Emotional intelligence Inventory (concise version).

RESULTS

Challenging interpersonal situations involving student-staff and intrastaff conflict, discourteous behaviour and criticism occurred during clinical placement. Students used personal and relational strategies, incorporating emotionally intelligent behaviours, to manage these encounters. Strategies included reflecting and reframing, being calm, controlling discomfort and expressing emotions appropriately.

CONCLUSIONS

Emotionally intelligent behaviours are effective to manage stressful interpersonal interactions. Methods for strengthening these behaviours should be integrated into education of nursing and pharmacy students and qualified professionals. Education within the clinical/workplace environment can incorporate key interpersonal skills of collaboration, social interaction and reflection, while also attending to sociocultural contexts of the healthcare setting.

RELEVANCE TO CLINICAL PRACTICE

Students and staff are frequently exposed to stressful clinical environments and challenging interpersonal encounters within healthcare settings. Use of emotionally intelligent behaviours to recognise and effectively manage these encounters may contribute to greater stress tolerance and enhanced professional relationships. Nursing and pharmacy students, and their qualified counterparts, need to be educated to strengthen their emotional intelligence skills.

Clinical audits to improve critical care: Part 1 Prepare and collect data

Clinical audits are used to examine current practice, compare this with established best practice and implementing change, to ensure patients receive the most effective treatment. They are successful in improving the quality and safety of care provided, and thereby clinical outcomes. Clinical audits are ubiquitous throughout critical care practice, but without the necessary focus, engagement, preparation, method, evaluation and communication, they may be a waste of resources. This article is the first of a two-paper series regarding audits in critical care. The article provides an overview of the structures and processes needed to prepare and collect data for clinical audits, to make them as effective as possible to improve patient outcomes. This is accomplished through a practical step-by-step guide, including links to valuable resources, which are relevant to all critical care clinicians planning on undertaking clinical audits.

Defining a Leader Role curriculum for radiation oncology: A global Delphi consensus study

BACKGROUND AND PURPOSE

The need for radiation oncologists and other radiation oncology (RO) professionals to lead quality improvement activities and contribute to shaping the future of our specialty is self-evident. Leadership knowledge, skills and behaviours, like other competencies, can be learned (Blumenthal et al., 2012). The objective of this study was to define a globally applicable competency set specific to radiation oncology for the CanMEDS Leader Role (Frank et al., 2015).

METHODS

A modified Delphi consensus process delivering two rounds of on-line surveys was used. Participants included trainees, radiation/clinical oncologists and other RO team members (radiation therapists, physicists, and nurses), professional educators and patients.

RESULTS

72 of 95 (76%) invitees from nine countries completed the Round 1 (R1) survey. Of the 72 respondents to RI, 70 completed Round 2 (R2) (97%). In R1, 35 items were deemed for 'inclusion' and 21 for 'exclusion', leaving 41 'undetermined'. After review of items, informed by participant comments, 14 competencies from the 'inclusion' group went into the final curriculum; 12 from the 'undetermined' group went to R2. In R2, 6 items reached consensus for inclusion.

CONCLUSION

This process resulted in 20 RO Leader Role competencies with apparent global applicability. This is the first step towards developing learning, teaching and assessment tools for this important area of training.

Intentional partnering: a grounded theory study on developing effective partnerships among nurse and physician managers as they co-lead in an evolving healthcare system

AIM

The aim of this study was to describe the process of how nurse and physician managers in formalized dyads work together to address clinical management issues in the surgical division of one hospital setting.

BACKGROUND

Nurse and physician managers are uniquely positioned to co-lead and transform healthcare delivery. However, little is known about how this management dyad functions in the healthcare setting.

DESIGN

A constructivist grounded theory approach was used to investigate the process of how nurse and physician managers work together in formalized dyads in an urban Canadian university affiliated teaching hospital.

METHODS

Data collection occurred from September 2013-August 2014. Data included participant observation (n = 142 hours) and intensive interviews (n = 36) with nurse-physician manager dyads (12 nurses, 9 physicians) collected in a surgical department. Theoretical sampling was used to elaborate on properties of emerging concepts and categories.

RESULTS/FINDINGS

A substantive theory on 'intentional partnering' was generated. Nurses' and physicians' professional agendas, which included their interests and purposes for working with each other served as the starting point of 'intentional partnering'. The theory explains how nurse and physician managers align their professional agendas through the processes of 'accepting mutual necessity', 'daring to risk (together)' and 'constructing a shared responsibility'. Being credible, earning trust and safeguarding respect were fundamental to communicating effectively.

CONCLUSION

Intentional partnering elucidates the relational components of working together and the strategizing that occurs as each partner deliberates on what he or she is willing to accept, risk and put into place to reap the benefits of collaborating.

The emotional intelligence of pediatric residents - a descriptive cross-sectional study

BACKGROUND

Emotional Intelligence (EI) is a type of social intelligence. Excellent scores are achieved by displaying high levels of empathy in interpersonal relationships, strong skills in managing stressful situations as well as other personal competencies. Many of the social competencies that EI describes may have a direct impact on patient care. The objective of this study was to describe EI of pediatric residents and to identify if there are EI skills that should be selected for targeted intervention.

METHODS

This was a cross-sectional study administering the EQ-i 2.0© psychometric instrument to pediatric residents at the University of Alberta.

RESULTS

Thirty-five residents completed the EQ-i 2.0© (100% response rate). Their overall EI score was not significantly different than a normative group of college-educated professionals. Residents had relative strengths in the subcategories of Emotional expression, Interpersonal Relationships, Empathy, and Impulse Control (all p<0.05). Areas of relative weakness were in the subcategories of Stress Tolerance, Assertiveness, Independence, and Problem Solving (all p<0.05).

CONCLUSION

The EI of pediatric residents is consistent with that of other professionals. Educational interventions may be useful in the areas of weakness to enhance the physician-patient relationship.

Using Objective Structured Teaching Encounters (OSTEs) to prepare chief residents to be emotionally intelligent leaders

BACKGROUND

Chief Residents must lead, manage and mentor a diverse and often large group of residents, however there is a lack of formal leadership training throughout graduate medical education.

OBJECTIVE

Development of a 3-part Chief Resident (CR) Program focused on leading, managing and mentoring.

DESIGN

Each participant completes an Emotional Intelligence (EI) Inventory prior to the day-long event. Participants receive their EI scores at the beginning of the program, which features interactive sessions on leadership, management, and feedback skills. The program then reinforces the application of their new knowledge about EI through a four station OSTE (Observed Structured Teaching Encounter). CRs practice feedback and coaching skills in a simulated environment where they need to provide the context of formative feedback to a standardized resident.

RESULTS

The aggregated mean pre-session EI score for all participants was 76.9 (an ideal score is >85). An independent-samples t-test compared the CRs' leadership and feedback performance on their first and second OSTE performance within a single afternoon session. There was a significant difference between the first OSTE performance (M = 47.92, SD = 7.8) and the second OSTE performance (M = 51.22, SD = 6.9); t (68) = 1.99, p = 0.006. These results suggest that participating in multiple OSTEs positively reinforces the core interpersonal and communication skills discussed in the didactic and practiced in the interactive portions of the program.

CONCLUSION

The low mean pre-session EI score achieved by our participants supports the idea that CRs enter their new roles with a level of EI that can be enhanced. CRs had an overall positive reaction to EI and its application to the core skills addressed in the program, highlighting the fact that similar programs could be used to train early career physicians to be more skilled and comfortable with leading, managing and mentoring.

ABBREVIATIONS

CR: Chief resident; EI: Emotional intelligence; GME: Graduate medical education; OSTE: Objective structured teaching encounter.

Leadership and the medical registrar: how can organisations support these unsung heroes?

Medical registrars have been described as the 'workhorses' of National Health Service hospitals, being at the interface of acute and chronic health services. They are expected to demonstrate effective leadership skills. There are concerns from the Royal College of Physicians that medical registrars are being overwhelmed and unsupported by organisations, and are struggling in their ability to provide safe, high-quality patient care. Junior colleagues are also being deterred by general medical specialties by the prospect of becoming the 'Med Reg'. There is a growing need to support medical registrars in several key aspects of training, not least medical leadership. Thus far, there has been a distinct disparity in the provision of medical leadership training for junior doctors in the UK that has adversely affected the standard of care given to patients. Recent landmark reviews and initiatives, principally the Medical Leadership Competency Framework, have raised awareness of leadership competencies for all doctors and the need for their incorporation into undergraduate and postgraduate curricula. It is hoped that interactive strategies to engage medical registrars in leadership training will lead to positive results including improvements in interdisciplinary communication, patient outcomes and fulfilment of curriculum competencies. Organisations have a duty to improve the quality of medical leadership training so that doctors feel equipped to influence change throughout their careers and be tomorrow's leaders. This review outlines the deficiencies in training, the importance of developing leadership skills in medical registrars and educational strategies that could be implemented by organisations in a cost-effective manner.

Improving vascular access outcomes: attributes of arteriovenous fistula cannulation success

BACKGROUND

Arteriovenous fistulas (AVFs) are the preferred access for hemodialysis (HD) yet they are underutilized. Cannulation of the fistula is a procedure requiring significant skill development and refinement and if not done well can have negative consequences for patients. The nurses' approach, attitude and skill with cannulation impacts greatly on the patient experience. Complications from miscannulation or an inability to needle fistulas can result in the increased use of central venous catheters. Some nurses remain in a state of a 'perpetual novice' resulting in a viscous cycle of negative patient consequences (bruising, pain), further influencing patients' decisions not to pursue a fistula or abandon cannulation.

METHOD

This qualitative study used organizational development theory (appreciative inquiry) and research method to determine what attributes/activities contribute to successful cannulation. This can be applied to interventions to promote change and skill development in staff members who have not advanced their proficiency. Eighteen HD nurses who self-identified with performing successful cannulation participated in audio-recorded interviews. The recordings were transcribed verbatim. The data were analyzed using content analysis.

RESULTS

Four common themes, including patient-centered care, teamwork, opportunity and skill and nurse self-awareness, represented successful fistula cannulation. Successful cannulation is more than a learned technique to correctly insert a needle, but rather represents contextual influences and interplay between the practice environment and personal attributes.

CONCLUSIONS

Practice changes based on these results may improve cannulation, decrease complications and result in better outcomes for patients. Efforts to nurture positive patient experiences around cannulation may influence patient decision-making regarding fistula use.

BETWEEN A ROCK AND A HARD PLACE: CAN PHYSICIANS PRESCRIBE OPIOIDS TO TREAT PAIN ADEQUATELY WHILE AVOIDING LEGAL SANCTION?

Prescription opioids are an important tool for physicians in treating pain but also carry significant risks of harm when prescribed inappropriately or misused by patients or others. Recent increases in opioid-related morbidity and mortality has reignited scrutiny of prescribing practices by law enforcement, regulatory agencies, and state medical boards. At the same time, the predominant 4D model of misprescribers is outdated and insufficient; it groups physician misprescribers as dated, duped, disabled, or dishonest. The weaknesses and inaccuracies of the 4D model are explored, along with the serious consequences of its application. This Article calls for development of an evidence base in this area and suggests an alternate model of misprescribers, the 3C model, which more accurately characterizes misprescribers as careless, corrupt, or compromised by impairment.

Leadership development programs for physicians: a systematic review

BACKGROUND

Physician leadership development programs typically aim to strengthen physicians' leadership competencies and improve organizational performance. We conducted a systematic review of medical literature on physician leadership development programs in order to characterize the setting, educational content, teaching methods, and learning outcomes achieved.

METHODS

Articles were identified through a search in Ovid MEDLINE from 1950 through November 2013. We included articles that described programs designed to expose physicians to leadership concepts, outlined teaching methods, and reported evaluation outcomes. A thematic analysis was conducted using a structured data entry form with categories for setting/target group, educational content, format, type of evaluation and outcomes.

RESULTS

We identified 45 studies that met eligibility criteria, of which 35 reported on programs exclusively targeting physicians. The majority of programs focused on skills training and technical and conceptual knowledge, while fewer programs focused on personal growth and awareness. Half of the studies used pre/post intervention designs, and four studies used a comparison group. Positive outcomes were reported in all studies, although the majority of studies relied on learner satisfaction scores and self-assessed knowledge or behavioral change. Only six studies documented favorable organizational outcomes, such as improvement in quality indicators for disease management. The leadership programs examined in these studies were characterized by the use of multiple learning methods, including lectures, seminars, group work, and action learning projects in multidisciplinary teams.

DISCUSSION

Physician leadership development programs are associated with increased self-assessed knowledge and expertise; however, few studies have examined outcomes at a system level. Our synthesis of the literature suggests important gaps, including a lack of programs that integrate non-physician and physician professionals, limited use of more interactive learning and feedback to develop greater self-awareness, and an overly narrow focus on individual-level rather than system-level outcomes.

Determinants of burnout among transplant surgeons: a national survey in the United States

Burnout is a response to chronic strain within the workplace characterized by feelings of inefficacy (reduced personal accomplishment), cynicism (depersonalization) and emotional exhaustion. The purpose of this study was to report prevalence and explore organizational and interpersonal contributors of burnout in transplant surgeons. We performed a national cross-sectional survey of 218 transplant surgeons on sociodemographics, professional characteristics, frequency of difficult patient interactions and comfort in dealing with difficult patient interactions, decisional authority, psychological job demands, supervisor and coworker support, with burnout as the outcome. 40.1% reported high levels of emotional exhaustion, 17.1% reported high levels of depersonalization and 46.5% reported low personal accomplishment. Greater emotional exhaustion was predicted by lower decisional authority, higher psychological work demands, and lower coworker support. Greater discomfort with difficult patient interactions and lower coworker support predicted depersonalization. Lastly, lower decisional authority, lower coworker support, less frequent difficult patient interactions but greater discomfort with difficult patient interactions predicted lower personal accomplishment. The findings of this study show that unsupportive environments with little decisional control and high work-related demands contribute to the development of burnout in transplant surgeons. Implications for interventions aimed at prevention of burnout in transplant surgeons are discussed.