"I Cannot Take This Any More!": Preparing Interns to Identify and Help a Struggling Colleague

Validity evidence for the clinical communication skills assessment tool (CCSAT) from 9 years of implementation in a high stakes medical student OSCE

OBJECTIVES

Communication and other clinical skills are routinely assessed in medical schools using Objective Structured Clinical Examinations (OSCEs) so routinely that it can be difficult to monitor and maintain validity. We report on the accumulation of validity evidence for the Clinical Communication Skills Assessment Tool (CCSAT) based on its use with 9 cohorts of medical students in a high stakes OSCE.

METHODS

We describe the implementation of the CCSAT including information on the underlying model, the tool's items, domains, scales and scoring, and its role in curriculum. Internal structure is explored through item, internal consistency, and confirmatory factor analyses. Evidence for CCSAT validity is synthesized within prevailing frameworks (Messick12 and Kane13) based on continuous quality improvement and use of the CCSAT for feedback, remediation, curricular design, and research.

RESULTS

Implementation of the CCSAT over time has facilitated our communication skills curriculum and training. Thoughtful case development and investment in standardized patient training has contributed to data quality. Item analysis supports our behaviorally anchored scale (not done, partly and well done) and the skills domains suggested by an a priori evidence-based clinical communication model were confirmed via analysis of actual student data. Evidence synthesized across the frameworks suggests consistent validity of the CCSAT for generalization inferences (that it captures the construct), responsiveness (sensitivity to change/difference), content validity/internal structure, relationships to other variables, and consequences/implications. More evidence is needed to strengthen validity of CCSAT scores for understanding extrapolation inferences and real-world implications.

CONCLUSIONS AND PRACTICE IMPLICATIONS

This pragmatic approach to evaluating validity within a program of assessment serves as a model for medical schools seeking to continuously monitor the quality of clinical skill assessments, a need made particularly relevant since the US NBME no longer requires the Step 2 Clinical Skills exam, leaving individual schools with the responsibility for ensuring graduates have acquired the requisite core clinical skills. We document strong evidence for CCSAT validity over time and across cohorts as well as areas for improvement and further examination.

Curriculum Innovation: A Standardized Experiential Simulation Curriculum Equips Residents to Face the Challenges of Chief Year

Introduction and Problem Statement

A chief resident's role incorporates administrative, academic, and interpersonal responsibilities essential to managing a successful residency program. However, rising chief residents receive little formal exposure to leadership training.

Objectives

To (1) define leadership styles; (2) understand the effect of cultural competence on leadership styles; (3) learn effective methods to advocate as the chief resident; (4) provide effective peer feedback; (5) provide effective supervisor feedback; (6) learn effective conflict management; (7) ensure psychological safety.

Methods and Curriculum Description

We developed a 1-day curriculum combining didactics and simulation activities for our program's rising chief residents. Implementation of our curricular design included a morning session focusing on small groups and didactic-based lectures on specific topics pertinent to leadership, along with a debriefing of a psychometric evaluation tool administered before the curriculum day. The simulation activity consisted of 3 group objective structured clinical examination (G-OSCE) scenarios: (1) providing a struggling junior trainee with feedback; (2) debriefing an adverse clinical outcome as the team leader; (3) navigating a challenging situation with a supervising physician. Standardized participants were surveyed for specific objectives. Learners completed precurricular and postcurricular surveys on their familiarity and preparedness for their chief year.

Results and Assessment Data

Comparison of preintervention (n = 16) and postintervention (n = 10) data shows improvements in familiarity with leadership models (p = 0.006), cultural competence in leadership (p = 0.027), and team organizational structure (p = 0.010) with notable improvement in report of advocating for the team to 100% of participants in the postcurricular survey. In addition, although not statistically significant, familiarity with specific strategies for feedback delivery improved (p = 0.053), as did learner comfort levels with feedback delivery (comparing 51% of learners were either very or somewhat comfortable precurriculum to 90% postcurriculum). This is further supported by standardized participant data after the G-OSCEs. Although familiarity with wellness resources did improve across learners (p = 0.421), learner-reported use of wellness resources was noted to be reduced after the curricular intervention and remains a result of further interest for exploration.

Discussion and Lessons Learned

A 1-day leadership development curriculum combining didactics and simulation is an effective means of preparing rising chief residents to succeed in their transition to this leadership role.

Interventions aimed at preventing suicide in the healthcare workforce: a systematic review

Healthcare workers are exposed to various factors in the workplace that may put them at an increased risk of suicide, but there is a lack of evidence reviewing interventions put in place by employers that may modify this risk. The authors undertook a systematic review to identify and assess organisational interventions aimed at preventing suicide in the healthcare workforce. Databases were systematically searched between January 2022 and August 2022. Eligibility for inclusion in the review was determined using a population, intervention, comparison, outcome framework, and 12 studies met the inclusion criteria. Studies were summarised using narrative synthesis and interventions included education, screening, modification of the workplace, referrals for support and/or therapy and peer support. Outcomes included: uptake, satisfaction, pre-training and post-training knowledge, symptoms, risk of suicide and economic costs. It was identified that various suicide prevention interventions are feasible in healthcare organisations and likely to have positive effects for staff. However, there is a lack of robust evaluation of these interventions, so further research is warranted.

Workplace interventions to prevent suicide: A scoping review

OBJECTIVES

To map organisational interventions for workplace suicide prevention, identifying the effects, mechanisms, moderators, implementation and economic costs, and how interventions are evaluated.

BACKGROUND

Suicide is a devastating event that can have a profound and lasting impact on the individuals and families affected, with the highest rates found among adults of work age. Employers have a legal and ethical responsibility to provide a safe working environment for their employees, which includes addressing the issue of suicide and promoting mental health and well-being.

METHODS

A realist perspective was taken, to identify within organisational suicide prevention interventions, what works, for whom and in what circumstances. Published and unpublished studies in six databases were searched. To extract and map data on the interventions the Effect, Mechanism, Moderator, Implementation, Economic (EMMIE) framework was used. Mechanisms were deductively analysed against Bronfenbrenner's socio-ecological model.

RESULTS

From 3187 records screened, 46 papers describing 36 interventions within the military, healthcare, the construction industry, emergency services, office workers, veterinary surgeons, the energy sector and higher education. Most mechanisms were aimed at the individual's immediate environment, with the most common being education or training on recognising signs of stress, suicidality or mental illness in oneself. Studies examined the effectiveness of interventions in terms of suicide rates, suicidality or symptoms of mental illness, and changes in perceptions, attitudes or beliefs, with most reporting positive results. Few studies reported economic costs but those that did suggested that the interventions are cost-effective.

CONCLUSIONS

It seems likely that organisational suicide prevention programmes can have a positive impact on attitudes and beliefs towards suicide as well reducing the risk of suicide. Education, to support individuals to recognise the signs and symptoms of stress, mental ill health and suicidality in both themselves and others, is likely to be an effective starting point for successful interventions.

Mental wellbeing of frontline health workers post-pandemic: lessons learned and a way forward

Objective

To assess the state of mental wellbeing among medical and dental frontline health workers as the COVID-19 pandemic transitions to an endemic phase and to determine what employer-provided intervention strategies these workers perceive as effective and desirable to improve their mental wellbeing.

Methods

An anonymous online survey distributed to frontline health workers in a hospitalist program of a tertiary care medical center and a university dental school in Minnesota in September 2022. The survey contained validated tools to measure depression severity, levels of perceived stress, and mental health status as well as questions to determine effective strategies to improve emotional wellbeing among these health workers. Data was evaluated on an aggregate level as well as stratified by level (e.g., physician, staff) and field (e.g., medicine, dentistry).

Results

On average, all groups of health workers suffered from moderate to moderately severe depression, had a much higher perceived stress level than average, and had a fair mental health status. There were no significant differences in depression severity, stress level, or mental health status among physicians, dentists, medical staff, and dental staff. The majority of the respondents perceived adjusted work hours, rewards and incentives, and teamwork as the most effective and desirable strategies to improve their mental wellbeing.

Conclusion

The current mental wellbeing of frontline health workers is poor. Many are dissatisfied with healthcare and consider leaving the industry. To improve their employees' mental wellbeing, healthcare employers might want to consider adjusted work hours, rewards, and teamwork as these intervention strategies are perceived as most effective and desirable by the intended recipients.

Imposter Syndrome Among Surgeons Is Associated With Intolerance of Uncertainty and Lower Confidence in Problem Solving

BACKGROUND

Feelings of imposter syndrome (inadequacy or incompetence) are common among physicians and are associated with diminished joy in practice. Identification of modifiable factors associated with feelings of imposter syndrome might inform strategies to ameliorate them. To this point, though, no such factors have been identified.

QUESTION/PURPOSE

Are intolerance of uncertainty and confidence in problem-solving skills independently associated with feelings of imposter syndrome after accounting for other factors?

METHODS

This survey-based experiment measured the relationship between feelings of imposter syndrome, intolerance of uncertainty, and confidence in problem-solving skills among musculoskeletal specialist surgeons. Approximately 200 surgeons who actively participate in the Science of Variation Group, a collaboration of mainly orthopaedic surgeons specializing in upper extremity illnesses primarily across Europe and North America, were invited to this survey-based experiment. One hundred two surgeons completed questionnaires measuring feelings of imposter syndrome (an adaptation of the Clance Imposter Phenomenon Scale), tolerance of uncertainty (the Intolerance of Uncertainty Scale-12), and confidence in problem-solving skills (the Personal Optimism and Self-Efficacy Optimism questionnaire), as well as basic demographics. The participants were characteristic of other Science of Variation Group experiments: the mean age was 52 ± 5 years, with 89% (91 of 102) being men, most self-reported White race (81% [83 of 102]), largely subspecializing in hand and/or wrist surgery (73% [74 of 102]), and with just over half of the group (54% [55 of 102]) having greater than 11 years of experience. We sought to identify factors associated with greater feelings of imposter syndrome in a multivariable statistical model.

RESULTS

Accounting for potential confounding factors such as years of experience or supervision of trainees in the multivariable linear regression analysis, greater feelings of imposter syndrome were modestly associated with higher intolerance of uncertainty (regression coefficient [β] 0.34 [95% confidence interval (CI) 0.16 to 0.51]; p < 0.01) and with lower confidence in problem-solving skills (β -0.70 [95% CI -1.0 to -0.35]; p < 0.01).

CONCLUSION

The finding that feelings of imposter syndrome may be modestly to notably associated with modifiable factors, such as difficulty managing uncertainty and lack of confidence in problem-solving, spark coaching opportunities to support and sustain a surgeon's mindset, which may lead to increased comfort and joy at work.

CLINICAL RELEVANCE

Beginning with premedical coursework and throughout medical training and continuing medical education, future studies can address the impact of learning and practicing tactics that increase comfort with uncertainty and greater confidence in problem solving on limiting feelings of imposter syndrome.

A Systematic Review of Wellness in Plastic Surgery Training

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Encouraging a Little Help from Our Friends: Resident Physician Burnout & Peer Communication Curriculum

INTRODUCTION

Resident physician burnout and depression rates are increasing faster than in the non-physician workforce. To foster a supportive community where such concerns may be addressed, residents can be educated in identification and first-line support of burnout in fellow residents. The literature has not described peer roleplaying applied toward aiding fellow residents with burnout.

METHOD

This pilot study evaluated an educational component aimed at fostering a strong emotional and informational social support system. The curriculum used peer roleplaying to develop self-awareness and social support, improve communication skills, and teach about existing mental health resources, thereby encouraging intervention. Residents listed behavioral manifestations of burnout and dysphoria that we developed into real-life scenarios. During experiential workshops, residents roleplayed "distressed" and "helper" residents and practiced communicating empathy. To tackle mental health stigma, all were required to practice expressing distress and seeking help. Residents completed a pre-roleplaying questionnaire, curriculum satisfaction questionnaire, and reflection essay.

RESULTS

All 42 Internal Medicine and Transitional Year residents (69% male, 93% international medical graduates) participated. Resident-reported comfort, competence, confidence, and knowledge increased, as did positive appraisals of the clinical teaching environment representing a safe atmosphere. Six themes were cited in >25% of essays: knowledge of communication techniques, knowledge of approach tactics or strategies, knowledge of hospital resources, commitment to helping colleagues, importance of burnout, and belief this training produced a better understanding of oneself.

CONCLUSION

As first-witnesses of resident physician distress, peers occupy an underutilized, yet crucial preventive and supportive role in burnout and mental health intervention, especially during times of shared crises such as the coronavirus pandemic. Creating roleplays from personal experiences facilitated meaningful discussion of burnout and dysphoric emotions. Roleplaying offered a low-cost, effective method to destigmatize and encourage discussion of burnout, educate on signs and symptoms, and learn available resources to offer an afflicted colleague in osteopathic and allopathic residency programs.

Foster Well-being Throughout the Career Trajectory: A Developmental Model of Physician Resilience Training

Physician burnout is common across specialties and largely driven by demands of the current health care industry. However, the obvious need for systems change does not address the unavoidable impact of providing care to those who suffer. An intentional, developmental, longitudinal approach to resiliency training would not distract from fixing a broken system or blame physicians for their distress. Existing models and approaches to resilience training are promising but limited in duration, scope, and depth. We call for and describe a career-long model, introduced early in undergraduate medical training, extending into graduate medical education, and integrated throughout professional training and continuing medical education, in intrapersonal and interpersonal skills that help physicians cope with the emotional, social, and physical impact of care provision.

Suicide among doctors: A narrative review

Doctors across the world work in stressful conditions, often making life or death decisions under considerable pressure. With changes in patient and societal expectations, these pressures continue to rise. For several decades, it has been illustrated that rates of psychiatric disorders, especially suicide, are considerably higher in doctors than the general population. We performed a comprehensive literature search of suicide in doctors. Using defined terms (suicide, self-harm, doctors, physicians, residents) in PubMed, we identified pertinent articles for review. We find that suicide in doctors is influenced by exposure to the physical and emotional distress endemic to the profession. These experiences may be compounded by emotional giving to the brink of exhaustion; a lack of positive feedback; alongside workplace isolation and poor support networks. Moreover, risks may be magnified by impacts outside of work; long hours, strained family relationships, poor work-life balance, as well as system and organizational politics. Despite this, doctors persistently avoid seeking help because of stigma against mental illnesses, stigma against themselves, and growing concerns that disclosure may impact their medical license. In many cases, doctors choose to self-medicate with prescription medications, alcohol, and a range of other substances. It is important that health services respond promptly, adequately, and sensibly to the needs of doctors in distress. Organizations including regulators have a moral responsibility to care for the wellbeing of its staff. A proactive approach to well-being, through training, and support will not only benefit doctors but also the patients who utilize their services each day.