Exploration of Mistreatment and Burnout Among Resident Physicians: a Cross-Specialty Observational Study

Implementation of a Trauma-Informed Challenging Interactions Reporting Tool to Improve our Clinical Learning Environment

PROBLEM

Workplace mistreatment is a contributor to resident burnout; understanding and intervening against mistreatment is one key tool in mitigating burnout. While Accreditation Council for Graduate Medical Education (ACGME) survey data alerts programs to general mistreatment trends, those data are not detailed enough to inform local interventions. Our team designed and implemented a Challenging Interactions Reporting Tool (CIRT) to characterize the experiences of our trainees at a granular level and to inform targeted interventions for improvement.

APPROACH

Our CIRT was offered to 158 residents in August 2020 via REDCap. Residents submit electronic reports that are reviewed weekly by program leaders who develop action plans for each report. Reporters can identify themselves or can choose to remain anonymous. When "hot spots" for mistreatment are identified in our hospital, we implement a targeted systems-level intervention.

OUTCOMES

Residents filed 275 reports between August 2020 and December 2022. Reports represented all training environments and involved all interprofessional members of clinical teams. Residents reported awareness of, use of, and satisfaction with the tool.

NEXT STEPS

Our program created the CIRT as a tool to inform local interventions for improving the safety of our clinical learning environment. We continue to disseminate our tool across our hospital's GME programs and are now measuring the impact of our interventions.

[Mistreatment of Paraguayan medical residents in 2022: a multicenter study]

Introducción

los residentes de postgrado tienden a sufrir maltratos durante sus prácticas hospitalarias y estos comportamientos abusivos no deben considerarse normales. El objetivo fue describir la frecuencia y las características del maltrato en residentes de medicina del Paraguay en 2022.

Metodología

se aplicó un diseño observacional de corte transversal. Se incluyó a los residentes de hospitales del Paraguay que aceptaban completar una encuesta online difundida por las redes sociales. Se utilizó un cuestionario de 23 preguntas que evalúa el maltrato psicológico, físico, académico y sexual. Adicionalmente se solicitó datos demográficos, académicos y aspectos relacionados a la denuncia del maltrato.

Resultados

el cuestionario fue llenado por 348 residentes. La edad media fue 28 ± 3 años y hubo predomino del sexo femenino (63,2%). Participaron residentes de 32 hospitales, la mayoría era de 1° año (50,3%) y de especialidades clínicas (60,6%). Acorde al cuestionario, 339 residentes (97,4%) refirieron algún grado de maltrato. Relacionando las especialidades con el maltrato, el mismo fue mayor en las quirúrgicas: RR 1,4 IC 95% 1,0-1,9 (p 0,01). Los principales responsables del maltrato fueron los residentes superiores (55,2%) y los jefes de salas (31,8%). La denuncia fue realizada por 8% de los afectados. El principal motivo para no denunciar fue el temor a que realizarla le traería problemas (67,8%).

Conclusiones

el maltrato fue referido por 97,4% de los residentes, siendo mayor en las especialidades quirúrgicas. Urge aplicar medidas preventivas para evitar este tipo de abusos durante la residencia.

Forum Theatre to Address Peer-to-Peer Mistreatment in General Surgery Residency

OBJECTIVE

Mistreatment is widespread in graduate medical education, and much attention has been generated on this topic and its relationship to burnout in general surgery residency. In particular, peer-to-peer mistreatment poses a developmental dilemma - as junior residents find themselves mistreated and some turn around and perpetuate that mistreatment. There is a paucity of effective interventions. Forum Theatre (FT) is a novel educational tool to engage participants in solving difficult situations. We present the use of FT as a tool to explore solutions to address peer-to-peer mistreatment in a surgery residency. FT starts with the performance of a culture-specific conflict scenario and then invites the audience to participate in renditions of the situation ending in a collective solution.

DESIGN

Stakeholder support was obtained from the general surgery program leadership. Time was protected during two 1-hour scheduled wellness didactic sessions. First, focus groups with each PG year identified the residents' experience of mistreatment. Themes regarding peer-to peer mistreatment were identified and presented to a group of 3 volunteer actor residents who chose to focus on the unintended consequences of public, corrective feedback with the understanding this would be presented to the residency at large. Following this, they developed a scenario for enactment which was implemented during the second didactic session. The enacted scenario posed a problem with public feedback ending unsatisfactorily. The audience was then invited to engage the actors and participate in replays of the situation until a collective solution was identified. Retrospective pre-post survey and a 6-month post survey were administered.

SETTING

General surgery residency at University of Texas Health San Antonio.

PARTICIPANTS

General surgery residents. 32 of 66 (48.5%) residents participated.

RESULTS

Participants noted an improved understanding of mistreatment, felt more confident in recognizing mistreatment, reported improved confidence in their ability to intervene when witnessing mistreatment and to recognize when they themselves were involved in mistreatment (p < 0.001 for all). In fact, of the residents who reported participating in mistreatment, 100% reported directing it towards peers. After the FT, 89% of residents said they "definitely" or "most likely" recommended participating in a FT to address mistreatment. 85.7% reported that the intervention was moderately to extremely effective for teaching topics in professionalism. These trends remained steady in the survey 6 months after the intervention as well.

CONCLUSIONS

We found FT was feasible to implement in a busy general surgery residency and well received with sustained, self- reported behavior change. FT is a novel tool to engage residents to self-evaluate and participate in methods to address mistreatment. FT interventions can be tailored to the local culture to address conflicts specific to that setting.

Endured and prevailed: a phenomenological study of doctors' first year of clinical practice

CONTEXT

The challenging nature of the transition from medical student to doctor is highlighted by the associated negative consequences to new doctors' mental health and wellbeing. Enhanced understanding of the lived experience of recent medical graduates as they move through the stages of transition over the first year of practice can inform interventions to ease the difficulties encountered.

METHODS

Using interpretative phenomenological analysis (IPA), a novel approach to this topic, we explored the lived experience of transition from student to doctor over the first year of practice after graduation. Twelve new graduates were purposively recruited. We conducted semi-structured interviews at the end of their first year of practice with respect to their experience over the first year.

RESULTS

The experience of transition was characterised by overlapping temporal stages. Participants' initial adjustment period was characterised by shock, coping and stabilisation. A phase of development followed, with growth in confidence and a focus on self-care. Adversity was experienced in the form of interprofessional tensions, overwork, isolation and mistreatment. Finally, a period of reflection and rationalisation marked the end of the first year.

DISCUSSION

Following initial anxiety regarding competence and performance, participants' experience of transition was predominantly influenced by cultural, relational and contextual aspects of clinical practice. Solutions to ease this challenging time include stage-specific transitional interventions, curricular change at both undergraduate and postgraduate levels and a re-evaluation of the clinical learning environment to mitigate the difficulties endured.

Trends in Surgeon Burnout in the US and Canada: Systematic Review and Meta-Regression Analysis

BACKGROUND

Burnout among surgeons is increasingly recognized as a crisis. However, little is known about changes in burnout prevalence over time. We evaluated temporal trends in burnout among surgeons and surgical trainees of all specialties in the US and Canada.

STUDY DESIGN

We systematically reviewed MEDLINE, Embase, and PsycINFO for studies assessing surgeon burnout from January 1981 through September 2021. Changes in dichotomized Maslach Burnout Inventory scores and mean subscale scores over time were assessed using multivariable random-effects meta-regression.

RESULTS

Of 3,575 studies screened, 103 studies representing 63,587 individuals met inclusion criteria. Publication dates ranged from 1996 through 2021. Overall, 41% of surgeons met criteria for burnout. Trainees were more affected than attending surgeons (46% vs 36%, p = 0.012). Prevalence remained stable over the study period (-4.8% per decade, 95% CI -13.2% to 3.5%). Mean scores for emotional exhaustion declined and depersonalization declined over time (-4.1 per decade, 95% CI -7.4 to -0.8 and -1.4 per decade, 95% CI -3.0 to -0.2). Personal accomplishment scores remained unchanged. A high degree of heterogeneity was noted in all analyses despite adjustment for training status, specialty, practice setting, and study quality.

CONCLUSIONS

Contrary to popular perceptions, we found no evidence of rising surgeon burnout in published literature. Rather, emotional exhaustion and depersonalization may be decreasing. Nonetheless, burnout levels remain unacceptably high, indicating a need for meaningful interventions across training levels and specialties. Future research should be deliberately designed to support longitudinal integration through prospective meta-regression to facilitate monitoring of trends in surgeon burnout.

Impact of workplace violence on anxiety and sleep disturbances among Egyptian medical residents: a cross-sectional study

BACKGROUND

Workplace violence (WPV) against healthcare workers is a common occurrence worldwide, especially among young physicians and medical residents. This study aimed to explore the negative health impacts of WPV among medical residents in Egypt, and their perception regarding how safe it is to report violence.

PURPOSE

To investigate the prevalence of WPV among medical residents, its possible negative health impacts, specifically on sleep quality and mental health, and the perceived workplace safety climate.

METHODS

This is a cross-sectional analytic study, using a convenience sample through an online questionnaire. An abuse index was calculated, generalized anxiety disorder (GAD) and sleep quality were collected from the reported outcomes.

RESULTS

The study sample included 101 residents (86.1% females). The most common reported form of abuse was verbal abuse, with the most common reported perpetrators being senior staff members (59.4%). About 86% of participants were classified as poor sleepers, while 59.4% had GAD, and there were significant positive correlations between GAD and Global Pittsburgh Sleep Quality Index (PSQI) scores with the abuse index. More than one third (35.6%) of residents reported a very high-risk Psychosocial Safety Climate (PSC) score, and 31.6% of them either strongly agreed or agreed that reporting a sexual harassment claim would be dangerous.

CONCLUSION

Workplace violence is common among Egyptian medical residents, with a significant negative impact on sleep quality and a rising risk of GAD. The promotion of a safe workplace environment is essential in protecting the health and wellbeing of medical residents.

Discrimination, harassment, and intimidation amongst otolaryngology: head and neck surgeons in Canada

BACKGROUND

Understanding mistreatment within medicine is an important first step in creating and maintaining a safe and inclusive work environment. The objective of this study was to quantify the prevalence of perceived workplace mistreatment amongst otolaryngology-head and neck surgery (OHNS) faculty and trainees in Canada.

METHODS

This national cross-sectional survey was administered to practicing otolaryngologists and residents training in an otolaryngology program in Canada during the 2020-2021 academic year. The prevalence and sources of mistreatment (intimidation, harassment, and discrimination) were ascertained. The availability, awareness, and rate of utilization of institutional resources to address mistreatment were also studied.

RESULTS

The survey was administered to 519 individuals and had an overall response rate of 39.1% (189/519). The respondents included faculty (n = 107; 56.6%) and trainees (n = 82; 43.4%). Mistreatment (intimidation, harassment, or discrimination) was reported in 47.6% of respondents. Of note, harassment was reported at a higher rate in female respondents (57.0%) and White/Caucasian faculty and trainees experienced less discrimination than their non-White colleagues (22.7% vs. 54.5%). The two most common sources of mistreatment were OHNS faculty and patients. Only 14.9% of those experiencing mistreatment sought assistance from institutional resources to address mistreatment. The low utilization rate was primarily attributed to concerns about retribution.

INTERPRETATION

Mistreatment is prevalent amongst Canadian OHNS trainees and faculty. A concerning majority of respondents reporting mistreatment did not access resources due to fear of confidentiality and retribution. Understanding the source and prevalence of mistreatment is the first step to enabling goal-directed initiatives to address this issue and maintain a safe and inclusive working environment.

What are the advantages of clock position method to determine fetal heart axis for inexperienced resident physicians? A comparative study

Objective

Residency training programs are challenging for young physicians with heavy workloads. Although ultrasonography (USG) is an imaging method that is frequently used in obstetrics practice, some basic USG skills can be acquired late in this intensive learning process. Likewise determining the fetal heart axis is an elementary evaluation but can turn into a challenging and time-consuming process, especially for inexperienced clinicians.

Material and Methods

Pregnant women between 20 and 37 weeks of gestation were recruited. Two observers assessed the axis of fetal heart by standard, Bronshtein and clock position methods. Fetal heart axis evaluation times were compared. Inter-observer and intra-observer agreements of the three methods were measured. One factor learning rates were calculated.

Results

A total of 31 pregnant patients between the ages of 18 and 40 years were included in the study. Fetal heart axis evaluation time by the clock position method was shorter than the Bronshtein and standard method in both observers. Furthermore diagnostic accuracy for both observers was 100% with the clock position method, while this fell to 100% in observer-1 and 96.8% in observer-2 using the Bronshtein method. The clock position method was learned faster than either of the other methods.

Conclusion

Clock position method is an easy and feasible method for inexperienced resident physicians in terms of learning and application to determine the fetal heart axis. The advantages of this method increase when patient numbers are higher.

Mistreatment Experiences, Protective Workplace Systems, and Occupational Distress in Physicians

IMPORTANCE

Reducing physician occupational distress requires understanding workplace mistreatment, its relationship to occupational well-being, and how mistreatment differentially impacts physicians of diverse identities.

OBJECTIVES

To assess the prevalence and sources of mistreatment among physicians and associations between mistreatment, occupational well-being, and physicians' perceptions of protective workplace systems.

DESIGN, SETTING, AND PARTICIPANTS

This survey study was administered in September and October 2020 to physicians at a large academic medical center. Statistical analysis was performed from May 2021 to February 2022.

MAIN OUTCOMES AND MEASURES

Primary measures were the Professional Fulfillment Index, a measure of intent to leave, and the Mistreatment, Protection, and Respect Measure (MPR). Main outcomes were the prevalence and sources of mistreatment. Secondary outcomes were the associations of mistreatment and perceptions of protective workplace systems with occupational well-being.

RESULTS

Of 1909 medical staff invited, 1505 (78.8%) completed the survey. Among respondents, 735 (48.8%) were women, 627 (47.1%) were men, and 143 (9.5%) did not share gender identity or chose "other"; 12 (0.8%) identified as African American or Black, 392 (26%) as Asian, 10 (0.7%) as multiracial, 736 (48.9%) as White, 63 (4.2%) as other, and 292 (19.4%) did not share race or ethnicity. Of the 1397 respondents who answered mistreatment questions, 327 (23.4%) reported experiencing mistreatment in the last 12 months. Patients and visitors were the most common source of mistreatment, reported by 232 physicians (16.6%). Women were more than twice as likely as men to experience mistreatment (31% [224 women] vs 15% [92 men]). On a scale of 0 to 10, mistreatment was associated with a 1.13 point increase in burnout (95% CI, 0.89 to 1.36), a 0.99-point decrease in professional fulfillment (95% CI, -1.24 to -0.73), and 129% higher odds of moderate or greater intent to leave (odds ratio, 2.29; 95% CI, 1.75 to 2.99). When compared with a perception that protective workplace systems are in place "to a very great extent," a perception that there are no protective workplace systems was associated with a 2.41-point increase in burnout (95% CI, 1.80 to 3.02), a 2.81-point lower professional fulfillment score (95% CI, -3.44 to -2.18), and 711% higher odds of intending to leave (odds ratio, 8.11; 95% CI, 3.67 to 18.35).

CONCLUSIONS AND RELEVANCE

This survey study found that mistreatment was common among physicians, varied by gender, and was associated with occupational distress. Patients and visitors were the most frequent source, and perceptions of protective workplace systems were associated with better occupational well-being. These findings suggest that health care organizations should prioritize reducing workplace mistreatment.

Mistreatment in Residency: Intervening With the REWIND Communication Tool

INTRODUCTION

There is a lack of curricula addressing the alarming rates of resident physician mistreatment. As the ACGME works to address diversity, equity, and inclusion in GME, there has been increasing attention paid to the issue of mistreatment. Previous studies have noted a high prevalence of mistreatment within GME. Despite this, there are few published interventions to address the mistreatment of residents. We developed a workshop for residents to provide an overview of mistreatment in residency and teach them REWIND (relax, express, why, inquire, negotiate, determine), a communication tool to address mistreatment directly.

METHODS

We designed a 60-minute workshop for residents with didactics on mistreatment in GME, followed by three case discussions. Four case scenarios were developed to represent different types of mistreatment and situations. We implemented the workshop twice and asked participants to self-rate proficiency around the workshop objectives with pre- and postsurveys.

RESULTS

A total of 11 GME learners completed both the pre- and postsurveys between the two workshop implementations. GME learners who responded demonstrated significantly higher self-rated proficiency on each objective postworkshop compared to preworkshop (p < .05). Free responses on the survey demonstrated that participants particularly enjoyed the case discussions and wanted more practice with REWIND.

DISCUSSION

Our workshop improved participant self-rated proficiency around the mistreatment of resident physicians. The workshop can be used in the future as part of a multifaceted institutional response to mistreatment.

Individual and residency program factors related to depression, anxiety and burnout in physician residents - a Brazilian survey

BACKGROUND

Psychological distress is common among medical trainees. This study aimed to assess the frequency of depression, anxiety and burnout among physician residents and their association with both individual and residency program-related factors.

METHODS

This was a cross-sectional study applying an online survey in a national-wide sample of medical residents from Brazil. Depression, anxiety, burnout and diurnal somnolence were assessed with validated tools (Patient Health Questionnaire-4, 2 items version of Maslach Burnout Inventory, and Epworth Sleepiness Scale). Socio-demographic and residency program-related factors were measured with internally validated instruments. We performed multivariate binary logistic regression analysis for each of the main outcomes.

RESULTS

Screening for depression, anxiety and burnout was positive respectively in 46.9%, 56.6% and 37.0% of our sample (n = 1,419). Depression was independently related to female sex, longer duty hours, absence of day off, poor learning perception, poor feeling about the residency program, overall occurrence of psychological abuse, anxiety, diurnal somnolence and burnout (AUROC = .859 [95%CI = .840-.878], p < .001). Anxiety was independently associated with female sex, higher age and duty hours, work-personal life conflicts, few classroom activities, providing assistance without supervision, depression and diurnal somnolence (837 [.816-.857], p < .001). Burnout was related to lower age and leisure time, male sex, longer duty hours, absence of day off, provision of care without supervision, choice of the wrong specialty, poor learning, psychological abuse, depression and diurnal somnolence (.780 [.753-.806], p < .001).

CONCLUSION

Frequency of psychological distress in residency training is high and related to both individuals and environmental factors, namely high workloads, occurrence of psychological abuse, poor faculty supervision, poor learning experience and work-personal life conflicts.

A cross-sectional survey of burnout in a sample of resident physicians in Sudan

BACKGROUND

Resident physicians in Sudan face a variety of physical and psychological stressors. Nevertheless, the prevalence of burnout syndrome among this critical population remains unknown. The purpose of this study was to estimate the prevalence rate of burnout and its associated factors in a sample of resident physicians in Sudan.

METHODS

A cross-sectional design was used to assess the burnout syndrome among resident physicians at the teaching hospitals of Wad-Medani in Gezira state, east-central Sudan. Three hundred resident physicians at the dermatology, general surgery, pediatrics, obstetrics and gynecology, psychiatry, ear, nose and throat (ENT), oncology, urology, and internal medicine departments, were approached and invited to participate in the study. The Arabic version of the Maslach Burnout Inventory was distributed to respondents from July to October 2021.

RESULTS

From the 300 resident physicians, 208 (69.3%) responded. The average age of the study population was 29.99 ± 3.01 years, with more than half were females (56.7%), single (59.6%), and with more than three years of residency experience (50.5%). In total, 86.1% met the criteria for burnout in at least one dimension and 13.9% in all three dimensions. On the dimension of emotional exhaustion (EE), 70.7% reported high levels of burnout. While, 44.2% reported high levels of depersonalization (DP), and 73.1% experienced a sense of decreased professional accomplishment (PA). There were significant differences in burnout, EE, and DP levels among different specialties, with the pediatrics-specialty trainees reported higher levels. Burnout syndrome was associated with the working hours per single duty; participants who reported working for more than 24 hours had experienced higher levels of burnout, EE, and DP.

CONCLUSION

Large-scale studies are required to assess the determinants of burnout syndrome among resident physicians in Sudan. In addition, Stakeholders should urgently implement effective remedies to protect the mental health of resident physicians.