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

Resident physician depression: systemic challenges and possible solutions

Resident physicians face intense stressors that significantly heighten their depression risk. This article discusses research findings on critical factors contributing to depression among resident physicians. Understanding these factors is essential to developing targeted interventions, fostering healthy work environments, and ultimately improving physician wellbeing and patient care.

Duration of New-Onset Depressive Symptoms During Medical Residency

Importance

The implications of new-onset depressive symptoms during residency, particularly for first-year physicians (ie, interns), on the long-term mental health of physicians are unknown.

Objective

To examine the association between and persistence of new-onset and long-term depressive symptoms among interns.

Design, Setting, and Participants

The ongoing Intern Health Study (IHS) is a prospective annual cohort study that assesses the mental health of incoming US-based resident physicians. The IHS began in 2007, and a total of 105 residency programs have been represented in this national study. Interns enrolled sequentially in annual cohorts and completed follow-up surveys to screen for depression using the 9-item Patient Health Questionnaire-9 (PHQ-9) throughout and after medical training. The data were analyzed from May 2023 to March 2024.

Exposure

A positive screening result for depression, defined as an elevated PHQ-9 score of 10 or greater (indicating moderate to severe depression) at 1 or more time points during the first postgraduate year of medical training (ie, the intern year).

Main Outcomes and Measures

The main outcomes assessed were mean PHQ-9 scores (continuous) and proportions of physicians with an elevated PHQ-9 score (≥10; categorical or binary) at the time of the annual follow-up survey. To account for repeated measures over time, a linear mixed model was used to analyze mean PHQ-9 scores and a generalized estimating equation (GEE) was used to analyze the binary indicator for a PHQ-9 score of 10 or greater.

Results

This study included 858 physicians with a PHQ-9 score of less than 10 before the start of their internship. Their mean (SD) age was 27.4 (9.0) years, and more than half (53.0% [95% CI, 48.5%-57.5%]) were women. Over the follow-up period, mean PHQ-9 scores did not return to the baseline level assessed before the start of the internship in either group (those with a positive depression screen as interns and those without). Among interns who screened positive for depression (PHQ-9 score ≥10) during their internship, mean PHQ-9 scores were significantly higher at both 5 years (4.7 [95% CI, 4.4-5.0] vs 2.8 [95% CI, 2.5-3.0]; P < .001) and 10 years (5.1 [95% CI, 4.5-5.7] vs 3.5 [95% CI, 3.0-4.0]; P < .001) of follow-up. Furthermore, interns with an elevated PHQ-9 score (≥10) demonstrated a higher likelihood of meeting this threshold during each year of follow-up.

Conclusions and Relevance

In this cohort study of IHS participants, a positive depression screening result during the intern year had long-term implications for physicians, including having persistently higher mean PHQ-9 scores and a higher likelihood of meeting this threshold again. These findings underscore the pressing need to address the mental health of physicians who experience depressive symptoms during their training and to emphasize the importance of interventions to sustain the health of physicians throughout their careers.

Framework proposal for Role-Playing Games as mental health intervention: the Critical Skills methodology

Gamified interventions are an emerging approach in mental health treatment and prevention. Their positive effects on managing various clinical conditions stem from enhancing social skills. However, cost-effective options like Table-top Role-Playing Games (TTRPGs), which offer similar benefits to other game-based interventions, lack standardized methods for ensuring replicability. In this regard, the method outlined in this study endeavors, in a structured and guided manner drawing from the Consolidated Framework for Implementation Research (CFIR), to establish a six-step protocol for developing an intervention method utilizing TTRPGs. In all Steps, we aim to anchor ourselves in robust literature concerning social skills training (SST), cognitive behavioral therapy (CBT), and gamification comprehensively. Thus, the method presented encompasses the objectives of SST, the strategies of CBT, and the dynamics of gamification via TTRPGs. Furthermore, we demonstrate a possible application of the method to illustrate its feasibility. Ultimately, the final method is structured, evidence-based, easily applicable, cost-effective, and thus viable. Mental health professionals seeking a structured and instructional tool for protocol development will find support in the method proposed here.

How different is the Learning Environment of Public and Private Sector Medical Colleges in Lahore, Pakistan?

Background &Objective

Regular assessment of the Learning Environment (LE) of health professions education institutions is important for their continuous improvement and to keep the students motivated. Pakistan Medical & Dental Council (PM&DC) applies uniform standards of quality in all public and private sector medical colleges of the country. However, the learning environment of these colleges might be different due to differences in their geographic location, structure, utilization of resources, and modus operandi. This study was conducted to measure the learning environment in selected public and private sector medical colleges in the city of Lahore, Pakistan, using a pre validated instrument (Jhon Hopkins Learning Environment Scale).

Methods

This cross-sectional descriptive study was conducted on 3,400 medical students from six public and private sector medical colleges of Lahore, during November and December 2020. Data was collected through Google forms. Two stage cluster random sampling technique was used to draw the study sample. John Hopkins Learning Environment Scale (JHLES) was used for data collection.

Results

Overall JHLES mean score was 81.75 ±13.5. Public sector colleges had a significantly higher mean JHLES score (82.1) than private-sector colleges (81.1), with small effect size (0.083). Male students rated LE slightly higher than females (82.0 and 81.6 respectively).

Conclusion

JHLES a relatively simpler tool (28 items) than DREEM, can be used effectively in the context of Pakistani environment to measure the LE in medical colleges. Both, public and private sector colleges had high overall JHLES mean scores, with public sector colleges having a significantly higher score than private-sector colleges.

The Association of Experienced Long Working Hours and Depression, Anxiety, and Suicidal Ideation Among Chinese Medical Residents During the COVID-19 Pandemic: A Multi-Center Cross-Sectional Study

Background

Long working hours are common among medical residents and may increase the risk of mental disorders. We aimed to investigate the association between experienced long working hours and depression, anxiety, and suicidal ideation among Chinese medical residents during the COVID-19 pandemic.

Methods

This study was conducted in September 2022; 1343 residents from three center in Northeastern China were included in the final analysis (effective response rate: 87.61%). The data were collected from participants via online self-administered questionnaires. Depression and anxiety were measured by the Patient Health Questionnaire (PHQ-9) and the General Anxiety Disorder (GAD-7) scale, respectively. Adjusted odds ratios and 95% confidence intervals were determined after adjusting for potential confounders by binary unconditional logistic regression.

Results

The effective response rate was 87.61%. Among the 1343 participants, 12.88% (173), 9.90% (133), and 9.68% (130) had experienced major depression, major anxiety, and suicidal ideation, respectively. We found that longer weekly worktime increased the risk of major depression, particularly in those who worked for more than 60 hours per week (≥ 61 hours vs ≤ 40 hours, OR=1.87, P for trend = 0.003). However, this trend was not observed for either major anxiety or suicidal ideation (P for trend > 0.05 for both).

Conclusion

This study revealed that there was a considerable incidence of poor mental health among medical residents; furthermore, the longer weekly worktime was associated with a higher risk of major depression, especially for those who worked more than 60 hours per week, but this association was not observed in either major anxiety or suicidal ideation. This may help policymakers to develop targeted interventions.

Assessing Interpersonal Relationships in Medical Education: the Connection Index

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Germany-wide evaluation of residency in neurological intensive care medicine

BACKGROUND

Neurointensive medicine is an important subspecialization of neurology. Its growing importance can be attributed to factors such as demographic change and the establishment of new therapeutic options. Part of the neurological residency in Germany is a six-month rotation on an intensive care unit (ICU), which has not yet been evaluated nationwide. The aim of this study was to evaluate kind and feasibility of neurointensive care training in Germany and to discover particularly successful training concepts.

METHODS

In a preliminary study, ten residents and ten instructors were interviewed. Using content analysis, two questionnaires were created, which contained questions about specific teaching methods as well as individual satisfaction. The questionnaires were sent to 187 neurological clinics in Germany, and residents and instructors were asked to participate in the study. The data analysis was performed using SPSS and content analysis for the free-text data.

RESULTS

Seventy of the 187 clinics contacted did not offer ICU-rotation. At 59,8% (n = 70) of the remaining hospitals, a total of 154 participants (84 residents, 70 educators) could be recruited. General satisfaction with the neurointensive medical training is high in both groups (residents: 3.34 ± 0.54; instructors: 3.79 ± 0.41, evaluated on the basis of a Likert scale from 1 = "not satisfied" to 5 = "fully satisfied"). Specific teaching methods (e.g. simulation trainings, feedback sessions) are perceived as very useful by residents, but rarely take place. Instructors are interested in educational opportunities such as didactic courses.

CONCLUSION

This study provides an overview of the ICU-rotation as part of the five-year neurological residency. Neurointensive care rotations usually take place at maximum care hospitals and last at least seven months. Despite frequent time and personnel restrictions, motivation of trainers and residents is high. Nevertheless, teaching methods as simulation training and educational opportunities for instructors must be expanded.

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.

Veterinary house officer perceptions of dimensions of well-being during postgraduate training

OBJECTIVE

To describe veterinary house officers’ perceptions of dimensions of well-being during postgraduate training and to identify potential areas for targeted intervention.

SAMPLE

303 house officers.

PROCEDURES

A 62-item questionnaire was generated by use of an online platform and sent to house officers at participating institutions in October 2020. Responses were analyzed for trends and associations between selected variables.

RESULTS

239 residents, 45 rotating interns, and 19 specialty interns responded to the survey. The majority of house officers felt that their training program negatively interfered with their exercise habits, diet, and social engagement. House officers reported engaging in exercise significantly less during times of clinical responsibility, averaging 1.6 exercise sessions/wk (SD ± 0.8) on clinical duty and 2.4 exercise sessions/wk (SD ± 0.9) when not on clinical duty (P < 0.001). Ninety-four percent of respondents reported experiencing some degree of anxiety regarding their physical health, and 95% of house officers reported feeling some degree of anxiety regarding their current financial situation. Overall, 47% reported that their work-life balance was unsustainable for > 1 year; there was no association between specialty and sustainability of work-life balance. Most house officers were satisfied with their current training program, level of clinical responsibility, and mentorship.

CLINICAL RELEVANCE

Veterinary house officers demonstrated a poor balance between the demands of postgraduate training and maintenance of personal health. Thoughtful interventions are needed to support the well-being of veterinary house officers.

Trends in Depressive Symptoms and Associated Factors During Residency, 2007 to 2019 : A Repeated Annual Cohort Study

BACKGROUND

Efforts to address the high depression rates among training physicians have been implemented at various levels of the U.S. medical education system. The cumulative effect of these efforts is unknown.

OBJECTIVE

To assess how the increase in depressive symptoms with residency has shifted over time and to identify parallel trends in factors that have previously been associated with resident physician depression.

DESIGN

Repeated annual cohort study.

SETTING

U.S. health care organizations.

PARTICIPANTS

First-year resident physicians (interns) who started training between 2007 and 2019.

MEASUREMENTS

Depressive symptoms (9-item Patient Health Questionnaire [PHQ-9]) assessed at baseline and quarterly throughout internship.

RESULTS

Among 16 965 interns, baseline depressive symptoms increased from 2007 to 2019 (PHQ-9 score, 2.3 to 2.9; difference, 0.6 [95% CI, 0.3 to 0.8]). The prevalence of baseline predictors of greater increase in depressive symptoms with internship also increased across cohorts. Despite the higher prevalence of baseline risk factors, the average change in depressive symptoms with internship decreased 24.4% from 2007 to 2019 (change in PHQ-9 score, 4.1 to 3.0; difference, -1.0 [CI, -1.5 to -0.6]). This change across cohorts was greater among women (4.7 to 3.3; difference, -1.4 [CI, -1.9 to -0.9]) than men (3.5 to 2.9; difference, -0.6 [CI, -1.2 to -0.05]) and greater among nonsurgical interns (4.1 to 3.0; difference, -1.1 [CI, -1.6 to -0.6]) than surgical interns (4.0 to 3.2; difference, -0.8 [CI, -1.2 to -0.4]). In parallel to the decrease in depressive symptom change, there were increases in sleep hours, quality of faculty feedback, and use of mental health services and a decrease in work hours across cohorts. The decrease in work hours was greater for nonsurgical than surgical interns. Further, the increase in mental health treatment across cohorts was greater for women than men.

LIMITATION

Data are observational and subject to biases due to nonrandom sampling, missing data, and unmeasured confounders, limiting causal conclusions.

CONCLUSION

Although depression during physician training remains high, the average increase in depressive symptoms associated with internship decreased between 2007 and 2019.

PRIMARY FUNDING SOURCE

National Institute of Mental Health.

Biological, Psychological, and Social Determinants of Depression: A Review of Recent Literature

Depression is one of the leading causes of disability, and, if left unmanaged, it can increase the risk for suicide. The evidence base on the determinants of depression is fragmented, which makes the interpretation of the results across studies difficult. The objective of this study is to conduct a thorough synthesis of the literature assessing the biological, psychological, and social determinants of depression in order to piece together the puzzle of the key factors that are related to this condition. Titles and abstracts published between 2017 and 2020 were identified in PubMed, as well as Medline, Scopus, and PsycInfo. Key words relating to biological, social, and psychological determinants as well as depression were applied to the databases, and the screening and data charting of the documents took place. We included 470 documents in this literature review. The findings showed that there are a plethora of risk and protective factors (relating to biological, psychological, and social determinants) that are related to depression; these determinants are interlinked and influence depression outcomes through a web of causation. In this paper, we describe and present the vast, fragmented, and complex literature related to this topic. This review may be used to guide practice, public health efforts, policy, and research related to mental health and, specifically, depression.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Residents' Perceptions of Faculty Behaviors and Resident Burnout: a Cross-Sectional Survey Study Across a Large Health Care Organization

BACKGROUND

Data suggests the learning environment factors influence resident well-being. The authors conducted an assessment of how residents' perceptions of faculty-resident relationships, faculty professional behaviors, and afforded autonomy related to resident burnout.

METHODS

All residents at one organization were surveyed in 2019 using two items from the Maslach Burnout Inventory and the faculty relationship subscale of the Johns Hopkins Learning Environment Scale (JHLES, range 6 to 30). Residents were also asked about faculty professional behaviors (range 0 to 30), and satisfaction with autonomy across various clinical settings.

RESULTS

A total of 762/1146 (66.5%) residents responded to the survey. After adjusting for age, gender, postgraduate year, and specialty, lower (less favorable) JHLES-faculty relationship subscale score (parameter estimate, - 3.08, 95% CI - 3.75, - 2.41, p < 0.0001), fewer observed faculty professional behaviors (parameter estimate, - 3.34, 95% CI - 4.02, - 2.67, p < 0.0001), and lower odds of satisfaction with autonomy in the intensive care settings (OR 0.46, 95% CI 0.30, 0.70, p = 0.001), but not other care settings, were reported by residents with burnout in comparison to those without. Similar relationships were observed when emotional exhaustion and depersonalization were analyzed separately as continuous variables.

CONCLUSION

In this cohort, resident perceptions of faculty relationships, faculty professional behaviors, and satisfaction with autonomy in the intensive care unit were associated with resident burnout. Additional longitudinal studies are needed to elucidate the direction of these relationships and determine if faculty development can reduce resident burnout.

Rethinking Strategies and Programs to Improve Physical and Emotional Well-being Among Healthcare Professionals: Facing the New Normalcy

Background

With the advent of coronavirus disease 2019 (COVID-19), a different perspective on the future of humanity has emerged that emphasizes the importance of building the capacities of healthcare providers in order to assist them with the heavy burden that these changes have placed on them both now and in the future. A reduction in the quality of life and the presence of prolonged fatigue are some of the most imminent problems that emerge among these professionals.

Objective

The aim of this study was to determine the effectiveness of a holistic intervention (workshop) for health science students aimed at developing skills that will enable them to obtain a better self-assessment of their quality of life, and prolonged fatigue.

Methods

Pre- and post-measures of quality of life, and prolonged fatigue were obtained from 130 health science students, including a group of 96 attendees (cases) of a 4-h wellness workshop and 34 students who did not attend (controls).

Results

Paired t tests indicated a significant improvement in nearly all dimensions related to quality of life, and prolonged fatigue in the case group who attended the workshop.

Conclusions

A comprehensive wellness strategy that utilizes a holistic approach can play an important role in improving and promoting essential skills to improve healthcare provider's self-assessment about the quality of life and reduce their prolonged fatigue. The critical importance of these needs has long been recognized, and this will also be crucial for addressing new challenges and emerging realities.

Redesigning the Learning Environment to Promote Learner Well-Being and Professional Development

There is a high prevalence of burnout and depression among medical students and residents (or learners), which can negatively impact them personally, their professional development, and the patients to whom they provide care. Educators have a responsibility for the system-level factors that influence learners' well-being. In this Invited Commentary, the authors outline strategies institutions and affiliated training sites responsible for educating learners can take to pursue the recommended goal related to learners, their well-being, and the learning environment in the National Academies of Sciences, Engineering, and Medicine consensus study report, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.

Outcomes in the age of competency-based medical education: Recommendations for emergency medicine training in Canada from the 2019 symposium of academic emergency physicians

Objectives

The national implementation of competency-based medical education (CBME) has prompted an increased interest in identifying and tracking clinical and educational outcomes for emergency medicine training programs. For the 2019 Canadian Association of Emergency Physicians (CAEP) Academic Symposium, we developed recommendations for measuring outcomes in emergency medicine training in the context of CBME to assist educational leaders and systems designers in program evaluation.

Methods

We conducted a three-phase study to generate educational and clinical outcomes for emergency medicine (EM) education in Canada. First, we elicited expert and community perspectives on the best educational and clinical outcomes through a structured consultation process using a targeted online survey. We then qualitatively analyzed these responses to generate a list of suggested outcomes. Last, we presented these outcomes to a diverse assembly of educators, trainees, and clinicians at the CAEP Academic Symposium for feedback and endorsement through a voting process.

Conclusion

Academic Symposium attendees endorsed the measurement and linkage of CBME educational and clinical outcomes. Twenty-five outcomes (15 educational, 10 clinical) were derived from the qualitative analysis of the survey results and the most important short- and long-term outcomes (both educational and clinical) were identified. These outcomes can be used to help measure the impact of CBME on the practice of Emergency Medicine in Canada to ensure that it meets both trainee and patient needs.

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.

In-the-Moment Feedback and Coaching: Improving R2C2 for a New Context

BACKGROUND

The R2C2, a 4-phase feedback and coaching model, builds relationships, explores reactions, determines content and coaches for change, and facilitates formal feedback conversations between clinical supervisors/preceptors and residents. Formal discussions about performance are typically based on collated information from daily encounter sheets, objective structured clinical examinations, multisource feedback, and other data. This model has not been studied in settings where brief feedback and coaching conversations occur immediately after a specific clinical experience.

OBJECTIVE

We explored how supervisors adapt the R2C2 model for in-the-moment feedback and coaching and developed a guide for its use in this context.

METHODS

Eleven purposefully selected supervisors were interviewed in 2018 to explore where they used the R2C2 model, how they adapted it for in-the-moment conversations, and phrases used corresponding to each phase that could guide design of a new R2C2 in-the-moment model.

RESULTS

Participants readily adapted the model to varied feedback situations; each of the 4 phases were relevant for conversations. Phase-specific phrases that could enable effective coaching conversations in a limited amount of time were identified. Data facilitated a revision of the original R2C2 model for in-the-moment feedback and coaching conversations and design of an accompanying trifold brochure to enable its effective use.

CONCLUSIONS

The R2C2 in-the-moment model offers a systematic approach to feedback and coaching that builds on the original model, yet addresses time constraints and the need for an iterative conversation between the reaction and content phases. The model enables supervisors to coach and co-create an action plan with residents to improve performance.

Physician-Friendly States for Mental Health: A Comparison of Medical Licensing Boards

Do medical boards undermine physician mental health by breaching physician confidentiality and privacy? We analyze the initial medical licensing process in each state to determine if qualified applicants who report mental illness experience discrimination. We then identify the most favorable states for physician mental health.  

Association Between Physician Depressive Symptoms and Medical Errors: A Systematic Review and Meta-analysis

IMPORTANCE

Depression is highly prevalent among physicians and has been associated with increased risk of medical errors. However, questions regarding the magnitude and temporal direction of these associations remain open in recent literature.

OBJECTIVE

To provide summary relative risk (RR) estimates for the associations between physician depressive symptoms and medical errors.

DATA SOURCES

A systematic search of Embase, ERIC, PubMed, PsycINFO, Scopus, and Web of Science was performed from database inception to December 31, 2018.

STUDY SELECTION

Peer-reviewed empirical studies that reported on a valid measure of physician depressive symptoms associated with perceived or observed medical errors were included. No language restrictions were applied.

DATA EXTRACTION AND SYNTHESIS

Study characteristics and RR estimates were extracted from each article. Estimates were pooled using random-effects meta-analysis. Differences by study-level characteristics were estimated using subgroup meta-analysis and metaregression. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed.

MAIN OUTCOMES AND MEASURES

Relative risk estimates for the associations between physician depressive symptoms and medical errors.

RESULTS

In total, 11 studies involving 21 517 physicians were included. Data were extracted from 7 longitudinal studies (64%; with 5595 individuals) and 4 cross-sectional studies (36%; with 15 922 individuals). The overall RR for medical errors among physicians with a positive screening for depression was 1.95 (95% CI, 1.63-2.33), with high heterogeneity across the studies (χ2 = 49.91; P < .001; I2 = 82%; τ2 = 0.06). Among the variables assessed, study design explained the most heterogeneity across studies, with lower RR estimates associated with medical errors in longitudinal studies (RR, 1.62; 95% CI, 1.43-1.84; χ2 = 5.77; P = .33; I2 = 13%; τ2 < 0.01) and higher RR estimates in cross-sectional studies (RR, 2.51; 95% CI, 2.20-2.83; χ2 = 5.44; P = .14; I2 = 45%; τ2 < 0.01). Similar to the results for the meta-analysis of physician depressive symptoms associated with subsequent medical errors, the meta-analysis of 4 longitudinal studies (involving 4462 individuals) found that medical errors associated with subsequent depressive symptoms had a pooled RR of 1.67 (95% CI, 1.48-1.87; χ2 = 1.85; P = .60; I2 = 0%; τ2 = 0), suggesting that the association between physician depressive symptoms and medical errors is bidirectional.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that physicians with a positive screening for depressive symptoms are at higher risk for medical errors. Further research is needed to evaluate whether interventions to reduce physician depressive symptoms could play a role in mitigating medical errors and thus improving physician well-being and patient care.