The psychological and physiological effects of acute occupational stress in new anesthesiology residents: a pilot trial

Career decisions, training priorities, and perceived challenges for anesthesiology residents in the United States

STUDY OBJECTIVE

This study sought to understand the timing and important factors identified by residents regarding their decision to pursue a career in anesthesiology, training areas deemed important to their future success, perceived greatest challenges facing the profession of anesthesiology, and their post-residency plans.

DESIGN

The American Board of Anesthesiology administered voluntary, anonymous, repeated cross-sectional surveys to residents who began clinical anesthesia training in the U.S. from 2013 to 2016 and were subsequently followed up yearly until the completion of their residency. The analyses included data from 12 surveys (4 cohorts from clinical anesthesia years 1 to 3), including multiple-choice questions, rankings, Likert scales, and free text responses. Free responses were analyzed using an iterative inductive coding process to determine the main themes.

MAIN RESULTS

The overall response rate was 36% (6480 responses to 17,793 invitations). Forty-five percent of residents chose anesthesiology during the 3rd year of medical school. "Nature of the clinical practice of anesthesiology" was the most important factor influencing their decision (average ranking of 5.93 out of 8 factors, 1 [least important] to 8 [most important]), followed by "ability to use pharmacology to acutely manipulate physiology" (5.75) and "favorable lifestyle" (5.22). "Practice management" and "political advocacy for anesthesiologists" (average rating 4.46 and 4.42, respectively, on a scale of 1 [very unimportant] to 5 [very important]) were considered the most important non-traditional training areas, followed by "anesthesiologists as leaders of the perioperative surgical home" (4.32), "structure and financing of the healthcare system" (4.27), and "principles of quality improvement" (4.26). Three out of 5 residents desired to pursue a fellowship; pain medicine, pediatric anesthesiology, and cardiac anesthesiology were the most popular choices, each accounting for approximately 20% of prospective fellows. Perceived greatest challenges facing the profession of anesthesiology included workforce competition from non-physician anesthesia providers and lack of advocacy for anesthesiologist values (referenced by 96% of respondents), changes and uncertainty in healthcare systems (30%), and personal challenges such as psychological well-being (3%).

CONCLUSIONS

Most residents identified anesthesiology as their career choice during medical school. Interest in non-traditional subjects and fellowship training was common. Competition from non-physician providers, healthcare system changes, and compromised psychological well-being were perceived concerns.

Implementation of an Un-Pairing Passport to Improve the Transition From Intern to Resident During a Critical Period of Anesthesiology Residency Training

Background

The transition from intern year to the first year of clinical anesthesiology residency (CA-1) is a challenging period for residents and their supervisors. Orientation methods and instructional material targeting this transition vary across U.S. residency programs. An un-pairing passport was implemented during the 2021-2022 transition to guide and provide expectations for interns, senior residents, and staff. The objective of this quality improvement project was to assess the effectiveness of the passport in improving the transition period and overall preparedness of the new CA-1s.

Methods

We surveyed 3 groups (CA-1s, CA-2s/CA-3s, and staff anesthesiologists) 6 months after the completion of passport implementation to retrospectively assess the 2021-2022 CA-1 class's preparedness across 7 domains compared with those who transitioned before passport implementation. Mann-Whitney U statistics and median effect sizes were used to compare pre- and postintervention.

Results

Self-reflected preparedness scores of the CA-1s were higher across all domains compared with the senior resident group (r = 0.328-0.548). Overall level of comfort and preparedness for the start of the CA-1 year was higher in the postintervention group (r = 0.162- 0.514). Staff anesthesiologists' perceived preparedness of the residents was also higher across all domains for the postintervention group (r = 0.197-0.387).

Conclusion

The un-pairing passport improved residents' and staff anesthesiologists' subjective assessments of the readiness of new CA-1 residents after a critical transition in their training. Similar tools can be more broadly applied to other anesthesiology residency and possibly fellowship programs as well as subspecialty rotations within those programs.

Occupational characteristics and incident anxiety and depression: A prospective cohort study of 206,790 participants

BACKGROUND

This study aimed to analyze the impact of a wide spectrum of occupational characteristics on the incidence of anxiety and depression, and to determine the features affecting adaptation to specific characteristics.

METHODS

Participants in paid employment or self-employed at baseline in UKB were included, with occupational characteristics extracted from O*NET. Cox-proportional-hazard models were conducted in the main analyses and subgroup analyses.

RESULTS

Direct work with the public and exposure to disease/infections were first time demonstrated to be risk factors for both anxiety and depression, along with occupations involving more physical activities and dealing with unpleasant/physically aggressive people. Protective factors for both: time spent sitting, communication, decision making, creativity and reasoning, and responsibility in work. Protective factors for anxiety only: Coordinating/leading, fluency of ideas, originality, problem sensitivity, decision latitude, and time pressure. Risk factor for depression only: Exposure to contaminants. Females were found more sensitive to dealing with unpleasant/physically aggressive people. The impact of exposure to disease/infections was more significant among those with lower education levels. Those with BMI over 24 were more sensitive to the risk factors.

LIMITATIONS

The short-term effect of the above exposures remained unclear. The scores of occupational characteristics were based on self-reported questionnaires. There was the potential for undiagnosed anxiety or depression events. The participants included only those aged from 40 to 69. Participants included in this cohort were mainly White British.

CONCLUSIONS

Our findings advocate closer monitoring of the mental health of workers with risk work-related factors.

High anesthetic exposure leads to oxidative damage and gene expression changes in physicians during medical residency: a cohort study

Evaluation of the possible toxic effects of occupational exposure to anesthetics is of great importance, and the literature is limited in assessing the possible association between occupational exposure to anesthetics and oxidative stress and genetic damage. To contribute to the gap of knowledge in relation to cause-effect, this cohort study was the first to monitor exposure assessment and to evaluate oxidative stress, DNA damage, and gene expression (OGG1, NRF2, HO-1, and TP53) in young adult physicians occupationally exposed to the most modern halogenated anesthetics (currently the commonly used inhalational anesthetics worldwide) in addition to nitrous oxide gas during the medical residency period. Therefore, the physicians were evaluated before the beginning of the medical residency (before the exposure to anesthetics-baseline), during (1 1/2 year) and at the end (2 1/2 years) of the medical residency. Anesthetic air monitoring was performed in operating rooms without adequate ventilation/scavenging systems, and biological samples were analyzed for lipid peroxidation, protein carbonyl content, primary and oxidative DNA damage, antioxidant enzymes and plasma antioxidant capacity, and expression of some key genes. The results showed induction of lipid peroxidation, DNA damage, glutathione peroxidase activity, and NRF2 and OGG1 expression up to the end of medical residency. Plasma antioxidant capacity progressively increased throughout medical residency; oxidative DNA damage levels started to increase during medical residency and were higher at the end of residency than at baseline. Protein carbonyls increased during but not at the end of medical residency compared to baseline. The antioxidant enzyme superoxide dismutase activity remained lower than baseline during and at the end of medical residency, and HO-1 (related to antioxidant defense) expression was downregulated at the end of medical residency. Additionally, anesthetic concentrations were above international recommendations. In conclusion, high concentrations of anesthetic in the workplace induce oxidative stress, gene expression modulation, and genotoxicity in physicians during their specialization period.

[Assessment method of cognitive load and stress inducer factors of surgeons and anesthetists in the operating room]

INTRODUCTION

For many years, surgeons and anesthetists have recognized that stress can be present in their daily professional practice. The goal of this study was to identify tools for assessing stress and cognitive load in the operating room.

MATERIAL AND METHODS

We conducted a literature review in the PubMed database of scientific articles published on the subject without date limit using the keywords anesthesia, surgery, surgeon, cognitive workload, definition, pathophysiology, physiological measurement, objective, subjective, stress.

RESULTS

Nineteen articles were selected, focusing on cardiac surgery, gastrointestinal surgery, vascular surgery and urology. No publications concerning ophthalmology were found through the literature search. The means of measurement found were either subjective, such as questionnaires, or objective, such as the study of heart rate variability (HRV), reaction time, eye movements, electrical conductivity of the skin, biological markers and electroencephalogram. Of all these measurement tools, the NASA-TLX questionnaire, used in four articles, and the HRV study, used in eight articles, appear to be the most widely used and are strongly correlated with stress.

CONCLUSION

The articles reviewed use only some of the available tools for assessment of stress and cognitive load. The main objective is to improve the quality of care and the quality of life of caregivers. It would be interesting to develop other methods to identify and better characterize the risk factors that increase stress and cognitive load.

The Nurse Empowerment Program for Nurses in Direct Care Positions

OBJECTIVE

An educational program including online generic and nursing-specific content was evaluated for self-assessed leadership skill outcomes.

BACKGROUND

Leadership development for nurses in direct care positions has not received the same support as for nurses in formal leadership positions. Pandemic and workforce changes make it critical that leadership skills be built at all levels of nursing.

METHODS

Early-career nurses (≤10 years of experience) were recruited to participate in an online leadership development program offering 9 LinkedIn Learning courses, 3 leadership courses from Sigma, an e-book, and a discussion board.

RESULTS

Most participants who responded to both immediate postsurvey and 3-month follow-up survey (98.6% of n = 69) reported having applied new or improved abilities in their nursing practice to at least a small degree, and the majority reported having done so to a moderate or great degree.

CONCLUSION

This online leadership development program was valued and was associated with improved self-assessed leadership.

A Perspective on Wellness in Anesthesiology Residency Programs: A Multi-Strategy Approach

Addressing resident wellness is an important topic given the high risk for burnout and depression in resident physicians compared with the general U.S. population. This article provides an overview of various approaches to help conceptualize and intervene on resident wellness, based on the 9-strategies framework to improve wellness laid out by Shanafelt and colleagues. This article outlines the most relevant literature in each strategy followed by the authors' experience within their anesthesiology residency program.

Early-Career Physician Burnout

Early-career physicians face a broad range of challenges unique to their phase of life and career. Beginning in residency, anesthesiologists encounter stressors unique to their work environment, which, when coupled with their personal life demands, places significant burden and creates potential for burnout. In this article, the authors review the literature to explore the contributors of burnout in early-career anesthesiologists, evaluate the relationship between compassionate care and empathic distress, and propose strategies to prevent and treat burnout in this specific subset of anesthesiologists.

Validation of Visual Analogue Scales of job demand and job control at the workplace: a cross-sectional study

OBJECTIVES

Work-related stress is a major concern. One of the best performing models is the Job Content Questionnaire (JCQ) of Karasek, assessing job demand and job control using 18 items. However, the JCQ is long and complex. Visual Analogue Scales (VASs) are easy to use and quick to implement. VASs have been validated to assess pain and occupational stress; however, VASs demand and control have not been evaluated. Therefore, we aimed to validate the use of VAS demand and control compared with the 18 items of the JCQ.

DESIGN

We implemented a cross-sectional observational study, by administering a self-reported questionnaire to the users of Wittyfit software, with a second test (retest) proposed 1 week later. In addition to JCQ, VAS demand and control, we measured sociodemographic outcomes, as well as characteristics of work, sleep, well-being, stress, depression and anxiety.

PARTICIPANTS

190 volunteers French workers using WittyFit software participated in the study, and 129 completed the test-retest.

RESULTS

VAS demand and VAS control correlated with the two Karasek domains from the JCQ, respectively, at 0.59 and 0.57 (p<0.001). Test-retest reliability highlighted concordance coefficients higher than 0.70. Sensitivity was higher than 70% for each VAS. External validity was acceptable. For both demand and control, VAS cut-offs were 75/100. Compared with other workers, senior executives and individuals with master's degrees had higher levels of job control but did not differ in job demand using the VAS and JCQ.

CONCLUSIONS

VAS demand and VAS control are valid, quick, easy to use, and reliable tools for the assessment of job demand and job control. They can be used in daily clinical practice for primary prevention and diagnosis. However, when results are over 75 mm on VAS, we promote the use of JCQ to be more discriminant and specific to initiate action plans to help workers.

TRIAL REGISTRATION NUMBER

NCT02596737.

Chronic stress indicated by hair cortisol concentration in anaesthesiologists and its relationship to work experience and emotional intelligence: A cross-sectional biomarker and survey study

BACKGROUND

Anaesthesia is a stressful medical specialty. The reaction to stress is constituted by behavioural, psychological and physiological components. Chronic physiological stress can have negative consequences for health.

OBJECTIVES

First, we hypothesised that chronic physiological stress is higher for both beginning and late-career consultant anaesthesiologists. Second, we hypothesised that individuals high in emotional intelligence endure lower physiological stress.

DESIGN

Cross-sectional biomarker and survey study.

SETTING

Participants were recruited during the May 2019 annual meeting of the Dutch Anaesthesia Society.

PARTICIPANTS

Of the 1348 colleagues who attended the meeting, 184 (70 male/114 female) participated in the study. Of the study participants, 123 (67%) were consultant anaesthesiologists (52 male/71 female) and 61 (33%) were resident anaesthesiologists (18 male/43 female). Exclusion criteria were endocrine disorders and not having enough hair. Also, experience of a recent major life event led to exclusion from analysis of our hypotheses.

MAIN OUTCOME MEASURES

Chronic physiological stress was measured by hair cortisol concentration. Emotional intelligence was assessed using a validated Dutch version of the Trait Emotional Intelligence Questionnaire. As secondary measures, psychological sources of stress were assessed using validated Dutch versions of the home-work interference (SWING) and the effort-reward imbalance questionnaires.

RESULTS

In support of Hypothesis 1, hair cortisol concentration was highest among early and late-career consultant anaesthesiologists (quadratic effect: b = 45.5, SE = 16.1, t = 2.8, P = 0.006, R2 = 0.14). This nonlinear pattern was not mirrored by self-reported sources of psychological stress. Our results did not support Hypothesis 2; we found no evidence for a relationship between emotional intelligence and physiological stress.

CONCLUSION

In the early and later phases of an anaesthesiologist's career, physiological chronic stress is higher than in the middle of the career. However, this physiological response could not be explained from known sources of psychological stress. We discuss these findings against the background of key differences between physiological and psychological stress.

Variations in Salivary Stress Biomarkers and Their Relationship with Anxiety, Self-Efficacy and Sleeping Quality in Emergency Health Care Professionals

Hospital healthcare workers of emergency departments (EDs) face a variety of occupational stressors on a daily basis. We have recently published that emergency professionals display increased salivary levels of α-amylase and dehydroepiandrosterone during the working day. The pattern of these markers may suggest a counteracting mechanism of dehydroepiandrosterone against the stress reflected by amylase increases. In order to verify this hypothesis, we have analysed different psychological aspects in the same group of healthcare professionals through different tests related to behaviours resulting from stress. These include the state-trait anxiety inventory, the self-efficacy test and the sleeping quality questionnaire. The tests were provided at the beginning of the working day and collected at the end. STAI scores (trait and state) were indicative of no anxiety. Self-efficacy scores were considered optimal, as well as those from the sleeping quality questionnaire. This is supported by the modest correlation between STAI scores and salivary levels of α-amylase and dehydroepiandrosterone. In conclusion, the emergency professionals of the studied hospitals seem to have adequate work management. Altogether it means that the stress generated during work performance is controlled, allowing a correct adaptation to the demanding situations undergone in emergency departments.

Stress Salivary Biomarkers Variation during the Work Day in Emergencies in Healthcare Professionals

OBJECTIVE

The work of health professionals in hospital emergency rooms is highly demanding due to the decisions they must take. In the present study, we consider assessing stress response in emergency health workers, measuring related biomarkers such as cortisol, dehydroepiandrosterone (DHEA) and salivary α-amylase during the whole working day.

METHOD

An analytical, descriptive and cross-sectional study was carried out. The study was conducted in the emergency rooms of two public hospitals. Ninety-seven professionals participated, 45 corresponding to one hospital and 52 to the other. Four salivary samples were obtained according to circadian rhythms: at 8:00, 12:00, 15:00 and 00:00 h/24 h. The data were subsequently analyzed.

RESULTS

Cortisol levels decreased throughout the working day, with minimum values being at 24 h. A similar pattern was observed in DHEA. The α-amylase levels increased throughout the working day, reaching its peak at 15:00 h, and decreasing at 24 h, compared to the data from the rest of the working day.

CONCLUSIONS

Since reference/baseline values are not presented, this work is focused on a stress situation experienced during one regular working day in emergency rooms with no extreme situations. In this context, stress, measured through cortisol and α-amylase, is present in emergency room doctors and nurses. However, the increase in DHEA, due to its anabolic condition, could counteract their effect, suggesting a positive effect on their professional actions.

Training the Trainer: Preparing Anesthesiology Residents to be Trainers in the Operating Room

INTRODUCTION

The transition into clinical anesthesiology is a challenging period that requires swift acquisition of clinical knowledge and procedural skills. Senior residents are in a prime position to help their junior colleagues into the operating room environment due to their ability to relate from personal experience. We created a workshop for enhancing peer apprenticeship during this transition.

METHODS

The workshop consisted of PowerPoint didactics interspersed with small-group practice sessions. Surveys were administered pre-, post-, 1-week post-, and 1-month postworkshop. The primary outcome was pre-post improvement in the proportion of residents prepared to be a trainer. Secondary outcomes included pre- to 1-week postworkshop improvement, pre-postworkshop change in knowledge of learning theory concepts, and pre-postworkshop change in first-year clinical anesthesiology perceptions of trainers.

RESULTS

Of residents, 12 of 43 (28%) eligible to be resident trainers attended the workshop. The proportion of residents who felt prepared increased from 75% preworkshop to 100% postworkshop and remained at 93% at 1 week. Knowledge of cognitive load and microskills improved from 0% preworkshop to 83% postworkshop but dropped to 0% at 1 month. Comfort using microskills improved from 0% preworkshop to 83% postworkshop.

DISCUSSION

Early anesthesiology training demands rapid acquisition of novel cognitive and procedural skills. Senior anesthesiology residents are in a prime position to train junior residents, yet many are uncomfortable with this role. We developed a workshop to transition residents into a peer trainer role and significantly increased their confidence to be a trainer. Other programs may benefit from implementing similar training.

A Muscular and Cerebral Physiological Indices Assessment for Stress Measuring during Virtual Wheelchair Guidance

The work presented in this manuscript has the purpose to assess the relationship between human factors and physiological indices. We discuss the relationship between stress as human factor and cerebral and muscular signals as features. Ten male paraplegic, right-handed subjects were volunteers for the experiment (mean age 34 ±6). They drove a virtual wheelchair in an indoor environment. They filled five missions where, in each one, an environmental parameter was changed. Meanwhile, they were equipped with Electromyography (EMG) sensors and Electroencephalography (EEG). Frequency and temporal features were filtered and extracted. Principal component analysis (PCA), Fisher's tests, repeated measure Anova and post hoc Tukey test (α = 0.05) were implemented for statistics. Environmental modifications are subject to induce stress, which impacts muscular and cerebral activities. While the time pressure parameter was the most influent, the transition from static to moving obstacles (avatars), tends to have a significant impact on stress levels. However, adding more moving obstacles did not show any impact. A synchronization factor was noticed between cerebral and muscular features in higher stress levels. Further examination is needed to assess EEG reliability in these situations.

Hepatotoxic and neuroendocrine effects in physicians occupationally exposed to most modern halogenated anesthetics and nitrous oxide

The lack of data on hepatic and hormonal markers for occupational exposure to most modern halogenated anesthetics has stimulated our research, which assessed liver enzymes, high-sensitivity C-reactive protein (hs-CRP) and neuroendocrine response. The study investigated 106 physicians who were categorized in an exposed group (primarily exposed to isoflurane and sevoflurane and less to desflurane and nitrous oxide) as well as as a control group. Anesthetic air monitoring was performed, and biological samples were analyzed for the most important liver enzymes, hs-CRP, adrenocorticotrophic hormone, cortisol and prolactin. No biomarkers were significantly different between the groups. Exposed males showed significant increases in cortisol and prolactin compared to unexposed males. However, values were within the reference ranges, and 22 % of exposed males versus 5 % of unexposed males exhibited higher prolactin values above the reference range. This study suggests that occupational exposure to the most commonly used inhalational anesthetics is not associated with hepatotoxicity or neurohormonal changes.

Family Comes First: A Pilot Study of the Incorporation of Social Support Into Resident Well-being

BACKGROUND

Recent work has shown that understanding of work-related stress by family and friends is associated with increased resident well-being. However, it is often difficult for residents to communicate with their support persons (SPs), especially those who have minimal understanding of the medical field, regarding even the most basic functions of their role in the health care system. This study aimed to pilot test an innovative wellness event focusing on the social relatedness component of resident well-being.

METHODS

The target population included 30 new residents at 2 anesthesiology residency programs and their SPs in 2017. The Family Anesthesia Experience (FAX) began with didactic presentations and a panel discussion about wellness topics. It concluded with a multifaceted simulation experience. Participants were surveyed before and after the event. Measures included SPs' understanding of residents' work and residents' stress, burnout, resilience, and social support levels. Student t tests, Mann-Whitney U tests, Wilcoxon signed-rank tests, and repeated measures analysis of variance were used to examine the impact of the event.

RESULTS

Twenty-two (84.6%) of the 26 intervention clinical anesthesia year 1 residents who attended FAX completed the postevent surveys, and all intervention SPs (100%, n = 33) completed both pre-event and postevent surveys. The event was well received by the residents (100%) and their SPs (100%). Improvement in perceived understanding in the intervention SPs group (Pre: 1.44 ± 0.63, Post: 2.69 ± 0.33, P < .0001) was observed. Not all metrics of well-being for the residents achieved significance in change; however, decreased stress was observed compared with historical controls (Control: 1.91 ± 0.61, Intervention: 1.54 ± 0.42, P = .019).

CONCLUSION

The event led to improved SPs' understanding of the role of an anesthesiology resident.

Methods of Orienting New Anesthesiology Residents to the Operating Room Environment: A National Survey of Residency Program Directors

BACKGROUND

The initial weeks of clinical anesthesiology are a formative period for new residents. Trainees may be clinically educated by a variety of individuals, and introductory didactic structure likely differs between institutions. This study was undertaken to define current orientation practices in US anesthesiology residency programs.

METHODS

A survey was created using Qualtrics© software and distributed to all US anesthesiology residency program directors through the Society of Academic Associations of Anesthesiology & Perioperative Medicine email newsletter and through direct email to program directors.

RESULTS

Fifty-six unique survey responses were received of 156 total programs. Eighty-nine percent of programs with an integrated intern year begin anesthesia-related orientation before the first year of clinical anesthesiology. Sixty-three percent of programs pair trainees with more than one specific individual during orientation. Programs most frequently pair trainees with anesthesiologists (75%) and/or senior residents (70%). Forty-six percent maintain this pairing for 4 weeks and 30% for 6 weeks or longer. Forty-three percent provide education on teaching practices to trainers. Introductory didactics last a median of 30 hours. Programs may blend lectures, simulations/workshops, digital content, problem-based learning, pocket references, and/or checklists into a cohesive introductory curriculum. Fifty-six percent begin call responsibilities in the sixth week of orientation or later.

CONCLUSIONS

Orientation practices for clinical anesthesia training vary across residency programs in the United States. We hope this information will help program directors compare their orientation practices to other programs and identify best practices and potentially useful variations.

Towards a Transversal Definition of Psychological Resilience: A Literature Review

Background and objectives: This paper addresses psychological resilience, a multidisciplinary theoretical construct with important practical implications for health sciences. Although many definitions have been proposed in several contexts, an essential understanding of the concept is still lacking up to now. This negatively affects comparisons among research results and makes objective measurement difficult. The aim of this review is to identify shared elements in defining the construct of resilience across the literature examined in order to move toward a conceptual unification of the term. Materials and methods: A literature review was performed using the electronic databases 'PubMed' and 'PsycINFO'. Scientific studies written in English between 2002 and May 2019 were included according to the following key terms: 'Psychological', 'resilience', and 'definition'. Results: The review identifies five macro-categories that summarize what has been reported in the recent literature concerning the resilience phenomenon. They serve as a preliminary and necessary step toward a conceptual clarification of the construct. Conclusions: We propose a definition of psychological resilience as the ability to maintain the persistence of one's orientation towards existential purposes. It constitutes a transversal attitude that can be understood as the ability to overcome the difficulties experienced in the different areas of one's life with perseverance, as well as good awareness of oneself and one's own internal coherence by activating a personal growth project. The conceptual clarification proposed will contribute to improving the accuracy of research on this topic by suggesting future paths of investigation aimed at deeply exploring the issues surrounding the promotion of resilience resources.

Repeated Cross-sectional Surveys of Burnout, Distress, and Depression among Anesthesiology Residents and First-year Graduates

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

This repeated cross-sectional survey study was conducted to determine the prevalence of, and factors associated with, burnout, distress, and depression among anesthesiology residents and first-year graduates. We hypothesized that heavy workload and student debt burden were associated with a higher risk of physician burnout, distress, and depression, and that perception of having adequate workplace resources, work–life balance, and social support were associated with a lower risk.

Methods

Physicians beginning U.S. anesthesiology residency between 2013 and 2016 were invited to take online surveys annually from their clinical anesthesia year 1 to 1 yr after residency graduation. The Maslach Burnout Inventory, the Physician Well-Being Index, and the Harvard Department of Psychiatry/National Depression Screening Day Scale were used to measure burnout, distress, and depression, respectively. Logistic regression analyses were conducted to examine whether self-reported demographics, personal, and professional factors were associated with the risk of burnout, distress, and depression.

Results

The response rate was 36% (5,295 of 14,529). The prevalence of burnout, distress, and depression was 51% (2,531 of 4,966), 32% (1,575 of 4,941), and 12% (565 of 4,840), respectively. Factors associated with a lower risk of all three outcomes included respondents’ perceived workplace resource availability, (odds ratio = 0.51 [95% CI, 0.45 to 0.57] for burnout; 0.51 [95% CI, 0.45 to 0.56] for distress; 0.52 [95% CI, 0.45 to 0.60] for depression) and perceived ability to maintain work–life balance (0.61 [95% CI, 0.56 to 0.67] for burnout; 0.50 [95% CI, 0.46 to 0.55] for distress; 0.58 [95% CI, 0.51 to 0.65] for depression). A greater number of hours worked per week and a higher amount of student debt were associated with a higher risk of distress and depression, but not burnout.

Conclusions

Burnout, distress, and depression are notable among anesthesiology residents. Perceived institutional support, work–life balance, strength of social support, workload, and student debt impact physician well-being.

Measurement of physiological responses to acute stress in multiple occupations: A systematic review and implications for front line healthcare providers

Optimizing performance of individuals in acutely stressful work-related situations requires a deeper understanding of the interaction between the demands of the stimuli and an individual's associated physiological response. Identifying these responses is particularly germane for healthcare professionals, who experience episodes of acute stress on a regular basis. The purpose of this review was to examine and synthesize empirical literature to identify studies assessing physiological responses to acute stress, determine common methods for measuring acute stress in near real-time, and identify common research designs employed across industries. A modified PRISMA approach was followed. Systematic searches were conducted of four databases (PsycINFO, Medline, PubMed, and Turning Research into Practice [TRIP]) to access eligibility. Reference list searches and a hand search were also conducted to identify other articles suitable for inclusion. Studies selected examined an acute physiological response while participants were engaged in a stress-inducing task. Twenty-two articles were included. Fifteen (68.2%) were centered on the human service industry while only three (13.6%) focused on healthcare professionals. Half of the studies incorporated a simulation into the research design while only two (9.1%) articles looked at physiological responses in real-world settings. Heart rate and cortisol emerged as the most common physiological measures collected. This review demonstrates that acute stress is primarily assessed retrospectively, and that there is a pragmatic gap in methodological approach, with many data collection methods inappropriate for the healthcare environment. Future research should capitalize on advancements in sensor technology to passively examine acute stress in healthcare professionals.

Variations in Physiological and Psychological Responses of Orthopaedic Surgeons and Clinical Fellows during Hip and Knee Arthroplasties

Background:

Both physical and mental stress is present within the practice of healthcare professionals, which in turn negatively affects the quality of the services provided to the population and therefore, leading to mental exhaustion of the individuals involved.

Purpose:

To track physiological and psychological responses to common hip and knee surgeries, and during clinic days, in a group of orthopaedic surgeons and their clinical fellows (trainees), and to compare the physiological and psychological results with baseline physiological stress tests.

Methods:

Heart Rate (HR), Breathing Rate (BR), and self-reported anxiety were recorded in 3 fellowship trained orthopaedic surgeons and 5 clinical fellows using a wearable Equivital EQO2 physiological monitor and the State-Trait Anxiety Inventory (STAI). Data was recorded for days in surgery as well as clinic for 6-8 hours/day. This data was compared to baseline physiological stress tests.

Results:

Mean HR and percentage of heart rate maximum (%HR-max) were not significantly different between staff and fellows throughout the surgery days regardless of the role occupied during both primary Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA). For Heart rate variability (HRV), there was no difference noted between staff and fellows at any moment around and during THA, however, fellows had significantly higher variability during TKA and maintained this increased variability in the postoperative period. In THA, staff failed to show any statistical difference between the HRV in the cases they were assuming the role of primary surgeon compared to the cases they were assisting and the clinic days. On the contrary, fellows showed significantly higher HRV when they were assisting during THA compared to when they were assuming the primary surgeon role or during their clinic days.

Conclusion:

Different stress patterns were noted in clinical fellows compared to the staff, especially showing a higher overall HRV during TKA.

Decreased Parasympathetic Activity of Heart Rate Variability During Anticipation of Night Duty in Anesthesiology Residents

BACKGROUND

In residency programs, it is well known that autonomic regulation is influenced by night duty due to workload stress and sleep deprivation. A less investigated question is the impact on the autonomic nervous system of residents before or when anticipating a night duty shift. In this study, heart rate variability (HRV) was evaluated as a measure of autonomic nervous system regulation.

METHODS

Eight residents in the Department of Anesthesiology were recruited, and 5 minutes of electrocardiography were recorded under 3 different conditions: (1) the morning of a regular work day (baseline); (2) the morning before a night duty shift (anticipating the night duty); and (3) the morning after a night duty shift. HRV parameters in the time and frequency domains were calculated. Repeated measures analysis of variance was performed to compare the HRV parameters among the 3 conditions.

RESULTS

There was a significant decrease of parasympathetic-related HRV measurements (high-frequency power and root mean square of the standard deviation of R-R intervals) in the morning before night duty compared with the regular work day. The mean difference of high-frequency power between the 2 groups was 80.2 ms (95% confidence interval, 14.5-146) and that of root mean square of the standard deviation of R-R intervals was 26 milliseconds (95% confidence interval, 7.2-44.8), with P = .016 and .007, respectively. These results suggest that the decrease of parasympathetic activity is associated with stress related to the condition of anticipating the night duty work. On the other hand, the HRV parameters in the morning after duty were not different from the regular workday.

CONCLUSIONS

The stress of anticipating the night duty work may affect regulation of the autonomic nervous system, mainly manifested as a decrease in parasympathetic activity. The effect of this change on the health of medical personnel deserves our concern.

Observational study evaluating obstetric anesthesiologist residents' well-being, anxiety and stress in a North American academic program

BACKGROUND

The obstetric work environment has a unique set of stressors that may be associated with burnout. We investigated how well-being during the obstetric anesthesia (ObA) rotation compared to other rotations; which workplace environment characteristics precipitated the greatest stress; and whether anxiety and stress levels changed in trainees before and after an ObA rotation.

METHODS

Using a survey, anesthesia residents (n=36) ranked their well-being on each anesthesia rotation and answered questions about their work environment. A separate survey measured anxiety and stress before and after an ObA rotation. Friedman's test was used to compare ranking data and Likert responses. T-tests were used to compare stress and anxiety scores.

RESULTS

Residents' ranking of well-being on ObA was higher than that on another high demand rotation (cardiothoracic anesthesia, P=0.007). Work environment stress scores were significantly higher among community and fairness domains than for workload (P=0.002 and P=0.0001, respectively). While stress and anxiety scores did not significantly differ before and after the ObA rotation, they were higher than the reference population scores.

CONCLUSIONS

We provide the first example of tools for assessing work environment stressors in ObA. Our study illustrates that beyond excessive workload, lack of fairness and community values are areas that impact physician well-being. Use of these tools can guide initiatives to address work environment concerns, and presents a need for a validated well-being instrument to gauge physician well-being, in order to create a cultural shift from burnout to one of well-being.

Linear and non-linear heart rate metrics for the assessment of anaesthetists' workload during general anaesthesia

BACKGROUND

Excessive workload may impact the anaesthetists' ability to adequately process information during clinical practice in the operation room and may result in inaccurate situational awareness and performance. This exploratory study investigated heart rate (HR), linear and non-linear heart rate variability (HRV) metrics and subjective ratings scales for the assessment of workload associated with the anaesthesia stages induction, maintenance and emergence.

METHODS

HR and HRV metrics were calculated based on five min segments from each of the three anaesthesia stages. The area under the receiver operating characteristics curve (AUC) of the investigated metrics was calculated to assess their ability to discriminate between the stages of anaesthesia. Additionally, a multiparametric approach based on logistic regression models was performed to further evaluate whether linear or non-linear heart rate metrics are suitable for the assessment of workload.

RESULTS

Mean HR and several linear and non-linear HRV metrics including subjective workload ratings differed significantly between stages of anaesthesia. Permutation Entropy (PeEn, AUC=0.828) and mean HR (AUC=0.826) discriminated best between the anaesthesia stages induction and maintenance. In the multiparametric approach using logistic regression models, the model based on non-linear heart rate metrics provided a higher AUC compared with the models based on linear metrics.

CONCLUSIONS

In this exploratory study based on short ECG segment analysis, PeEn and HR seem to be promising to separate workload levels between different stages of anaesthesia. The multiparametric analysis of the regression models favours non-linear heart rate metrics over linear metrics.

What Do We Mean by Physician Wellness? A Systematic Review of Its Definition and Measurement

OBJECTIVE

Physician wellness (well-being) is recognized for its intrinsic importance and impact on patient care, but it is a construct that lacks conceptual clarity. The authors conducted a systematic review to characterize the conceptualization of physician wellness in the literature by synthesizing definitions and measures used to operationalize the construct.

METHODS

A total of 3057 references identified from PubMed, Web of Science, and a manual reference check were reviewed for studies that quantitatively assessed the "wellness" or "well-being" of physicians. Definitions of physician wellness were thematically synthesized. Measures of physician wellness were classified based on their dimensional, contextual, and valence attributes, and changes in the operationalization of physician wellness were assessed over time (1989-2015).

RESULTS

Only 14% of included papers (11/78) explicitly defined physician wellness. At least one measure of mental, social, physical, and integrated well-being was present in 89, 50, 49, and 37% of papers, respectively. The number of papers operationalizing physician wellness using integrated, general-life well-being measures (e.g., meaning in life) increased [X ² = 5.08, p = 0.02] over time. Changes in measurement across mental, physical, and social domains remained stable over time.

CONCLUSIONS

Conceptualizations of physician wellness varied widely, with greatest emphasis on negative moods/emotions (e.g., burnout). Clarity and consensus regarding the conceptual definition of physician wellness is needed to advance the development of valid and reliable physician wellness measures, improve the consistency by which the construct is operationalized, and increase comparability of findings across studies. To guide future physician wellness assessments and interventions, the authors propose a holistic definition.

Long-term follow-up of mind-body medicine practices among medical school graduates

INTRODUCTION

We sought to determine the long-term use of mind-body medicine (MBM) skills after graduation from medical school.

METHODS

An online survey was sent to Georgetown University School of Medicine (GUSOM) graduates who completed at least one semester of a MBM skills training course. Using a quantitative-qualitative mixed-methods approach, we assessed the personal and professional practices of graduates, and identified factors that may influence practice/training after graduation.

RESULTS

Current personal practices were positively related to the level of the course completed and amount of home practice during medical school (N = 112). Over half the sample indicated they currently practice MBM and refer patients to MBM. Moreover, physician specialty and awareness of home institution MBM training was associated with MBM patient training and referral. Participants reported a dearth of MBM training at their home institutions, and provided qualitative insights about the personal and professional impact of MBM training as well as barriers to continued MBM practice.

CONCLUSIONS

The results provide preliminary evidence that MBM training during medical school may be related over time to physician trainee self-care and patient care. Rigorous tests of these relationships should be conducted in future work.

Encouraging Mindfulness in Medical House Staff via Smartphone App: A Pilot Study

BACKGROUND

Stress and burnout are increasingly recognized as urgent issues among resident physicians, especially given the concerning implications of burnout on physician well-being and patient care outcomes.

OBJECTIVE

The authors assessed how a mindfulness and meditation practice among residents, supported via a self-guided, smartphone-based mindfulness app, affects wellness as measured by prevalidated surveys.

METHODS

Residents in the departments of general surgery, anesthesia, and obstetrics and gynecology were recruited for participation in this survey-based, four-week, single-arm study. All participants used the app (Headspace) on a self-guided basis, and took surveys at enrollment, at 2 weeks, and at 4 weeks. The Positive and Negative Affect Schedule (PANAS) assessed mood, and the Freiburg Mindfulness Inventory (FMI) measured mindfulness.

RESULTS

Forty-three residents enrolled in this study from April 2015 to August 2016; 30 residents (90% female) completed two or more surveys, and so were included for further analysis. In a comparison of baseline scores to week four scores, there was a significant increase in FMI at week four (36.88 ± 7.00; Cohen's d = 0.77, p = 0.005), a trend toward increase in the positive affect score (PAS) (31.73 ± 6.07; Cohen's d = 0.38, p = 0.08), and no change in negative affect score (NAS) (21.62 ± 7.85; Cohen's d = -0.15, p = NS). In mixed-effect multivariate modeling, both the PAS and the FMI scores showed significant positive change with increasing use of the smartphone app (PAS, 0.31 (95% CI 0.03-0.57); FMI, 0.38 (95% CI 0.11-0.66)), while the NAS did not show significant change.

CONCLUSIONS

Study limitations include self-guided app usage, a homogenous study subject population, insufficient study subjects to perform stratified analysis of the impact of specialty on the findings, lack of control group, and possible influence from the Hawthorne effect. This study suggests the feasibility and efficacy of a short mindfulness intervention delivered by a smartphone app to improve mindfulness and associated resident physician wellness parameters.

Heart Rate Variability in Obstetricians Working 14-Hour Call Compared to 24-Hour Call in Labour and Delivery

INTRODUCTION

Obstetricians have stressful and demanding jobs that may impact their health. A physiological measurement of cardiac function which varies with stress is heart rate variability (HRV). By measuring the cyclic variations in R-R intervals, or beat-to-beat differences, HRV reflects the continuous interplay of the controlling forces in the autonomic nervous system. Studies have shown HRV to be reduced during periods of work-induced stress, including 24-hour shifts.

OBJECTIVE

Our study aimed to determine if there was a correlation between length of shift worked and HRV. We hypothesised that working for a full 24-hour period is more stressful than a shorter, nighttime-only period, and HRV analyses were used to measure this objectively.

METHODS

Obstetricians wore an HRV monitor for 24 hours during both a regular day followed by a 14-hour night shift and a continuous 24-hour shift in labour and delivery. The 24-hour samples were analysed using standard HRV measurements. HRV measurements obtained from each physician were then compared according to shift type, with each physician acting as his or her own comparator.

RESULTS

There were no statistically significant differences in the most important measures of HRV between 24-hour periods which included either a 14-hour overnight shift or a continuous 24-hour shift on labour and delivery.

CONCLUSION

We found no significant differences in key HRV measures in obstetricians working 14 hours versus 24 hours in labour and delivery. An anecdotal increase in physician awareness of his/her own health related to working conditions was noted during the study. Future studies should attempt to control for the hours prior to a night shift, assess associated endocrine variations, and focus upon HRV in the post-shift period.